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Nisivaco S, McCarthy PM, Kruse J, Andre AC, Zhao M, Thomas JD. Late results of chord transfer and other techniques for anterior leaflet repair without neochords. J Thorac Cardiovasc Surg 2024; 168:1045-1056.e3. [PMID: 37453720 DOI: 10.1016/j.jtcvs.2023.05.047] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 05/02/2023] [Accepted: 05/09/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE Anterior and bileaflet degenerative mitral regurgitation repairs are challenging. We examined our early and late outcomes for repair using 4 techniques, without neochord repair. METHODS Between February 1, 2006, and June 30, 2021, a total of 2368 patients received mitral valve ± other surgery by 1 surgeon, including 1160 with degenerative mitral regurgitation. Clinical follow-up was conducted annually (mean 6.8 ± 4.4 years). RESULTS Repair was performed in 1137 patients (98%) (mean age, 60.5 ± 11.9 years). Repair rate varied between groups: 99% for isolated posterior leaflet (794/799), 91% for isolated anterior leaflet (83/91), and 96% for bileaflet prolapse (260/270; P < .001). Thirty-day mortality was 0.2%. On a scale of 0 to 4+ mitral regurgitation, mean mitral regurgitation grade decreased from 3.8 ± 0.6 preoperatively to 0.07 ± 0.3 at discharge, including moderate (2+) in 0.6% (7/1137) overall and 0.9% (3/343) with anterior prolapse. None were more than 2+ at discharge. Among the 3 groups of leaflet prolapse, there was no significant difference in long-term survival (P = .26), freedom from mitral valve reintervention (P = .12; 99.4% overall), and freedom from more than moderate (2+) mitral regurgitation (P = .16; 98.3% overall). The 4 most common anterior leaflet repair techniques (chord transfer 17%; commissuroplasty 10%; Alfieri [edge-to-edge] 6%); ring with posterior resection (4.3%) had similar freedom from 10-year reintervention (99.4%, 94%, 100%, and 100%, respectively; P = .29). CONCLUSIONS Complex anterior leaflet prolapse repairs are successful using a variety of techniques without neochord implantation. Although neochords are popular, there are other ways to repair complex valves that do not require as much judgment and experience.
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Affiliation(s)
- Sarah Nisivaco
- Division of Cardiac Surgery, Bluhm Cardiovascular Institute, Northwestern Medicine and Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Patrick M McCarthy
- Division of Cardiac Surgery, Bluhm Cardiovascular Institute, Northwestern Medicine and Northwestern University Feinberg School of Medicine, Chicago, Ill.
| | - Jane Kruse
- Division of Cardiac Surgery, Bluhm Cardiovascular Institute, Northwestern Medicine and Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Adin-Cristian Andre
- Division Biostatistics, Department of Preventive Medicine, Northwestern Medicine and Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Manyun Zhao
- Division of Cardiac Surgery, Bluhm Cardiovascular Institute, Northwestern Medicine and Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - James D Thomas
- Division of Cardiology, Bluhm Cardiovascular Institute, Northwestern Medicine and Northwestern University Feinberg School of Medicine, Chicago, Ill
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Malas J, Chen Q, Emerson D, Gill G, Rowe G, Egorova N, Trento A, Chikwe J, Bowdish ME. Socioeconomic disparities in midterm outcomes after repair for degenerative mitral regurgitation. J Thorac Cardiovasc Surg 2024; 168:809-817.e20. [PMID: 37385524 PMCID: PMC11181753 DOI: 10.1016/j.jtcvs.2023.05.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 05/17/2023] [Accepted: 05/29/2023] [Indexed: 07/01/2023]
Abstract
OBJECTIVE The influence of socioeconomic disparities on survival after mitral repair is poorly defined. We examined the association between socioeconomic disadvantage and midterm outcomes of repair in Medicare beneficiaries with degenerative mitral regurgitation. METHODS US Centers for Medicare and Medicaid Services data were used to identify 10,322 patients undergoing isolated first-time repair for degenerative mitral regurgitation between 2012 and 2019. Zip code-level socioeconomic disadvantage was dichotomized with the Distressed Communities Index, which incorporates education level, poverty, unemployment, housing security, median income, and business growth; those with Distressed Communities Index score ≥80 were classified as distressed. The primary outcome was survival, censored at 3 years. Secondary outcomes included cumulative incidences of heart failure readmission, mitral reintervention, and stroke. RESULTS Of the 10,322 patients undergoing degenerative mitral repair, 9.7% (n = 1003) came from distressed communities. Patients from distressed communities underwent surgery at lower volume centers (11 vs 16 cases/year) and traveled further for surgical care (40 vs 17 miles) (both P values < .001). At 3 years, unadjusted survival (85.4%; 95% CI, 82.9%-87.5% vs 89.7%; 95% CI, 89.0%-90.4%) and cumulative incidence of heart failure readmission (11.5%; 95% CI, 9.6%-13.7% vs 7.4%; 95% CI, 6.9%-8.0%) were worse in patients from distressed communities (all P values < .001), whereas mitral reintervention rates were similar (2.7%; 95% CI, 1.8%-4.0% vs 2.8%; 95% CI, 2.5%-3.2%; P = .75). After adjustment, community distress was independently associated with 3-year mortality (hazard ratio, 1.21; 95% CI, 1.01-1.46) and heart failure readmissions (hazard ratio, 1.28; 95% CI, 1.04-1.58). CONCLUSIONS Community-level socioeconomic distress is associated with worse outcomes in degenerative mitral repair among Medicare beneficiaries.
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Affiliation(s)
- Jad Malas
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, Calif
| | - Qiudong Chen
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, Calif
| | - Dominic Emerson
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, Calif
| | - George Gill
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, Calif
| | - Georgina Rowe
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, Calif
| | - Natalia Egorova
- Department of Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alfredo Trento
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, Calif
| | - Joanna Chikwe
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, Calif
| | - Michael E Bowdish
- Department of Cardiac Surgery, Cedars-Sinai Medical Center, Smidt Heart Institute, Los Angeles, Calif.
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Kosaki R, Mochizuki Y, Toyosaki E, Fukuoka H, Shinke T. Successful transcatheter edge-to-edge repair for atrial functional mitral regurgitation after surgical annuloplasty ring dehiscence: a case report. Eur Heart J Case Rep 2024; 8:ytae396. [PMID: 39156952 PMCID: PMC11328528 DOI: 10.1093/ehjcr/ytae396] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2024] [Revised: 05/10/2024] [Accepted: 07/29/2024] [Indexed: 08/20/2024]
Abstract
Background Annuloplasty ring dehiscence (ARD) after surgical mitral valve repair is a rare complication, which causes recurrent mitral regurgitation (MR) and is associated with adverse outcomes in patients with a prohibitive risk of repeat surgery. However, a patient developed severe MR, when challenging transcatheter edge-to-edge repair (TEER) after surgical ring dehiscence, it should be considering the relative efficacy and safety. Case summary An 89-year-old man underwent mitral valve repair with an annuloplasty ring for moderate atrial functional MR (AFMR). Post-operative transthoracic echocardiography on Day 7 suggested a dislodged mitral annuloplasty ring and recurrent moderate AFMR. However, the MR developed severely, which led to two hospitalizations for congestive heart failure in the past year. Transoesophageal echocardiography (TOE) was performed carefully to ensure that the TEER clip did not interfere with the dislodged annuloplasty ring. Consequently, only the therapeutic target on the medial side of the A2-P2 region was approached posteriorly behind the peri-ring space, without gripper interference. Discussion Transcatheter edge-to-edge repair using the G4-MitraClip® system is feasible and safe in patients with recurrent severe AFMR after surgical mitral valve repair concomitant with ARD. Meticulous simulation with pre-operative TOE is one of the crucial steps for successful outcomes.
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Affiliation(s)
- Ryota Kosaki
- Division of Cardiology, Department of Medicine, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8555, Japan
| | - Yasuhide Mochizuki
- Division of Cardiology, Department of Medicine, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8555, Japan
| | - Eiji Toyosaki
- Division of Cardiology, Department of Medicine, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8555, Japan
| | - Hiroto Fukuoka
- Division of Cardiology, Department of Medicine, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8555, Japan
| | - Toshiro Shinke
- Division of Cardiology, Department of Medicine, Showa University School of Medicine, 1-5-8 Hatanodai, Shinagawa-ku, Tokyo 142-8555, Japan
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Niu Y, Cheng S, Dong N, Zhou C. Case Report: Allograft aortic valve replacement in irreparable infant mitral valve. Front Cardiovasc Med 2024; 11:1425900. [PMID: 39114560 PMCID: PMC11303175 DOI: 10.3389/fcvm.2024.1425900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Accepted: 07/12/2024] [Indexed: 08/10/2024] Open
Abstract
This case report describes a 3-month-old male infant diagnosed with severe mitral stenosis (MS) and mitral regurgitation (MR) by transthoracic echocardiography. The male infant initially underwent complex mitral valve repair surgery. However, postoperative deterioration occurred with hemodynamic instability and shock, necessitating multiple resuscitation efforts and ultimately requiring support from Extracorporeal Membrane Oxygenation (ECMO). Given the serious conditions, the cardiac team decided to perform mitral valve replacement with a fresh allograft aortic valve. Postoperatively, the patient was promptly weaned off ECMO support, and the valve demonstrated sustained functionality throughout the long-term follow-up.
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Affiliation(s)
- Yuqing Niu
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Jingshan Union Hospital, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shaoxian Cheng
- Jingshan Union Hospital, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Nianguo Dong
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Cheng Zhou
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Song K, Lee JH, Woo HT, Kim YS, Jang WS, Chung S, Cho YH, Kim WS, Sung K. Surgical outcome of mitral valve surgery in atrial functional mitral regurgitation compared with degenerative etiology. J Thorac Cardiovasc Surg 2024:S0022-5223(24)00515-4. [PMID: 38879118 DOI: 10.1016/j.jtcvs.2024.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2024] [Revised: 05/06/2024] [Accepted: 06/02/2024] [Indexed: 07/07/2024]
Abstract
OBJECTIVE To analyze and compare the outcomes of mitral valve surgery for atrial functional mitral regurgitation (AFMR) and for degenerative mitral regurgitation (DMR). METHODS Patients with AFMR or DMR who underwent mitral valve repair/replacement at 2 institutions between January 2012 and December 2022 were included. Patients <18 years of age and patients undergoing concomitant cardiac surgery (except for the maze procedure or tricuspid annuloplasty) were excluded. Propensity score analysis was used to adjust for baseline differences. RESULTS A total of 642 patients were enrolled. After propensity score analysis, 164 patients were classified into the DMR group, and 82 patients were classified into the AFMR group. All matched patients in both groups had atrial fibrillation. In DMR and AFMR, the 5-year freedom from readmission for heart failure and cardiac death was 96.3% in the DMR group versus 88.6% in the AFMR group (P = .045) and freedom from readmission for cardiac death in the 2 groups was 100% and 90.0%, respectively (P = .002). The recurrence rate of significant mitral regurgitation (MR) after mitral valve repair was not significantly different between the 2 groups (P = .699, log-rank test), and the 5-year freedom from MR recurrence (moderate or greater) was 89.8% and 93.0%, respectively. After the maze procedure, significantly more patients in the AFMR group than the DMR group were in junctional rhythm (49.1% vs 3.3%; P < .001) and required permanent pacemaker insertion during the follow-up period (11.4% vs 1.5% after 5 years; P = .041, log-rank test). CONCLUSIONS AFMR was associated with acceptable outcomes of mitral valve surgery, and mitral valve repair is a good treatment option. However, significantly more patients were in junctional rhythm after the maze procedure, needing more permanent pacemaker insertion.
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Affiliation(s)
- Kyungsub Song
- Department of Thoracic and Cardiovascular Surgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Jun Ho Lee
- Department of Thoracic and Cardiovascular Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Republic of Korea
| | - Hyeong Taek Woo
- Department of Preventive Medicine, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Yun Seok Kim
- Department of Thoracic and Cardiovascular Surgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Woo Sung Jang
- Department of Thoracic and Cardiovascular Surgery, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Suryeun Chung
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Yang Hyun Cho
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Wook Sung Kim
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Kiick Sung
- Department of Thoracic and Cardiovascular Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea.
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Werner P, Aref T, Uyanik-Uenal K, Kocher A, Tozzi P, Laufer G, Andreas M. First-in-Man Study of a Novel, Balloon-Adjustable Mitral Annuloplasty Ring. J Clin Med 2024; 13:3214. [PMID: 38892924 PMCID: PMC11172768 DOI: 10.3390/jcm13113214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Revised: 05/09/2024] [Accepted: 05/24/2024] [Indexed: 06/21/2024] Open
Abstract
Objectives: Mitral valve repair is the current standard approach for mitral valve regurgitation. However, patients suffering from functional mitral regurgitation have a significant risk of recurrent regurgitation. Adjustable mitral rings may provide a solution for this adverse event. Methods: A single-center, first-in-man clinical study was performed on patients suffering from mitral valve regurgitation. Patients were implanted with the study ring and followed for six months. A balloon catheter can be inserted into the study ring frame at any time after implantation and inflated independently in the areas P1, P2, or P3, which reduces the anterior-posterior diameter. Results: Five patients (75.4 ± 6.1 years; EuroSCORE II 2.1 ± 0.9%; three female) were successfully implanted. Mechanisms of mitral regurgitation were prolapse of the P2-segment in three patients and annular dilation in two patients. Surgical implantation according to the protocol was feasible and is described herein. Median cardiopulmonary bypass time and cross clamp time were 105 (118; 195) and 94 (90; 151) min, respectively. The median intensive care unit stay was 2 (2; 3) days. No perioperative, 30-day, or 6-month mortality was observed, and the repair was stable without residual or recurrent regurgitation ≥ grade 2. All patients reached the primary endpoint without device-related morbidity. Conclusions: Successful implantation was completed in five patients without device-related adverse events. Ring implantation was safe and feasible for all patients. The opportunity of post-implant adjustment to improve leaflet coaptation is a promising new therapeutic strategy that is assessed in a phase II study.
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Affiliation(s)
- Paul Werner
- Department of Cardiac Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria; (T.A.); (K.U.-U.); (A.K.); (G.L.); (M.A.)
| | - Tandis Aref
- Department of Cardiac Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria; (T.A.); (K.U.-U.); (A.K.); (G.L.); (M.A.)
| | - Keziban Uyanik-Uenal
- Department of Cardiac Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria; (T.A.); (K.U.-U.); (A.K.); (G.L.); (M.A.)
| | - Alfred Kocher
- Department of Cardiac Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria; (T.A.); (K.U.-U.); (A.K.); (G.L.); (M.A.)
| | - Piergiorgio Tozzi
- Department of Cardiovascular Surgery, Center Hospitalier Universitaire Vaudois, 1005 Lausanne, Switzerland;
| | - Guenther Laufer
- Department of Cardiac Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria; (T.A.); (K.U.-U.); (A.K.); (G.L.); (M.A.)
| | - Martin Andreas
- Department of Cardiac Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090 Vienna, Austria; (T.A.); (K.U.-U.); (A.K.); (G.L.); (M.A.)
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Recco DP, Kneier NE, Earley PD, Kizilski SB, Hammer PE, Hoganson DM. Fiberscope-Based Measurement of Coaptation Height for Intraoperative Assessment of Mitral Valve Repair. World J Pediatr Congenit Heart Surg 2024; 15:371-379. [PMID: 38327093 DOI: 10.1177/21501351231221459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
BACKGROUND Restoring adequate coaptation height is a key principle of mitral valve (MV) repair. This study aimed to evaluate the utility of fiberscope (FS) technology to assess MV coaptation height for intraoperative use. METHODS Ex-vivo testing was performed on five adult porcine hearts. The left atrium (LA) was resected, and the left ventricle (LV) was pressurized retrograde to 27 ± 1mm Hg. An endoscope was inserted into the LV apex, centered under the MV orifice. An FS system (Milliscope II camera, LED light source, and 0.7 mm diameter × 15 cm long) 90° semirigid scope with 1.2 mm focal length) was mounted above the MV annulus in a custom alignment and measuring fixture. Three blinded measurements were taken at two locations on each MV, A2 and P2 segment, from the top of coaptation to the leaflet edge identified by the FS. Accurate positioning was verified using the LV endoscope. A control (metal rod of similar thickness) was used for comparison, with coaptation height recorded when the control was seen via the endoscope. RESULTS Coaptation heights were similar for the control and FS methods across all hearts at A2 (11.6 ± 2.6 mm control vs 11.8 ± 2.2 mm FS) and P2 (13.3 ± 2.6 mm control vs 13.4 ± 2.9 mm FS) segments, with similar measurement variability (control SD 0.1-1.0 mm; FS SD 0.1-0.9 mm). One outlier was excluded from analysis (n = 19/20). The maximum absolute difference and percent error between measurement methods were less than 1.1 mm (median [IQR], 0.6 [0.3-0.9] mm) and less than 14% (4.1 [2.2-7.6]%). CONCLUSIONS Utilization of a miniaturized FS enabled precise and accurate quantification of MV coaptation. This technique is promising for evaluating post-repair valve competence and coaptation height.
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Affiliation(s)
- Dominic P Recco
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Nicholas E Kneier
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Patrick D Earley
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Shannen B Kizilski
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Peter E Hammer
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - David M Hoganson
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Marcoff L, Koulogiannis K, Aldaia L, Mediratta A, Chadderdon SM, Makar MM, Ruf TF, Gößler T, Zaroff JG, Leung GK, Ku IA, Nabauer M, Grayburn PA, Wang Z, Hawthorne KM, Fowler DE, Dal-Bianco JP, Vannan MA, Bevilacqua C, Meineri M, Ender J, Forner AF, Puthumana JJ, Mansoor AH, Lloyd DJ, Voskanian SJ, Ghobrial A, Hahn RT, Mahmood F, Haeffele C, Ong G, Schneider LM, Wang DD, Sekaran NK, Koss E, Mehla P, Harb S, Miyasaka R, Ivannikova M, Stewart-Dehner T, Mitchel L, Raissi SR, Kalbacher D, Biswas S, Ho EC, Goldberg Y, Smith RL, Hausleiter J, Lim DS, Gillam LD. Echocardiographic Outcomes With Transcatheter Edge-to-Edge Repair for Degenerative Mitral Regurgitation in Prohibitive Surgical Risk Patients. JACC Cardiovasc Imaging 2024; 17:471-485. [PMID: 38099912 DOI: 10.1016/j.jcmg.2023.09.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 09/18/2023] [Accepted: 09/29/2023] [Indexed: 06/09/2024]
Abstract
BACKGROUND The CLASP IID randomized trial (Edwards PASCAL TrAnScatheter Valve RePair System Pivotal Clinical Trial) demonstrated the safety and effectiveness of the PASCAL system for mitral transcatheter edge-to-edge repair (M-TEER) in patients at prohibitive surgical risk with significant symptomatic degenerative mitral regurgitation (DMR). OBJECTIVES This study describes the echocardiographic methods and outcomes from the CLASP IID trial and analyzes baseline variables associated with residual mitral regurgitation (MR) ≤1+. METHODS An independent echocardiographic core laboratory assessed echocardiographic parameters based on American Society of Echocardiography guidelines focusing on MR mechanism, severity, and feasibility of M-TEER. Factors associated with residual MR ≤1+ were identified using logistic regression. RESULTS In 180 randomized patients, baseline echocardiographic parameters were well matched between the PASCAL (n = 117) and MitraClip (n = 63) groups, with flail leaflets present in 79.2% of patients. Baseline MR was 4+ in 76.4% and 3+ in 23.6% of patients. All patients achieved MR ≤2+ at discharge. The proportion of patients with MR ≤1+ was similar in both groups at discharge but diverged at 6 months, favoring PASCAL (83.7% vs 71.2%). Overall, patients with a smaller flail gap were significantly more likely to achieve MR ≤1+ at discharge (adjusted OR: 0.70; 95% CI: 0.50-0.99). Patients treated with PASCAL and those with a smaller flail gap were significantly more likely to sustain MR ≤1+ to 6 months (adjusted OR: 2.72 and 0.76; 95% CI: 1.08-6.89 and 0.60-0.98, respectively). CONCLUSIONS The study used DMR-specific echocardiographic methodology for M-TEER reflecting current guidelines and advances in 3-dimensional echocardiography. Treatment with PASCAL and a smaller flail gap were significant factors in sustaining MR ≤1+ to 6 months. Results demonstrate that MR ≤1+ is an achievable benchmark for successful M-TEER. (Edwards PASCAL TrAnScatheter Valve RePair System Pivotal Clinical Trial [CLASP IID]; NCT03706833).
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Affiliation(s)
- Leo Marcoff
- Morristown Medical Center, Atlantic Health System, Morristown, New Jersey, USA.
| | | | - Lilian Aldaia
- Morristown Medical Center, Atlantic Health System, Morristown, New Jersey, USA
| | - Anuj Mediratta
- Morristown Medical Center, Atlantic Health System, Morristown, New Jersey, USA
| | | | - Moody M Makar
- Cedars-Sinai Medical Center, Los Angeles, California, USA
| | | | | | - Jonathan G Zaroff
- Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | - Gordon K Leung
- Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | - Ivy A Ku
- Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | | | - Paul A Grayburn
- Baylor Scott and White: The Heart Hospital, Plano, Texas, USA
| | - Zuyue Wang
- Baylor Scott and White: The Heart Hospital, Plano, Texas, USA
| | | | - Dale E Fowler
- University of Virginia Health System Hospital, Charlottesville, Virginia, USA
| | | | - Mani A Vannan
- Marcus Heart Valve Center, Piedmont Heart Institute, Atlanta, Georgia, USA
| | | | | | | | | | | | | | - Dustin J Lloyd
- Los Robles Regional Medical Center, Thousand Oaks, California, USA
| | | | - Andrew Ghobrial
- Los Robles Regional Medical Center, Thousand Oaks, California, USA
| | - Rebecca T Hahn
- Columbia University Medical Center, New York, New York, USA
| | - Feroze Mahmood
- Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | | | | | | | | | | | - Elana Koss
- Northwell-North Shore, Manhasset, New York, USA
| | - Priti Mehla
- Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Serge Harb
- Cleveland Clinic Foundation, Cleveland, Ohio, USA
| | | | | | | | - Lucas Mitchel
- St. Vincent Heart Center of Indiana, Indianapolis, Indiana, USA
| | - Sasan R Raissi
- Ascension Saint Thomas Hospital, Nashville, Tennessee, USA
| | | | | | - Edwin C Ho
- Montefiore Medical Center, Bronx, New York, USA
| | | | - Robert L Smith
- Baylor Scott and White: The Heart Hospital, Plano, Texas, USA
| | | | - D Scott Lim
- University of Virginia Health System Hospital, Charlottesville, Virginia, USA
| | - Linda D Gillam
- Morristown Medical Center, Atlantic Health System, Morristown, New Jersey, USA
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9
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Praz F, Beyersdorf F, Haugaa K, Prendergast B. Valvular heart disease: from mechanisms to management. Lancet 2024; 403:1576-1589. [PMID: 38554728 DOI: 10.1016/s0140-6736(23)02755-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 08/16/2023] [Accepted: 12/06/2023] [Indexed: 04/02/2024]
Abstract
Valvular heart disease is common and its prevalence is rapidly increasing worldwide. Effective medical therapies are insufficient and treatment was historically limited to the surgical techniques of valve repair or replacement, resulting in systematic underprovision of care to older patients and those with substantial comorbidities, frailty, or left ventricular dysfunction. Advances in imaging and surgical techniques over the past 20 years have transformed the management of valvular heart disease. Better understanding of the mechanisms and causes of disease and an increasingly extensive and robust evidence base provide a platform for the delivery of individualised treatment by multidisciplinary heart teams working within networks of diagnostic facilities and specialist heart valve centres. In this Series paper, we aim to provide an overview of the current and future management of valvular heart disease and propose treatment approaches based on an understanding of the underlying pathophysiology and the application of multidisciplinary treatment strategies to individual patients.
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Affiliation(s)
- Fabien Praz
- University Hospital Bern Inselspital, University of Bern, Bern, Switzerland.
| | - Friedhelm Beyersdorf
- Department of Cardiovascular Surgery, Heart Center, University of Freiburg, Freiburg, Germany; Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Kristina Haugaa
- Department of Cardiology, Oslo University Hospital, Rikshospitalet and University of Oslo, Oslo, Norway
| | - Bernard Prendergast
- Heart Vascular and Thoracic Institute, Cleveland Clinic London, London, UK; Department of Cardiology, St Thomas' Hospital, London, UK
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10
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Zhu K, Xu H, Zheng S, Liu S, Zhong Z, Sun H, Duan F, Liu S. A complexity evaluation system for mitral valve repair based on preoperative echocardiographic and machine learning. Hellenic J Cardiol 2024:S1109-9666(24)00078-2. [PMID: 38636776 DOI: 10.1016/j.hjc.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 03/19/2024] [Accepted: 04/10/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND To develop a novel complexity evaluation system for mitral valve repair based on preoperative echocardiographic data and multiple machine learning algorithms. METHODS From March 2021 to March 2023, 231 consecutive patients underwent mitral valve repair. Clinical and echocardiographic data were included in the analysis. The end points included immediate mitral valve repair failure (mitral replacement secondary to mitral repair failure) and recurrence regurgitation (moderate or greater mitral regurgitation [MR] before discharge). Various machine learning algorithms were used to establish the complexity evaluation system. RESULTS A total of 231 patients were included in this study; the median ejection fraction was 66% (63-70%), and 159 (68.8%) patients were men. Mitral repair was successful in 90.9% (210 of 231) of patients. The linear support vector classification model has the best prediction results in training and test cohorts and the variables of age, A2 lesions, leaflet height, MR grades, and so on were risk factors for failure of mitral valve repair. CONCLUSION The linear support vector classification prediction model may allow the evaluation of the complexity of mitral valve repair. Age, A2 lesions, leaflet height, MR grades, and so on may be associated with mitral repair failure.
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Affiliation(s)
- Kun Zhu
- Cardiac Surgery Center, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Hang Xu
- Cardiac Surgery Center, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Shanshan Zheng
- Cardiac Surgery Center, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Shui Liu
- Department of Radiology, Aerospace Center Hospital, Beijing 100049, China
| | - Zhaoji Zhong
- Cardiac Surgery Center, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Haining Sun
- Cardiac Surgery Center, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Fujian Duan
- Department of Echocardiography, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Sheng Liu
- Cardiac Surgery Center, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China.
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11
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Guedeney P, Barthelemy O, Montalescot G. Transcatheter Mitral Valve Replacement for Valve-in-Ring: Innovative or Palliative Procedure? JACC Cardiovasc Interv 2024; 17:887-889. [PMID: 38599691 DOI: 10.1016/j.jcin.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 03/04/2024] [Indexed: 04/12/2024]
Affiliation(s)
- Paul Guedeney
- Sorbonne Université, ACTION Group, INSERM UMRS 1166, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (Assistance publique Hôpitaux de Paris), Paris, France.
| | - Olivier Barthelemy
- Sorbonne Université, ACTION Group, INSERM UMRS 1166, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (Assistance publique Hôpitaux de Paris), Paris, France
| | - Gilles Montalescot
- Sorbonne Université, ACTION Group, INSERM UMRS 1166, Institut de Cardiologie, Hôpital Pitié-Salpêtrière (Assistance publique Hôpitaux de Paris), Paris, France
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12
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Mihara K, Kanemoto I, Sato K, Yasuhira Y, Watanabe I, Suzuki Y, Nagura J, Misumi K. Effects of mitral valve repair on valvular geometry and hemodynamics in dogs with myxomatous mitral valve disease. Vet Surg 2024; 53:415-425. [PMID: 38205863 DOI: 10.1111/vsu.14068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 10/10/2023] [Accepted: 12/14/2023] [Indexed: 01/12/2024]
Abstract
OBJECTIVE To investigate the effects of mitral valve repair on the geometry of the mitral valve complex, hemodynamics, and cardiac function of dogs with myxomatous mitral valve disease (MMVD). STUDY DESIGN Retrospective cohort study. SAMPLE POPULATION Dogs (n = 77) with stage C MMVD undergoing mitral valve repair under cardiopulmonary bypass. METHODS Mitral valve geometry and cardiac function were assessed using echocardiography preoperatively, 1 week postoperatively and 3 months postoperatively. RESULTS The coaptation length (0 [0-0] vs. 7 [6-8.5] mm, p < .001) and forward stroke volume index (1.5 ± 0.4 vs. 2.3 ± 0.6 mL/kg, p < .001) were higher at 3-months postoperatively than preoperatively, whereas the vertebral heart score (12.3 ± 1.2 vs. 10.8 ± 0.8 V, p < .001), left atrial-to-aortic ratio (2.2 ± 0.7 vs. 1.2 ± 0.3, p < .001), peak velocity of early diastolic transmitral flow (144 ± 34 vs. 91 ± 18 cm/s, p < .001), and regurgitant volume index (11.3 [8.2-14.0] vs. 1.6 [0.95-2.35] mL/kg, p < .001) were lower. Postoperatively, mitral valve geometry was completely changed within 1 week, whereas changes in vertebral heart score lasted for 3 months. CONCLUSION Mitral valve repair changed valvular geometry and improved hemodynamics as assessed by follow-up echocardiography. CLINICAL SIGNIFICANCE This study acts as reference for surgeons and cardiologists considering or evaluating the effects of mitral valve repair in dogs and provides useful data for the enhancement of relevant surgical techniques and the selection of relevant pre- and postoperative observations.
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Affiliation(s)
- Kippei Mihara
- Joint Graduate School of Veterinary Medicine, Kagoshima University, Kagoshima, Japan
- Chayagasaka Animal Hospital, Nagoya, Japan
| | | | | | | | | | | | | | - Kazuhiro Misumi
- Joint Graduate School of Veterinary Medicine, Kagoshima University, Kagoshima, Japan
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13
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Moore RA, Wierup P, Tappuni S, Houghtaling PL, Burns DJP, Chemtob R, Blackstone EH, Svensson LG, Gillinov AM. Reoperation after early and late failure of mitral valve repair for degenerative disease. J Thorac Cardiovasc Surg 2024; 167:1251-1262.e8. [PMID: 36323616 DOI: 10.1016/j.jtcvs.2022.09.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Revised: 08/25/2022] [Accepted: 09/11/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To determine mechanisms of early and late failure after mitral valve repair for degenerative disease, identify factors associated with re-repair, and evaluate durability of re-repair. METHODS From January 2008 to July 2020, 330 reoperations were performed for recurrent mitral valve dysfunction after initial valve repair for degenerative disease. Mechanisms of repair failure were determined by review of preoperative imaging and operative reports. Multivariable analysis was performed to identify factors associated with likelihood of re-repair or replacement. Durability of re-repair was assessed using longitudinal analysis of postoperative echo data. RESULTS Eighty-five of 330 (26%) reoperations were performed for early repair failure within 1 year and 245/330 (74%) for late failure thereafter. Suture/annuloplasty dehiscence, systolic anterior motion, hemolysis, and ventricular remodeling were more common mechanisms of early failure and disease progression and fibrosis late failure. Forty percent (34/85) of early failures were re-repaired versus 24% (59/245) of late failures. Re-repair was more common than replacement in recent years and was associated with earlier reoperation (median 1.5 vs 3.9 years; P = .0001). No in-hospital deaths occurred after re-repair; 2 patients (0.8%) died after valve replacement. Freedom from severe mitral regurgitation after re-repair was 93% at 7 years. CONCLUSIONS Mitral valve re-repair can be performed with low rates of mortality and morbidity for early and late valve dysfunction. Mechanisms of early repair failure differ from those of late failure and are generally more amenable to re-repair. In selected patients who present after failed repair, we prefer mitral re-repair to valve replacement whenever technically feasible.
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Affiliation(s)
- Ryan A Moore
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Per Wierup
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Shahed Tappuni
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Penny L Houghtaling
- Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Daniel J P Burns
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Raphaelle Chemtob
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eugene H Blackstone
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio; Department of Quantitative Health Sciences, Lerner Research Institute, Cleveland Clinic, Cleveland, Ohio
| | - Lars G Svensson
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio
| | - A Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Heart, Vascular, and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio.
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14
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Rafael AE, Meyer DM. Respect Versus Resect Approaches for Mitral Valve Repair-A Meta-Analysis of Reconstructed Time-to-Event Data. Am J Cardiol 2024; 215:91. [PMID: 38280404 DOI: 10.1016/j.amjcard.2024.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 01/12/2024] [Indexed: 01/29/2024]
Affiliation(s)
- Aldo E Rafael
- Cardiovascular and Thoracic Surgery, Baylor University Medical Center at Dallas, Dallas, Texas
| | - Dan M Meyer
- Cardiovascular and Thoracic Surgery, Baylor University Medical Center at Dallas, Dallas, Texas.
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15
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Gillinov M, Hodges K, Burns DJP. Commentary: What is a good mitral valve repair? J Thorac Cardiovasc Surg 2024; 167:955-956. [PMID: 36038385 DOI: 10.1016/j.jtcvs.2022.07.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2022] [Accepted: 07/07/2022] [Indexed: 11/18/2022]
Affiliation(s)
- Marc Gillinov
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio.
| | - Kevin Hodges
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
| | - Daniel J P Burns
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, Ohio
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16
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Chen Q, Roach A, Trento A, Rowe G, Gill G, Peiris A, Emerson D, Ramzy D, Egorova N, Bowdish ME, Chikwe J. Robotic degenerative mitral repair: Factors associated with intraoperative revision and impact of mild residual regurgitation. J Thorac Cardiovasc Surg 2024; 167:944-954.e6. [PMID: 36182583 PMCID: PMC11181750 DOI: 10.1016/j.jtcvs.2022.06.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Revised: 06/06/2022] [Accepted: 06/27/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVES National registry data show wide variability in degenerative mitral repair rates and infrequent use of intraoperative repair revision to eliminate residual mitral regurgitation (MR). The consequence of uncorrected mild residual MR is also not clear. We identified factors associated with intraoperative revision of degenerative mitral repair and evaluated long-term effects of intraoperative mild residual MR. METHODS A prospective institutional registry of 858 patients with degenerative MR undergoing robotic mitral surgery was linked to statewide databases. Univariate logistic regression identified factors associated with intraoperative repair revision. Survival was estimated using the Kaplan-Meier method and adjusted with Cox regression. Late freedom from more-than-moderate MR or reintervention was estimated with death as a competing risk. RESULTS Repair rate was 99.3%. Repair was revised intraoperatively in 19 patients and was associated with anterior or bileaflet prolapse, adjunctive repair techniques, and annuloplasty band size (all P < .05). Intraoperative repair revision did not result in increased postoperative complications. Intraoperative mild residual MR (n = 111) was independently associated with inferior 8-year survival (hazard ratio, 2.97; 95% CI, 1.33-6.23), worse freedom from more than moderate MR (hazard ratio, 3.35; 95% CI, 1.60-7.00), and worse freedom from mitral reintervention (hazard ratio, 6.40; 95% CI, 2.19-18.72) (all P < .01). CONCLUSIONS A near 100% repair rate with acceptable durability may be achieved safely with intraoperative revision of postrepair residual MR. Mild residual MR was independently associated with reduced survival, worse freedom from more-than-moderate MR, and worse freedom from mitral reintervention at 8-year follow-up.
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Affiliation(s)
- Qiudong Chen
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Amy Roach
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Alfredo Trento
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Georgina Rowe
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - George Gill
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Achille Peiris
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Dominic Emerson
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Danny Ramzy
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Natalia Egorova
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Michael E Bowdish
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif
| | - Joanna Chikwe
- Department of Cardiac Surgery, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, Calif.
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17
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Abdelrehim AA, Dearani JA, Miranda WR, Connolly HM, Stephens EH. Surgical Considerations for the Mitral Valve in Congenitally Corrected Transposition. Ann Thorac Surg 2024; 117:560-566. [PMID: 37488004 DOI: 10.1016/j.athoracsur.2023.07.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 06/20/2023] [Accepted: 07/11/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Systemic atrioventricular valve (morphologic tricuspid valve [TV]) regurgitation has been implicated in the development of systemic ventricular failure in congenitally corrected transposition of the great arteries (ccTGA), leading to timely referral for valve replacement. However, the surgical management of subpulmonary atrioventricular valve (morphologic mitral valve [MV]) regurgitation and outcomes has not been well studied. METHODS Of 108 ccTGA patients undergoing atrioventricular valve surgery from 1979 to 2022, 22 patients (20%) underwent MV surgery. Demographics, etiology of valve regurgitation, operative details, and outcomes of these 22 patients were retrospectively reviewed. Follow-up at 1, 5, and 10 years was available for 18 (82%), 13 (59%), and 11 patients (50%), respectively. RESULTS Median age was 37 years (interquartile range, 29-57 years). Intrinsic MV pathology was present in 18 individuals (82%). Operations included repair in 16 patients (73%), replacement in 6 (27%), and concomitant replacement of TV in 16 (73%). There was 1 perioperative death (5%) in a patient undergoing an emergent operation for severe acute-on-chronic heart failure due to worsening TV regurgitation. During a median follow-up of 12 years (interquartile range, 2-19 years), 7 patients (32%) died. Among the 16 patients who underwent repair, recurrent moderate or greater regurgitation was seen in 15%, 29%, and 43% of repairs in patients with annular, leaflet, and lead-induced regurgitation, respectively. CONCLUSIONS Concomitant TV and MV disease occur much less frequently than isolated TV disease in ccTGA. Intrinsic MV disease is most commonly observed but appears less amenable to successful repair compared with mitral repair in the systemic position and suggests MV replacement may be preferred in ccTGA patients.
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Affiliation(s)
| | - Joseph A Dearani
- Department of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota
| | - William R Miranda
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Heidi M Connolly
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
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18
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Caldonazo T, Sá MP, Jacquemyn X, Van den Eynde J, Kirov H, Harik L, Fischer J, Vervoort D, Bonatti J, Sultan I, Doenst T. Respect Versus Resect Approaches for Mitral Valve Repair: A Meta-Analysis of Reconstructed Time-to-Event Data. Am J Cardiol 2024; 213:5-11. [PMID: 38104750 DOI: 10.1016/j.amjcard.2023.12.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Revised: 11/15/2023] [Accepted: 12/01/2023] [Indexed: 12/19/2023]
Abstract
Mitral valve repair (MVr) has been associated with superior long-term survival and freedom from valve-related complications compared with mitral valve replacement for primary mitral regurgitation (MR). The 2 main approaches for MVr are chordal replacement ("respect approach") and leaflet resection ("resect approach"). We performed a systematic review and a meta-analysis using 3 search databases to compare the long-term end points between both approaches. The primary end point was long-term survival. The secondary end points were long-term MR recurrence and reoperation. After reconstruction of time-to-event data for the individual survival analysis, pooled Kaplan-Meier curves for the end points were generated. A total of 14 studies (5,565 patients) were included in the analysis. The respect approach was associated with superior survival compared with the resect approach in the overall sample (hazard ratio [HR] 0.73, 95% confidence interval [CI] 0.56 to 0.96, p = 0.024, n = 3,901 patients) but not in the risk-adjusted sample (HR 1.00, 95% CI 0.55 to 1.82, p = 0.991, n = 620 patients). There was no difference between the approaches in the rate of MR recurrence in the overall sample (HR 1.39, 95% CI 0.92 to 2.08, p = 0.116, n = 1,882 patients) or in the risk-adjusted sample (HR 1.62, 95% CI 0.76 to 3.47, p = 0.211, n = 288 patients). The data for reoperation were only available in the overall sample and did not reveal a difference (HR 0.92, 95% CI 0.62 to 1.35, p = 0.663, n = 3,505 patients). In conclusion, the current evidence suggests no difference in long-term mortality, MR recurrence, or reoperation between the resect and respect approaches for MVr after adjusting for patient risk factors. More long-term follow-up data are warranted.
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Affiliation(s)
- Tulio Caldonazo
- Department of Cardiothoracic Surgery, Jena University Hospital, Jena, Germany.
| | - Michel Pompeu Sá
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Xander Jacquemyn
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | | | - Hristo Kirov
- Department of Cardiothoracic Surgery, Jena University Hospital, Jena, Germany
| | - Lamia Harik
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York City, New York
| | - Johannes Fischer
- Department of Cardiothoracic Surgery, Jena University Hospital, Jena, Germany
| | - Dominique Vervoort
- Division of Cardiac Surgery, University of Toronto, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Johannes Bonatti
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Ibrahim Sultan
- Department of Cardiothoracic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania; UPMC Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, Jena University Hospital, Jena, Germany
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19
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Kawamura M, Monta O, Maeda S, Tsutsumi Y. Mitral valve repair for degenerative mitral regurgitation with Carpentier's functional classification type II in elderly patients: a single center experience. J Cardiothorac Surg 2024; 19:75. [PMID: 38331949 PMCID: PMC10854023 DOI: 10.1186/s13019-024-02578-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Accepted: 01/30/2024] [Indexed: 02/10/2024] Open
Abstract
OBJECTIVE Mitral valve (MV) repair for Carpentier functional classification Type II (C-II) mitral regurgitation (MR) is widely accepted because of its efficacy. It is unclear whether MV repair has the same benefits in elderly patients as in younger patients because of their lower life expectancy. Herein, we examined the midterm results of MV repair for C-II mitral regurgitation, especially in patients aged ≧70 years. METHOD A retrospective review was performed on 176 patients who underwent MV repair for C-II mitral regurgitation with a median age of 65 years; 55 (31%) patients were ≧70 years, and 124 were male (71%). Lesions of the mitral valve were isolated from the anterior leaflet (48 patients), posterior leaflet (113 patients), and both leaflets (15 patients), and included seven patients with Barlow's disease. We compared the outcomes between patients aged ≧70 years (≧70 years; median age, 76 years) and those aged < 70 years (median age, 60 years). RESULTS In terms of the durability of MV repair in elderly patients, there were no significant differences in the rates of freedom from reoperation or MR recurrence at 5 years between patients aged < 70 years and those aged ≧70 years (reoperation:98% in < 70 years versus 89% in ≧70 years; P = 0.4053; MR recurrence:95% in < 70 years versus 81% in ≧70 years; P = 0.095). The mitral valve complexity was divided into two grades: Simple (isolated posterior mitral lesion) and Complex (isolated anterior lesion or both lesions). In patients aged < 70 years, there was no significant difference in the rate of freedom from MR recurrence at 5 years between the Simple and Complex groups (96% vs. 91%; P = 0.1029). In contrast, in patients aged ≧70 years, the MR recurrence rate at 3 years in Complex was significantly higher in the Complex group than in the Simple (100% vs. 80%; P = 0.0265). CONCLUSIONS We studied the outcomes of MV repair for C-II in MR. In elderly patients, MR recurrence was higher in complex lesions than in simple lesions. MV replacement may be considered for elderly patients with complex mitral valve lesions, if appropriately selected.
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Affiliation(s)
- Masashi Kawamura
- Department of Cardiovascular Surgery, Fukui CardioVascular Center, Shinbo 2-228, Fukui City, Fukui Prefecture, 910-0833, Japan.
| | - Osamu Monta
- Department of Cardiovascular Surgery, Fukui CardioVascular Center, Shinbo 2-228, Fukui City, Fukui Prefecture, 910-0833, Japan
| | - Shusaku Maeda
- Department of Cardiovascular Surgery, Fukui CardioVascular Center, Shinbo 2-228, Fukui City, Fukui Prefecture, 910-0833, Japan
| | - Yasushi Tsutsumi
- Department of Cardiovascular Surgery, Fukui CardioVascular Center, Shinbo 2-228, Fukui City, Fukui Prefecture, 910-0833, Japan
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20
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Wagner CM, Brescia AA, Watt TMF, Bergquist C, Rosenbloom LM, Ceniza NN, Markey GE, Ailawadi G, Romano MA, Bolling SF. Surgical strategy and outcomes for atrial functional mitral regurgitation: All functional mitral regurgitation is not the same! J Thorac Cardiovasc Surg 2024; 167:647-655. [PMID: 35618531 DOI: 10.1016/j.jtcvs.2022.02.056] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 01/10/2022] [Accepted: 02/23/2022] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Functional mitral regurgitation (FMR) is a cardiac pathology that causes the mitral valve to malfunction, leading to mitral regurgitation (MR). The optimal strategy for FMR remains unclear, and FMR outcomes are poor. All etiologies of FMR might not be the same, and subdividing patients with FMR caused by atrial (AFMR) versus ventricular FMR pathology might be important. Herein, we present outcomes of patients with AFMR to define this "new" population. METHODS Data of patients who underwent mitral valve repair for MR from 2000 to 2020 were reviewed. Patients with degenerative/myxomatous disease, ejection fraction <50% (ventricular FMR), and miscellaneous etiologies including endocarditis and rheumatic disease were excluded to isolate a population of "pure" AFMR patients. Descriptive characteristics and outcomes data were analyzed. RESULTS Among 123 total AFMR patients, mean preoperative left atrial dimensions were enlarged to 4.9 (95% CI, 4.7-5.0) cm, whereas mean preoperative left ventricular diastolic dimensions remained near normal at 5.0 (95% CI, 4.9-5.2) cm. Preoperative atrial fibrillation was noted in 61% (74/123). Echocardiogram was performed in 58% (71/123) of patients at a median of 569 (interquartile range, 75-1782) days after surgery. Of those, 72% (51/71) had trivial or no MR, 22% (16/71) mild, and only 6% (4/71) moderate or greater MR. Only 1.6% (2/123) required redo mitral valve reoperation. Estimated 5-year survival was 74%. CONCLUSIONS Patients with AFMR do well after mitral valve repair using an annuloplasty ring, with low rates of reoperation, mortality, and recurrence of MR. Mitral annuloplasty should be considered the surgical therapy of choice for AFMR.
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Affiliation(s)
| | | | - Tessa M F Watt
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Curtis Bergquist
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Liza M Rosenbloom
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Nicolas N Ceniza
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Grace E Markey
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Gorav Ailawadi
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Matthew A Romano
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich
| | - Steven F Bolling
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich.
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Kakuta T, Peng D, Yong MS, Skarsgard P, Cook R, Ye J. Long-term outcome of isolated mitral valve repair versus replacement for degenerative mitral regurgitation in propensity-matched patients. JTCVS OPEN 2024; 17:84-97. [PMID: 38420543 PMCID: PMC10897656 DOI: 10.1016/j.xjon.2023.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 11/22/2023] [Accepted: 12/10/2023] [Indexed: 03/02/2024]
Abstract
Objective This study was performed to investigate the long-term outcomes in patients with degenerative mitral regurgitation (MR) undergoing mitral valve repair (MVr) versus mitral valve replacement (MVR) without concomitant surgeries. Methods The study cohort comprised 1493 patients with degenerative MR who were treated with isolated mitral valve surgery between January 2000 and December 2017 in a large multicenter (5 hospitals) registry of the Province of British Columbia, Canada, including 991 with repair and 502 with replacement. A propensity-matched comparison and risk-adjusted model were used to analyze the outcomes. Results After propensity matching (415 matched pairs), the 30-day mortalities were 2.4% and 3.6% in the MVr and MVR groups respectively (odds ratio [OR], 1.500; 95% confidence interval [CI], 0.674-3.339; P = .32). The MVR group had significantly greater rates of prolonged inotrope usage >24 hours (P = .024), prolonged ventilation (P = .039), and blood transfusion (P = .023). The respective 1-, 5-, 10-, and 15-year survival rates were 95.7%, 88.8%, 71.4%, and 53.3% in the MVr group, and 93.0%, 81.6%, 61.3%, and 46.0% in the MVR group (hazard ratio [HR], 1.355; 95% CI, 1.105-1.661; P = .004). A multivariable analysis revealed that MVR was an independent risk factor for 30-day mortality (OR, 2.270; 95% CI, 1.089-4.732; P = .029) and long-term mortality (HR, 1.417; 95% CI, 1.161-1.729; P < .001). The HR of MVR over MVr remained consistently greater than 1.0 across all ages. Conclusions MVr is associated with lower postoperative morbidity and better long-term survival compared with MVR in patients undergoing isolated mitral valve surgery for degenerative MR. The benefit of MVr appears age-independent.
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Affiliation(s)
- Takashi Kakuta
- Division of Cardiovascular Surgery, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Defen Peng
- Division of Cardiovascular Surgery, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, British Columbia, Canada
| | - Matthew S Yong
- Division of Cardiovascular Surgery, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Peter Skarsgard
- Division of Cardiovascular Surgery, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Richard Cook
- Division of Cardiovascular Surgery, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jian Ye
- Division of Cardiovascular Surgery, St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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Gedela M, Cangut B, Safi L, Krishnamoorthy P, Pandis D, El-Eshmawi A, Tang GHL. Mitral Valve Intervention in Elderly or High-Risk Patients: A Review of Current Surgical and Interventional Management. Can J Cardiol 2024; 40:250-262. [PMID: 38042339 DOI: 10.1016/j.cjca.2023.11.031] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 11/25/2023] [Accepted: 11/26/2023] [Indexed: 12/04/2023] Open
Abstract
Mitral regurgitation is a prevalent valvular disease, and its management has gained increasing importance because of the aging population. Although traditional surgery remains the gold standard, the field of transcatheter therapies, including transcatheter edge-to-edge repair and, more recently transcatheter mitral valve replacement are advancing and are being explored as viable alternatives, particularly for patients at high surgical risk. It is essential to emphasize the necessity of a multidisciplinary team approach, involving specialized valve teams, imaging experts, cardiac anaesthesiologists, and other relevant specialists, is crucial in achieving optimal outcomes. Furthermore, proper execution of procedures, postprocedural care, and diligent follow-up for these patients are essential components for successful results. It is essential to underscore that traditional mitral valve surgery continues to play a significant role. Simultaneously, it is important to acknowledge the expanding array of transcatheter interventions available for this specific patient population.
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Affiliation(s)
- Maheedhar Gedela
- Heartland Cardiology, Wesley Medical Center, Wichita, Kansas, USA
| | - Busra Cangut
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lucy Safi
- Division of Cardiology, Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Parasuram Krishnamoorthy
- Division of Cardiology, Mount Sinai Fuster Heart Hospital, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Dimosthenis Pandis
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Ahmed El-Eshmawi
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Gilbert H L Tang
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
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23
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Ota M, Kitai T. Echocardiographic Evaluation of Successful Mitral Valve Repair or Need for a Second Pump Run in the Operating Room. Interv Cardiol Clin 2024; 13:71-80. [PMID: 37980068 DOI: 10.1016/j.iccl.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2023]
Abstract
Detailed preoperative and intraoperative echocardiographic assessment of the mitral valve apparatus is critical for a successful repair. The recent advent of 3-dimensional transesophageal echocardiography has added an extra pivotal role to transesophageal echocardiography in the assessment of mitral apparatus and mitral regurgitation. Because surgeons must rapidly decide whether cardiopulmonary bypass should be continued to be weaned off or a second pump run should be selected, the echocardiographer conducting intraoperative transesophageal echocardiography is required to be trained according to a certain algorithm. This review summarizes the current clinical role of intraoperative transesophageal echocardiography in mitral valve repair in the operating room.
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Affiliation(s)
- Mitsuhiko Ota
- Department of Cardiovascular Center, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo 105-8470, Japan.
| | - Takeshi Kitai
- Department of Cardiovascular Medicine, Kobe City Medical Center General Hospital, 2-1-1 Minatojima Minamimachi, Chuo-ku, Kobe 650-0047, Japan
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24
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Schneider LM, Worthley S, Nickenig G, Huczek Z, Wojakowski W, Tchetche D, Dubois C, Nasr M, Verhees L, Rothman M, Piazza N, Buithieu J, Yeow WL, Keßler M, Rottbauer W. 1-Year Outcomes Following Transfemoral Transseptal Transcatheter Mitral Valve Replacement: The HighLife TSMVR Feasibility Study. JACC Cardiovasc Interv 2023; 16:2854-2865. [PMID: 37999708 DOI: 10.1016/j.jcin.2023.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 08/29/2023] [Accepted: 09/05/2023] [Indexed: 11/25/2023]
Abstract
BACKGROUND A significant number of patients with severe mitral regurgitation (MR) are not suitable for either surgical or transcatheter edge-to-edge repair because of high surgical risk or inappropriate mitral valve anatomy. OBJECTIVES The aim of this study was to evaluate the HighLife Trans-Septal Mitral Valve Replacement (TSMVR) system in patients with symptomatic MR and high surgical risk. METHODS This prospective, multicenter, nonrandomized feasibility study evaluated the safety and performance of the HighLife TSMVR system in patients with moderate to severe or severe symptomatic MR during 1-year follow-up. Echocardiographic data were assessed at an independent core laboratory. RESULTS A total of 30 patients (mean age 75.6 years, 27% women, median Society of Thoracic Surgeons score 5.5%) with severe MR (90% with secondary MR, median left ventricular ejection fraction 43%) were treated at 13 sites. In 27 of the 30 patients, the HighLife TSMVR system was implanted successfully (technical success rate 90%). Device success at 30 days was 83%. After 1 year, 5 patients (17%) had died. None of the patients who underwent implantation required mitral valve reintervention. All patients who underwent implantation had no or trace (78%) or mild (22%) MR, the mean gradient of the HighLife valve was 5.1 mm Hg, and there were no signs of left ventricular outflow tract obstruction (mean gradient 2.0 mm Hg). CONCLUSIONS The 1-year results from the HighLife TSMVR feasibility study demonstrate a high technical success rate, excellent valve function, no left ventricular outflow tract obstruction, and no need for mitral valve reintervention. Additional patient outcomes and longer follow-up are needed to confirm these findings. (Expanded Study of the HighLife 28mm Trans-Septal Trans-Catheter Mitral Valve in Patients With Moderate-Severe or Severe Mitral Regurgitation and at High Surgical Risk; NCT04029363).
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Nicolo Piazza
- McGill University Health Center, Montreal, Quebec, Canada
| | - Jean Buithieu
- McGill University Health Center, Montreal, Quebec, Canada
| | | | - Mirjam Keßler
- Department of Cardiology, University Heart Center Ulm, Ulm, Germany
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25
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Hu YN, Lee WH, Tsai MT, Wang YC, Shih CJ, Huang YC, Roan JN. The Predictors and Outcomes of Functional Mitral Stenosis following Surgical Mitral Valve Repair: A Retrospective Analysis. J Cardiovasc Dev Dis 2023; 10:470. [PMID: 37998528 PMCID: PMC10672255 DOI: 10.3390/jcdd10110470] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 11/14/2023] [Accepted: 11/17/2023] [Indexed: 11/25/2023] Open
Abstract
To optimize mitral valve repair outcomes, it is crucial to comprehend the predictors of functional mitral valve stenosis (FMS), to enhance preoperative assessments, and to adapt intraoperative treatment strategies. This study aimed to identify FMS risk factors, contributing valuable insights for refining surgical techniques. Among 228 selected patients, 215 underwent postoperative echocardiography follow-ups, and 36 met the FMS criteria based on a mean trans-mitral pressure gradient of >5 mmHg. Patients with FMS exhibited higher pulmonary systolic arterial pressure and increased late mortality during the follow-up. Univariable logistic regression analysis identified several risk factors for FMS, including end-stage renal disease, anterior leaflet lesion, concomitant aortic valve replacement, smaller ring size, ring type, and neochordae implantation. Conversely, resection alone and resection combined with neochordae implantation had protective effects against FMS. Multivariable logistic regression analysis revealed that smaller ring sizes and patch repair independently predicted FMS. When focusing on degenerative mitral regurgitation, the neochordae implantation without resection in leaflet repair, emerged as an independent predictor of FMS. Surgeons should weigh the substantial impact of surgical procedures on postoperative trans-mitral pressure gradients, emphasizing preoperative evaluation and techniques such as precise ring size assessment and effective leaflet management.
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Affiliation(s)
- Yu-Ning Hu
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan; (Y.-N.H.); (M.-T.T.); (Y.-C.W.); (C.-J.S.); (Y.-C.H.)
| | - Wen-Huang Lee
- Division of Cardiology, Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan;
| | - Meng-Ta Tsai
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan; (Y.-N.H.); (M.-T.T.); (Y.-C.W.); (C.-J.S.); (Y.-C.H.)
| | - Yi-Chen Wang
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan; (Y.-N.H.); (M.-T.T.); (Y.-C.W.); (C.-J.S.); (Y.-C.H.)
| | - Chao-Jung Shih
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan; (Y.-N.H.); (M.-T.T.); (Y.-C.W.); (C.-J.S.); (Y.-C.H.)
| | - Yu-Ching Huang
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan; (Y.-N.H.); (M.-T.T.); (Y.-C.W.); (C.-J.S.); (Y.-C.H.)
| | - Jun-Neng Roan
- Division of Cardiovascular Surgery, Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan 704, Taiwan; (Y.-N.H.); (M.-T.T.); (Y.-C.W.); (C.-J.S.); (Y.-C.H.)
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26
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Kang Y, Sohn SH, Choi JW, Hwang HY, Kim KH. Machine-learning-based prediction of survival and mitral regurgitation recurrence in patients undergoing mitral valve repair. INTERDISCIPLINARY CARDIOVASCULAR AND THORACIC SURGERY 2023; 37:ivad176. [PMID: 37966944 PMCID: PMC10903183 DOI: 10.1093/icvts/ivad176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 09/25/2023] [Accepted: 11/14/2023] [Indexed: 11/17/2023]
Abstract
OBJECTIVES This study was conducted to assess long-term clinical outcomes after mitral valve repair using machine-learning techniques. METHODS We retrospectively evaluated 436 consecutive patients (mean age: 54.7 ± 15.4; 235 males) who underwent mitral valve repair between January 2000 and December 2017. Actuarial survival and freedom from significant (≥ moderate) mitral regurgitation (MR) were clinical end points. To evaluate the independent risk factors, random survival forest (RSF), extreme gradient boost (XGBoost), support vector machine, Cox proportional hazards model and general linear models with elastic net regularization were used. Concordance indices (C-indices) of each model were estimated. RESULTS The operative mortality was 0.9% (N = 4). Reoperation was required in 15 patients (3.5%). In terms of C-index, the overall performance of the XGBoost (C-index 0.806) and RSF models (C-index 0.814) was better than that of the Cox model (C-index 0.733) in overall survival. For the recurrent MR, the C-index for XGBoost was 0.718, which was the highest among the 5 models. Compared to the Cox model (C-index 0.545), the C-indices of the XGBoost (C-index 0.718) and RSF models (C-index 0.692) were higher. CONCLUSIONS Machine-learning techniques can be a useful tool for both prediction and interpretation in the survival and recurrent MR. From the machine-learning techniques examined here, the long-term clinical outcomes of mitral valve repair were excellent. The complexity of MV increased the risk of late mitral valve-related reoperation.
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Affiliation(s)
- Yoonjin Kang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Suk Ho Sohn
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Jae Woong Choi
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ho Young Hwang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul, Republic of Korea
| | - Kyung Hwan Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul, Republic of Korea
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27
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Quentin V, Mesnier J, Delhomme C, Sayah N, Guedeney P, Barthélémy O, Suc G, Collet JP. Transcatheter Mitral Valve Replacement Using Transcatheter Aortic Valve or Dedicated Devices: Current Evidence and Future Prospects. J Clin Med 2023; 12:6712. [PMID: 37959178 PMCID: PMC10647634 DOI: 10.3390/jcm12216712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2023] [Revised: 10/16/2023] [Accepted: 10/22/2023] [Indexed: 11/15/2023] Open
Abstract
Transcatheter mitral valve replacement (TMVR) is a novel and evolving field dedicated to addressing the therapeutic challenges posed by patients at high surgical risk with mitral valve disease. TMVR can be categorized into two distinct fields based on the type of device and its specific indications: TMVR with transcatheter aortic valves (TAV) and TMVR with dedicated devices. Similar to aortic stenosis, TMVR with TAV requires a rigid support structure to secure the valve in place. As a result, it is indicated for patients with failing bioprothesis or surgical rings or mitral valve disease associated with severe mitral annular calcification (MAC), which furnishes the necessary foundation for valve anchoring. While TMVR with TAV has shown promising outcomes in valve-in-valve procedures, its effectiveness remains more contentious in valve-in-ring or valve-in-MAC procedures. Conversely, TMVR with dedicated devices seeks to address native mitral regurgitation, whether accompanied by MAC or not, providing an alternative to Transcatheter Edge-to-Edge Repair (TEER) when TEER is not feasible or expected to yield unsatisfactory results. This emerging field is gradually surmounting technical challenges, including anchoring a valve in a non-calcified annulus and transitioning from the transapical route to the transeptal approach. Numerous devices are presently undergoing clinical trials. This review aims to furnish an overview of the supporting evidence for TMVR using TAV in each specific indication (valve-in-valve, valve-in-ring, valve-in-MAC). Subsequently, we will discuss the anticipated benefits of TMVR with dedicated devices over TEER, summarize the characteristics and clinical results of TMVR systems currently under investigation, and outline future prospects in this field.
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Affiliation(s)
- Victor Quentin
- Department of Cardiology, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris Cité Université, 75005 Paris, France
| | - Jules Mesnier
- Department of Cardiology, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris Cité Université, 75005 Paris, France
| | - Clémence Delhomme
- Department of Cardiology, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris Cité Université, 75005 Paris, France
| | - Neila Sayah
- Department of Cardiology, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris Cité Université, 75005 Paris, France
| | - Paul Guedeney
- ACTION Study Group, INSERM UMRS_1166, Institut de Cardiologie (AP-HP), Sorbonne Université, 75013 Paris, France
| | - Olivier Barthélémy
- ACTION Study Group, INSERM UMRS_1166, Institut de Cardiologie (AP-HP), Sorbonne Université, 75013 Paris, France
| | - Gaspard Suc
- Department of Cardiology, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris Cité Université, 75005 Paris, France
| | - Jean-Philippe Collet
- ACTION Study Group, INSERM UMRS_1166, Institut de Cardiologie (AP-HP), Sorbonne Université, 75013 Paris, France
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28
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Kurlansky PA, Traad EA, Ebra G. Mitral Repair vs Replacement for Degenerative Mitral Regurgitation in Patients Aged ≥65 Years. Ann Thorac Surg 2023; 116:736-742. [PMID: 37308067 DOI: 10.1016/j.athoracsur.2023.05.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 05/11/2023] [Accepted: 05/30/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND The benefits of mitral valve repair vs replacement are well documented. However, survival benefits in the elderly population are more controversial. In this novel lifetime analysis, we hypothesize that survival benefits for valve repair vs replacement in the elderly are sustained throughout the patient's lifetime. METHODS From January 1985 through December 2005, 663 patients, aged ≥65 years with myxomatous degenerative mitral valve disease underwent primary isolated mitral valve repair (n = 434) or replacement (n = 229). Propensity score matching was used to balance variables potentially related to outcome. RESULTS Follow-up was complete in 99.1% of mitral repair and 99.6% of mitral replacement patients. In matched patients, perioperative mortality was 3.9% (9 of 229) for repair and 10.9% (25 of 229) for replacement (P = .004). Survival estimates (95% confidence limits) from 29-year follow-up for matched patients were 54.6% (48.0%, 61.1%) and 11.0% (6.8%, 15.2%) at 10 years and 20 years for repair patients, and 34.2% (27.7%, 40.7%) and 3.7% (1%, 6.4%) for replacement patients, respectively. Median survival (95% confidence limits) was 11.3 years (9.6, 12.2 years) for repair patients compared with 6.9 years (6.3, 8.0 years) for replacement patients (P < .001). CONCLUSIONS This study demonstrates that although the elderly population is prone to multiple comorbidities, survival benefits of isolated mitral valve repair vs replacement are sustained throughout the patient's lifetime.
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Affiliation(s)
- Paul A Kurlansky
- Division of Cardiac Surgery, Columbia University, New York, New York; Center for Innovation and Outcomes Research, Department of Surgery, Columbia University, New York, New York.
| | - Ernest A Traad
- Cardiac Thoracic Vascular Surgical Associates, Miami, Florida
| | - George Ebra
- Cardiac Thoracic Vascular Surgical Associates, Miami, Florida; Premier Cardiovascular Surgeons, Tampa, Florida
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29
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Yajima S, Zhu Y, Stark CJ, Wilkerson RJ, Park MH, Stefan E, Woo YJ. Chordal force profile after neochordal repair of anterior mitral valve prolapse: An ex vivo study. JTCVS OPEN 2023; 15:164-172. [PMID: 37808060 PMCID: PMC10556825 DOI: 10.1016/j.xjon.2023.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 04/17/2023] [Accepted: 04/17/2023] [Indexed: 10/10/2023]
Abstract
Objective This study aimed to biomechanically evaluate the force profiles on the anterior primary and secondary chordae after neochord repair for anterior valve prolapse with varied degrees of residual mitral regurgitation using an ex vivo heart simulator. Methods The experiment used 8 healthy porcine mitral valves. Chordal forces were measured using fiber Bragg grating sensors on primary and secondary chordae from A2 segments. The anterior valve prolapse model was generated by excising 2 primary chordae at the A2 segment. Neochord repair was performed with 2 pairs of neochords. Varying neochord lengths simulated postrepair residual mitral regurgitation with regurgitant fraction at >30% (moderate), 10% to 30% (mild), and <10% (perfect repair). Results Regurgitant fractions of baseline, moderate, mild, and perfect repair were 4.7% ± 0.8%, 35.8% ± 2.1%, 19.8% ± 2.0%, and 6.0% ± 0.7%, respectively (P < .001). Moderate had a greater peak force of the anterior primary chordae (0.43 ± 0.06 N) than those of baseline (0.19 ± 0.04 N; P = .011), mild (0.23 ± 0.05 N; P = .041), and perfect repair (0.21 ± 0.03 N; P = .006). In addition, moderate had a greater peak force of the anterior secondary chordae (1.67 ± 0.17 N) than those of baseline (0.64 ± 0.13 N; P = .003), mild (0.84 ± 0.24 N; P = .019), and perfect repair (0.68 ± 0.14 N; P = .001). No significant differences in peak and average forces on both primary and secondary anterior chordae were observed between the baseline and perfect repair as well as the mild and perfect repair. Conclusions Moderate residual mitral regurgitation after neochord repair was associated with increased anterior primary and secondary chordae forces in our ex vivo anterior valve prolapse model. This difference in chordal force profile may influence long-term repair durability, providing biomechanical evidence in support of obtaining minimal regurgitation when repairing mitral anterior valve prolapse.
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Affiliation(s)
- Shin Yajima
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
| | - Yuanjia Zhu
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
- Department of Bioengineering, Stanford University, Stanford, Calif
| | - Charles J. Stark
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
| | | | - Matthew H. Park
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
- Department of Mechanical Engineering, Stanford University, Stanford, Calif
| | - Elde Stefan
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
| | - Y. Joseph Woo
- Department of Cardiothoracic Surgery, Stanford University, Stanford, Calif
- Department of Bioengineering, Stanford University, Stanford, Calif
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30
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Craven TP, Chew PG, Dobson LE, Gorecka M, Parent M, Brown LAE, Saunderson CED, Das A, Chowdhary A, Jex N, Higgins DM, Dall'Armellina E, Levelt E, Schlosshan D, Swoboda PP, Plein S, Greenwood JP. Cardiac reverse remodeling in primary mitral regurgitation: mitral valve replacement vs. mitral valve repair. J Cardiovasc Magn Reson 2023; 25:43. [PMID: 37496072 PMCID: PMC10373289 DOI: 10.1186/s12968-023-00946-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 06/09/2023] [Indexed: 07/28/2023] Open
Abstract
BACKGROUND When feasible, guidelines recommend mitral valve repair (MVr) over mitral valve replacement (MVR) to treat primary mitral regurgitation (MR), based upon historic outcome studies and transthoracic echocardiography (TTE) reverse remodeling studies. Cardiovascular magnetic resonance (CMR) offers reference standard biventricular assessment with superior MR quantification compared to TTE. Using serial CMR in primary MR patients, we aimed to investigate cardiac reverse remodeling and residual MR post-MVr vs MVR with chordal preservation. METHODS 83 patients with ≥ moderate-severe MR on TTE were prospectively recruited. 6-min walk tests (6MWT) and CMR imaging including cine imaging, aortic/pulmonary through-plane phase contrast imaging, T1 maps and late-gadolinium-enhanced (LGE) imaging were performed at baseline and 6 months after mitral surgery or watchful waiting (control group). RESULTS 72 patients completed follow-up (Controls = 20, MVr = 30 and MVR = 22). Surgical groups demonstrated comparable baseline cardiac indices and co-morbidities. At 6-months, MVr and MVR groups demonstrated comparable improvements in 6MWT distances (+ 57 ± 54 m vs + 64 ± 76 m respectively, p = 1), reduced indexed left ventricular end-diastolic volumes (LVEDVi; - 29 ± 21 ml/m2 vs - 37 ± 22 ml/m2 respectively, p = 0.584) and left atrial volumes (- 23 ± 30 ml/m2 and - 39 ± 26 ml/m2 respectively, p = 0.545). At 6-months, compared with controls, right ventricular ejection fraction was poorer post-MVr (47 ± 6.1% vs 53 ± 8.0% respectively, p = 0.01) compared to post-MVR (50 ± 5.7% vs 53 ± 8.0% respectively, p = 0.698). MVR resulted in lower residual MR-regurgitant fraction (RF) than MVr (12 ± 8.0% vs 21 ± 11% respectively, p = 0.022). Baseline and follow-up indices of diffuse and focal myocardial fibrosis (Native T1 relaxation times, extra-cellular volume and quantified LGE respectively) were comparable between groups. Stepwise multiple linear regression of indexed variables in the surgical groups demonstrated baseline indexed mitral regurgitant volume as the sole multivariate predictor of left ventricular (LV) end-diastolic reverse remodelling, baseline LVEDVi as the most significant independent multivariate predictor of follow-up LVEDVi, baseline indexed LV end-systolic volume as the sole multivariate predictor of follow-up LV ejection fraction and undergoing MVR (vs MVr) as the most significant (p < 0.001) baseline multivariate predictor of lower residual MR. CONCLUSION In primary MR, MVR with chordal preservation may offer comparable cardiac reverse remodeling and functional benefits at 6-months when compared to MVr. Larger, multicenter CMR studies are required, which if the findings are confirmed could impact future surgical practice.
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Affiliation(s)
- Thomas P Craven
- Multidisciplinary Cardiovascular Research Centre & Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, LS2 9JT, UK
| | - Pei G Chew
- Multidisciplinary Cardiovascular Research Centre & Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, LS2 9JT, UK
| | - Laura E Dobson
- Department of Cardiology, Wythenshawe Hospital, Manchester University NHS Trust, Manchester, UK
| | - Miroslawa Gorecka
- Multidisciplinary Cardiovascular Research Centre & Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, LS2 9JT, UK
| | - Martine Parent
- Multidisciplinary Cardiovascular Research Centre & Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, LS2 9JT, UK
| | - Louise A E Brown
- Multidisciplinary Cardiovascular Research Centre & Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, LS2 9JT, UK
| | - Christopher E D Saunderson
- Multidisciplinary Cardiovascular Research Centre & Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, LS2 9JT, UK
| | - Arka Das
- Multidisciplinary Cardiovascular Research Centre & Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, LS2 9JT, UK
| | - Amrit Chowdhary
- Multidisciplinary Cardiovascular Research Centre & Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, LS2 9JT, UK
| | - Nicholas Jex
- Multidisciplinary Cardiovascular Research Centre & Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, LS2 9JT, UK
| | | | - Erica Dall'Armellina
- Multidisciplinary Cardiovascular Research Centre & Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, LS2 9JT, UK
| | - Eylem Levelt
- Multidisciplinary Cardiovascular Research Centre & Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, LS2 9JT, UK
| | | | - Peter P Swoboda
- Multidisciplinary Cardiovascular Research Centre & Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, LS2 9JT, UK
| | - Sven Plein
- Multidisciplinary Cardiovascular Research Centre & Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, LS2 9JT, UK
| | - John P Greenwood
- Multidisciplinary Cardiovascular Research Centre & Department of Biomedical Imaging Science, Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, LS2 9JT, UK.
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Casey L, Jinih M, MacHale J, Kirby F, O’ Neill JO, Byrne R, McCarthy JF. Predictability and durability of mitral valve repair in patients with severe degenerative mitral regurgitation in medium sized centres. Ann R Coll Surg Engl 2023; 105:532-539. [PMID: 36622239 PMCID: PMC10313449 DOI: 10.1308/rcsann.2022.0076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2022] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Mitral valve repair (MVr) is now the treatment of choice to correct severe degenerative mitral regurgitation (MR). Repair rates vary greatly from centre to centre, and the concept of heart valve centres of excellence has been established. OBJECTIVE The purpose of this study was to see whether large international centre repair rates, and outcomes, are transferrable to medium-sized centres with an interest in mitral repair. METHODS Between 2011 and 2018, a total of 346 patients underwent mitral valve surgery by a single surgeon. Of these, 238 consecutive patients had repairs, or attempted repairs for degenerative MR, and are included in this study. RESULTS The study sample consisted of 71% male patients and had a mean age of 64.4 ± 12.3 years; 66% of the study population had concomitant procedures. The overall repair rate in this cohort is 99%. Mean follow up was 3.7 ± 1.9 years. At 5 years, the freedom from MR ≥ 3+ was 95.9 ± 1.9% and at 7 years 91.1 ± 3.8%. Freedom from reoperation at 5 years was 92.9 ± 3.7%, while the 5 years actuarial survival was 89.1 ± 3.7%. On a multivariate analysis, predischarge echo grade was associated with higher risk of future reoperation (odds ratio (OR) = 21.82, p = 0.05). Only age (OR = 1.3, p = 0.03) was predictive of long-term survival. CONCLUSIONS In specialised medium-sized heart centres, where the surgical team have undergone specialist mitral training, favourable short- and long-term outcomes are achievable with mitral repair rates similar to those from large international centres of excellence. In these heart centres, early surgery should be considered for all patients with severe degenerative MR.
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Affiliation(s)
- L Casey
- Mater Misericordiae University Hospital, Dublin, Ireland
| | - M Jinih
- Mater Private Hospital, Dublin, Ireland
| | - J MacHale
- Mater Misericordiae University Hospital, Dublin, Ireland
| | - F Kirby
- Blackrock Clinic, Dublin, Ireland
| | - JO O’ Neill
- Mater Misericordiae University Hospital, Dublin, Ireland
| | - R Byrne
- Mater Misericordiae University Hospital, Dublin, Ireland
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Enriquez-Sarano M. Valve Repair for Degenerative Mitral Regurgitation. JAMA 2023; 329:1922-1923. [PMID: 37314285 DOI: 10.1001/jama.2023.9668] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
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Tomšič A, Palmen M. Robotic mitral valve repair surgery: where do we go from here? Front Cardiovasc Med 2023; 10:1156495. [PMID: 37293277 PMCID: PMC10244781 DOI: 10.3389/fcvm.2023.1156495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 05/08/2023] [Indexed: 06/10/2023] Open
Abstract
Surgical mitral valve repair through median sternotomy has long presented the treatment of choice for degenerative mitral valve disease. In recent decades, minimal invasive surgical techniques have been developed and are now gaining widespread popularity. Robotic cardiac surgery presents an emerging field, initially adopted only by selected centres, mostly in the United States. In recent years, the number of centers interested in robotic mitral valve surgery has grown with an increasing adoption in Europe as well. Increasing interest and surgical experience gained are stimulating further developments in the field and the full potential of robotic mitral valve surgery remains to be developed.
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Tomšič A, Klautz RJM, Borger MA, Palmen M. Microinvasive mitral valve surgery: Current status and status quo. Front Cardiovasc Med 2023; 10:1094969. [PMID: 37180783 PMCID: PMC10169618 DOI: 10.3389/fcvm.2023.1094969] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Accepted: 04/11/2023] [Indexed: 05/16/2023] Open
Abstract
Surgical mitral valve repair, performed either through median sternotomy or minimal invasive approach, presents the gold standard treatment for degenerative mitral valve disease. In dedicated centres, high repair and low complication rates have been established with excellent valve repair durability. Recently, new techniques have been introduced, that allow mitral valve repair to be performed through small surgical incisions and while avoiding cardio-pulmonary bypass. These new techniques, however, conceptually differ significantly when compared to surgical repair and it remains questionable whether they are capable of reproducing the results of surgical treatment.
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Affiliation(s)
- Anton Tomšič
- Department of Cardiothoracic Surgery, Leiden University Medical Centre, Leiden, Netherlands
| | - Robert J. M. Klautz
- Department of Cardiothoracic Surgery, Leiden University Medical Centre, Leiden, Netherlands
| | - Michael A. Borger
- Leipzig Heart Center, University Clinic for Cardiac Surgery, Leipzig, Germany
| | - Meindert Palmen
- Department of Cardiothoracic Surgery, Leiden University Medical Centre, Leiden, Netherlands
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Sehgal S, Subramanyam P, Ahluwalia M, Rastogi A, Bergman G. Transcatheter mitral valve implantation: Implications of interventional technique and 3D echocardiography for complex valve-in-valve paravalvular leak. Ann Card Anaesth 2023; 26:227-231. [PMID: 37706394 PMCID: PMC10284472 DOI: 10.4103/aca.aca_166_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2021] [Revised: 06/07/2022] [Accepted: 07/09/2022] [Indexed: 09/15/2023] Open
Abstract
Transcatheter mitral valve replacement (TMVR) has emerged as a feasible alternative to surgical reoperation in failed bioprostheses and rings. Residual mitral regurgitation following TMVR can present as a valve-in-valve paravalvular leak (PVL) and is associated with increased morbidity and mortality. Current therapies for valve-in-valve PVL are limited. We present a case of a symptomatic patient with severe valve-in-valve PVL after TMVR for a previous surgical bioprosthesis leak, who then underwent a second TMVR as a valve-in-valve-in-valve implantation with a 29 mm Edwards® SAPIEN 3 valve via transseptal approach using three-dimensional (3D) echocardiography. This unique case highlights the complexity of this clinical entity and recognizes 3D transesophageal echocardiography as a valuable tool to guide valve-in-valve PVL closures.
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Affiliation(s)
- Sankalp Sehgal
- Department of Anesthesiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Division of Cardiothoracic Anesthesia, Critical Care and Pain Medicine, 330 Brookline Ave, Boston, MA, USA
| | - Pritha Subramanyam
- Weill Cornell Medical College, New York Presbyterian Hospital, Division of Cardiology, 525 E. 68th Street, New York, NY, USA
| | - Monica Ahluwalia
- Boston Medical Center, Boston University School of Medicine, Division of Cardiovascular Medicine, 72 E. Concord St, Boston, MA, USA
| | - Ashish Rastogi
- Owensboro Health Cardiology, 1301 Pleasant Valley Road, Owensboro, KY, USA
| | - Geoffrey Bergman
- Weill Cornell Medical College, New York Presbyterian Hospital, Division of Cardiology, 525 E. 68th Street, New York, NY, USA
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Boekstegers P, Hausleiter J, Schmitz T, Bufe A, Comberg T, Seyfarth M, Frerker C, Beucher H, Rottländer D, Higuchi S, Ouarrak T, Schneider S. Intraprocedural Residual Mitral Regurgitation and Survival After Transcatheter Edge-to-Edge Repair: Prospective German Multicenter Registry (MITRA-PRO). JACC Cardiovasc Interv 2023; 16:574-585. [PMID: 36922044 DOI: 10.1016/j.jcin.2022.12.015] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Revised: 12/06/2022] [Accepted: 12/13/2022] [Indexed: 03/18/2023]
Abstract
BACKGROUND Residual mitral regurgitation (MR) is thought to be an important predictor of long-term survival following transcatheter edge-to-edge repair (TEER). Intraprocedural MR assessment using transesophageal echocardiography could be limited by image quality, hemodynamics, and patient sedation. The MitraScore is a validated multimodal approach for intraprocedural MR assessment during TEER. OBJECTIVES This study aimed to assess the impact of residual MR using the MitraScore on 1-year mortality. METHODS Patients undergoing mitral TEER were eligible for inclusion in the prospective, multicenter MITRA-PRO registry (A Prospective Registry Study on 1-Year Mortality and the Prognostic Significance of MitraScore After MitraClip Implantation in Patients With Mitral Regurgitation). Patients with a MitraScore ≤3 were defined as patients with mild residual MR after mitral TEER, whereas a MitraScore ≥4 was considered as relevant residual MR. Mortality, rehospitalization, and major adverse events were assessed 1 year after TEER. RESULTS A MitraScore ≤3 was found in 1,059 patients (71.0%), whereas 432 patients revealed a MitraScore ≥4 (29.0%). One-year mortality was significantly lower in patients with nonrelevant residual MR (MitraScore ≤3 14.6% vs MitraScore≥4 22.1%). An almost linear relationship between intraprocedural MitraScore after TEER and mortality was observed. The combined clinical endpoint of mortality and rehospitalization within the 1-year follow-up was also significantly lower in the MitraScore ≤3 group (31.5%) than in the MitraScore ≥4 group (40.8%). A subgroup analysis confirmed the predictive value of the MitraScore in patients with primary, secondary, or mixed MR etiologies. CONCLUSIONS Residual MR assessed by intraprocedural MitraScore after TEER predicts 1-year mortality and rehospitalization. Therefore, the multimodal MitraScore improves MR assessment during mitral TEER and might improve patient survival.(A Prospective Registry Study on 1-Year Mortality and the Prognostic Significance of MitraScore After MitraClip Implantation in Patients With Mitral Regurgitation [MITRA-PRO]; DRKS00012288).
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Affiliation(s)
- Peter Boekstegers
- Department of Cardiology, Helios Klinikum Siegburg, Siegburg, Germany; Department of Cardiology, Faculty of Health, School of Medicine, Witten, Witten/Herdecke University.
| | - Jörg Hausleiter
- Department of Cardiology, Klinikum der Universität München, Ludwig-Maximilians-Universität, Munich, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
| | - Thomas Schmitz
- Department of Cardiology, Elisabeth Krankenhaus, Essen, Germany
| | - Alexander Bufe
- Department of Cardiology, Faculty of Health, School of Medicine, Witten, Witten/Herdecke University; Department of Cardiology, Heart Centre Niederrhein, Helios Clinic Krefeld, Krefeld, Germany
| | - Thomas Comberg
- Department of Cardiology and Angiology II, University Heart Center Freiburg, Bad Krozingen, Germany
| | - Melchior Seyfarth
- Department of Cardiology, Faculty of Health, School of Medicine, Witten, Witten/Herdecke University; Department of Cardiology, University Hospital Helios Wuppertal, Wuppertal, Germany
| | - Christian Frerker
- Department of Cardiology, University Heart Center Lübeck, Lübeck, Germany; DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck, Lübeck, Germany
| | - Harald Beucher
- Department of Cardiology, Helios Klinikum Siegburg, Siegburg, Germany
| | - Dennis Rottländer
- Department of Cardiology, Faculty of Health, School of Medicine, Witten, Witten/Herdecke University; Department of Cardiology, Krankenhaus Porz am Rhein, Cologne, Germany
| | - Satoshi Higuchi
- Department of Cardiology, Klinikum der Universität München, Ludwig-Maximilians-Universität, Munich, Germany; DZHK (German Center for Cardiovascular Research), Partner Site Munich Heart Alliance, Munich, Germany
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Mick SL, Gaudino M. Commentary: Repair of the tricuspid aortic valve: Simplicity is the ultimate sophistication. J Thorac Cardiovasc Surg 2023; 165:1008-1009. [PMID: 34020801 DOI: 10.1016/j.jtcvs.2021.04.071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 04/21/2021] [Accepted: 04/22/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Stephanie L Mick
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY.
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McCarthy PM, Whisenant B, Asgar AW, Ailawadi G, Hermiller J, Williams M, Morse A, Rinaldi M, Grayburn P, Thomas JD, Martin R, Asch FM, Shu Y, Sundareswaran K, Moat N, Kar S. Percutaneous MitraClip Device or Surgical Mitral Valve Repair in Patients With Primary Mitral Regurgitation Who Are Candidates for Surgery: Design and Rationale of the REPAIR MR Trial. J Am Heart Assoc 2023; 12:e027504. [PMID: 36752231 PMCID: PMC10111491 DOI: 10.1161/jaha.122.027504] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
Background The current standard of care for the treatment of patients with primary mitral regurgitation (MR) is surgical mitral valve repair. Transcatheter edge-to-edge repair with the MitraClip device provides a less invasive treatment option for patients with both primary and secondary MR. Worldwide, >150 000 patients have been treated with the MitraClip device. However, in the United States, MitraClip is approved for use only in primary patients with MR who are at high or prohibitive risk for mitral valve surgery. The REPAIR MR (Percutaneous MitraClip Device or Surgical Mitral Valve Repair in Patients With Primary Mitral Regurgitation Who Are Candidates for Surgery) trial is designed to compare early and late outcomes associated with transcatheter edge-to-edge repair with the MitraClip and surgical repair of primary MR in older or moderate surgical risk patients. Methods and Results The REPAIR MR trial is a prospective, randomized, parallel-controlled, open-label multicenter, noninferiority trial for the treatment of severe primary MR (verified by an independent echocardiographic core laboratory). Patients with severe MR and indications for surgery because of symptoms (New York Heart Association class II-IV), or without symptoms with left ventricular ejection fraction ≤60%, pulmonary artery systolic pressure >50 mm Hg, or left ventricular end-systolic diameter ≥40 mm are eligible for the trial provided they meet the moderate surgical risk criteria as follows: (1) ≥75 years of age, or (2) if <75 years of age, then the subject has a Society of Thoracic Surgeons Predicted Risk Of Mortality score of ≥2% for mitral repair (or Society of Thoracic Surgeons replacement score of ≥4%), or the presence of a comorbidity that may introduce a surgery-specific risk. The local surgeon must determine that the mitral valve can be surgically repaired. Additionally, an independent eligibility committee will confirm that the MR can be reduced to mild or less with both the MitraClip and surgical mitral valve repair with a high degree of certainty. A total of 500 eligible subjects will be randomized in a 1:1 ratio to receive the MitraClip device or to undergo surgical mitral valve repair (control group). There are 2 co-primary end points for the trial, both of which will be evaluated at 2 years. Each subject will be followed for 10 years after enrollment. The study has received approval from both the Food and Drug Administration and the Centers for Medicare and Medicaid Services, and enrolled its first subject in July 2020. Conclusions The REPAIR MR trial will determine the safety and effectiveness of transcatheter edge-to-edge repair with the MitraClip in patients with primary MR who are at moderate surgical risk and are candidates for surgical MV repair. The trial will generate contemporary comparative clinical evidence for the MitraClip device and surgical MV repair. Registration https://clinicaltrials.gov/ct2/show/NCT04198870; NCT04198870.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Saibal Kar
- Los Robles Medical Center Thousand Oaks CA
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Joseph MS, Bach DS. Transcatheter Edge-to-Edge Repair for Degenerative Mitral Regurgitation With Complex Mitral Valve Anatomy. J Am Coll Cardiol 2023; 81:443-445. [PMID: 36725172 DOI: 10.1016/j.jacc.2022.11.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 11/10/2022] [Indexed: 02/01/2023]
Affiliation(s)
- Megan S Joseph
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA.
| | - David S Bach
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, Michigan, USA
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Lin X, Chen L, Zhang D, Luo S, Sheng Y, Liu X, Liu Q, Li J, Shi B, Peng G, Zhong X, Huang Y, Li D, Qin G, Yin Z, Xu J, Meng C, Liu Y. Prediction of Surgical Approach in Mitral Valve Disease by XGBoost Algorithm Based on Echocardiographic Features. J Clin Med 2023; 12:jcm12031193. [PMID: 36769840 PMCID: PMC9917697 DOI: 10.3390/jcm12031193] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Revised: 01/22/2023] [Accepted: 01/30/2023] [Indexed: 02/05/2023] Open
Abstract
In this study, we aimed to develop a prediction model to assist surgeons in choosing an appropriate surgical approach for mitral valve disease patients. We retrospectively analyzed a total of 143 patients who underwent surgery for mitral valve disease. The XGBoost algorithm was used to establish a predictive model to decide a surgical approach (mitral valve repair or replacement) based on the echocardiographic features of the mitral valve apparatus, such as leaflets, the annulus, and sub-valvular structures. The results showed that the accuracy of the predictive model was 81.09% in predicting the appropriate surgical approach based on the patient's preoperative echocardiography. The result of the predictive model was superior to the traditional complexity score (81.09% vs. 75%). Additionally, the predictive model showed that the three main factors affecting the choice of surgical approach were leaflet restriction, calcification of the leaflet, and perforation or cleft of the leaflet. We developed a novel predictive model using the XGBoost algorithm based on echocardiographic features to assist surgeons in choosing an appropriate surgical approach for patients with mitral valve disease.
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Affiliation(s)
- Xiaoxuan Lin
- Department of Ultrasound, The Second Clinical Medical College, Jinan University (Shenzhen People’s Hospital), Shenzhen 518020, China
| | - Lixin Chen
- Department of Ultrasound, The Second Clinical Medical College, Jinan University (Shenzhen People’s Hospital), Shenzhen 518020, China
| | - Defu Zhang
- Department of Ultrasound, The Second Clinical Medical College, Jinan University (Shenzhen People’s Hospital), Shenzhen 518020, China
| | - Shuyu Luo
- Department of Ultrasound, The Second Clinical Medical College, Jinan University (Shenzhen People’s Hospital), Shenzhen 518020, China
| | - Yuanyuan Sheng
- Department of Ultrasound, The Second Clinical Medical College, Jinan University (Shenzhen People’s Hospital), Shenzhen 518020, China
| | - Xiaohua Liu
- Department of Ultrasound, The Second Clinical Medical College, Jinan University (Shenzhen People’s Hospital), Shenzhen 518020, China
| | - Qian Liu
- Department of Ultrasound, The Second Clinical Medical College, Jinan University (Shenzhen People’s Hospital), Shenzhen 518020, China
| | - Jian Li
- Department of Ultrasound, The Second Clinical Medical College, Jinan University (Shenzhen People’s Hospital), Shenzhen 518020, China
| | - Bobo Shi
- Department of Ultrasound, The Second Clinical Medical College, Jinan University (Shenzhen People’s Hospital), Shenzhen 518020, China
| | - Guijuan Peng
- Department of Ultrasound, The Second Clinical Medical College, Jinan University (Shenzhen People’s Hospital), Shenzhen 518020, China
| | - Xiaofang Zhong
- Department of Ultrasound, The Second Clinical Medical College, Jinan University (Shenzhen People’s Hospital), Shenzhen 518020, China
| | - Yuxiang Huang
- Department of Ultrasound, The Second Clinical Medical College, Jinan University (Shenzhen People’s Hospital), Shenzhen 518020, China
| | - Dagang Li
- Department of Cardiovascular Surgery, Shenzhen People’s Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen 518020, China
| | - Gengliang Qin
- Department of Cardiovascular Surgery, Shenzhen People’s Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen 518020, China
| | - Zhiqiang Yin
- Department of Cardiovascular Surgery, Shenzhen People’s Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen 518020, China
| | - Jinfeng Xu
- Department of Ultrasound, The Second Clinical Medical College, Jinan University (Shenzhen People’s Hospital), Shenzhen 518020, China
- Correspondence: (J.X.); (C.M.); (Y.L.)
| | - Chunying Meng
- Department of Cardiovascular Surgery, Shenzhen People’s Hospital (The Second Clinical Medical College, Jinan University; The First Affiliated Hospital, Southern University of Science and Technology), Shenzhen 518020, China
- Correspondence: (J.X.); (C.M.); (Y.L.)
| | - Yingying Liu
- Department of Ultrasound, The Second Clinical Medical College, Jinan University (Shenzhen People’s Hospital), Shenzhen 518020, China
- Correspondence: (J.X.); (C.M.); (Y.L.)
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Reparación valvular mitral por prolapso del velo posterior: resultados y seguimiento a 20 años. CIRUGIA CARDIOVASCULAR 2023. [DOI: 10.1016/j.circv.2022.10.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023] Open
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Sorajja P, Sato H, Bapat VN, Cavalcante JL, Bae R, Fukui M, Stanberry L, Enriquez-Sarano M. Contemporary Anatomic Criteria and Clinical Outcomes With Transcatheter Mitral Repair. Circ Cardiovasc Interv 2023; 16:e012486. [PMID: 36802803 DOI: 10.1161/circinterventions.122.012486] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
BACKGROUND Consensus-driven criteria have recently been proposed for prediction of mitral transcatheter edge-to-edge repair outcomes, yet validation for response to therapy is needed. We examined the relation between contemporary criteria and outcomes with mitral transcatheter edge-to-edge repair therapy. METHODS Mitral transcatheter edge-to-edge repair patients were classified according to anatomic and clinical criteria (1) Heart Valve Collaboratory criteria for nonsuitability; (2) commercial indications (suitable); and (3) neither (ie, intermediate). Analyses for Mitral Valve Academic Research Consortium-defined outcomes of reduction in mitral regurgitation and survival were performed. RESULTS Among 386 patients (median age, 82 years; 48% women), the most common classification was intermediate (46%), with 138 patients (36%) and 70 patients (18%) in the suitable and nonsuitable categories, respectively. Nonsuitable classification was related to prior valve surgery, smaller mitral valve area, type IIIa morphology, larger coaptation depth, and shorter posterior leaflet. Nonsuitable classification was associated with less technical success (P<0.001) and survival free of mortality, heart failure hospitalization, and mitral surgery (P<0.001). Among the nonsuitable patients, technical failure or any 30-day major adverse cardiac event occurred in 25.7%. Nevertheless, in these patients, acceptable mitral regurgitation reduction without adverse events still occurred in 69%, and their 1-year survival with mild or no symptoms was 52%. CONCLUSIONS Contemporary classification criteria identify patients less suitable for mitral transcatheter edge-to-edge repair with respect to acute procedural success and survival, though patients most commonly fit an intermediate category. In experienced centers, sufficient mitral regurgitation reduction can be achieved safely in the selected patients even with challenging anatomy.
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Affiliation(s)
- Paul Sorajja
- Valve Science Center, Minneapolis Heart Institute Foundation, MN (P.S., H.S., V.N.B., J.L.C., R.B., M.F., L.S., M.E.-S.)
| | - Hirotomo Sato
- Valve Science Center, Minneapolis Heart Institute Foundation, MN (P.S., H.S., V.N.B., J.L.C., R.B., M.F., L.S., M.E.-S.)
| | - Vinayak N Bapat
- Valve Science Center, Minneapolis Heart Institute Foundation, MN (P.S., H.S., V.N.B., J.L.C., R.B., M.F., L.S., M.E.-S.).,Minneapolis Heart Institute at Abbott Northwestern Hospital, MN (P.S., V.N.B., J.L.C., R.B.)
| | - João L Cavalcante
- Valve Science Center, Minneapolis Heart Institute Foundation, MN (P.S., H.S., V.N.B., J.L.C., R.B., M.F., L.S., M.E.-S.).,Minneapolis Heart Institute at Abbott Northwestern Hospital, MN (P.S., V.N.B., J.L.C., R.B.)
| | - Richard Bae
- Valve Science Center, Minneapolis Heart Institute Foundation, MN (P.S., H.S., V.N.B., J.L.C., R.B., M.F., L.S., M.E.-S.).,Minneapolis Heart Institute at Abbott Northwestern Hospital, MN (P.S., V.N.B., J.L.C., R.B.)
| | - Miho Fukui
- Valve Science Center, Minneapolis Heart Institute Foundation, MN (P.S., H.S., V.N.B., J.L.C., R.B., M.F., L.S., M.E.-S.)
| | - Larissa Stanberry
- Valve Science Center, Minneapolis Heart Institute Foundation, MN (P.S., H.S., V.N.B., J.L.C., R.B., M.F., L.S., M.E.-S.)
| | - Maurice Enriquez-Sarano
- Valve Science Center, Minneapolis Heart Institute Foundation, MN (P.S., H.S., V.N.B., J.L.C., R.B., M.F., L.S., M.E.-S.)
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Del Forno B, Carino D, Bisogno A, Rizzello A, Lapenna E, Ascione G, Gramegna F, Iaci G, Agricola E, Monaco F, Alfieri O, Castiglioni A, Maisano F, De Bonis M. Mitral Repair With Complete Rings or Posterior Bands in Barlow Disease: Long-term Results. Ann Thorac Surg 2023; 115:421-427. [PMID: 35780815 DOI: 10.1016/j.athoracsur.2022.06.015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 05/26/2022] [Accepted: 06/05/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND Complete rings or posterior bands are both commonly used during mitral valve repair, but which one ensures the best long-term outcome in patients with Barlow disease is a topic of debate. This study evaluated whether the type of annuloplasty device affects the long-term durability of the repair. METHODS We selected 296 consecutive patients with severe mitral regurgitation due to Barlow disease who underwent edge-to-edge mitral repair at our institution between 2004 and 2013. For the edge-to-edge repair, a complete semirigid ring was used in 151 patients, whereas a posterior flexible band was used in 145 patients. The clinical and echocardiographic outcomes of both groups were compared at long-term follow-up. RESULTS At 14 years, the overall survival was 87.3% ± 2.79% in the ring group and 94.1% ± 2.30% in the band group (P = .056). The incidence of mitral valve reintervention was 4.9% ± 1.95% in the ring group and 5.5% ± 2.53% in the band group (P = .371) at 14 years. The incidence of recurrence of mitral regurgitation ≥3+ and ≥2+ was 8.3% ± 2.64% in the ring group and 8.7% ± 3.07% in the band group (P = .991) and 26.5% ± 4.23% in the ring group and 17.4% ± 3.26% in the band group (P = .697), respectively. Mitral regurgitation ≥1+ at discharge was the only independent predictor of reoperation and recurrence of mitral regurgitation ≥3+ in the long-term. CONCLUSIONS In patients with Barlow disease undergoing edge-to-edge mitral valve repair, the type of annuloplasty device does not influence the long-term results. Achieving an optimal immediate result remains the key to maintain the stability of the repair at long-term.
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Affiliation(s)
- Benedetto Del Forno
- Department of Cardiac Surgery, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy.
| | - Davide Carino
- Department of Cardiac Surgery, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Arturo Bisogno
- Department of Cardiac Surgery, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Angelica Rizzello
- Department of Cardiac Surgery, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Elisabetta Lapenna
- Department of Cardiac Surgery, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Guido Ascione
- Department of Cardiac Surgery, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Federica Gramegna
- Department of Cardiac Surgery, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Giuseppe Iaci
- Department of Cardiac Surgery, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Eustachio Agricola
- Cardiovascular Imaging Unit, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Fabrizio Monaco
- Department of Anesthesiology, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Ottavio Alfieri
- Department of Cardiac Surgery, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Castiglioni
- Department of Cardiac Surgery, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Francesco Maisano
- Department of Cardiac Surgery, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
| | - Michele De Bonis
- Department of Cardiac Surgery, Istituto di Ricovero e Cura a Carattere Scientifico San Raffaele Hospital, Vita-Salute San Raffaele University, Milan, Italy
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Mantegazza V, Gripari P, Tamborini G, Muratori M, Fusini L, Ghulam Ali S, Garlaschè A, Pepi M. 3D echocardiography in mitral valve prolapse. Front Cardiovasc Med 2023; 9:1050476. [PMID: 36704460 PMCID: PMC9871497 DOI: 10.3389/fcvm.2022.1050476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 12/20/2022] [Indexed: 01/11/2023] Open
Abstract
Mitral valve prolapse (MVP) is the leading cause of mitral valve surgery. Echocardiography is the principal imaging modality used to diagnose MVP, assess the mitral valve morphology and mitral annulus dynamics, and quantify mitral regurgitation. Three-dimensional (3D) echocardiographic (3DE) imaging represents a consistent innovation in cardiovascular ultrasound in the last decades, and it has been implemented in routine clinical practice for the evaluation of mitral valve diseases. The focus of this review is the role and the advantages of 3DE in the comprehensive evaluation of MVP, intraoperative and intraprocedural monitoring.
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Affiliation(s)
- Valentina Mantegazza
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, Milan, Italy,Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy,*Correspondence: Valentina Mantegazza ✉
| | - Paola Gripari
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Gloria Tamborini
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Manuela Muratori
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Laura Fusini
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, Milan, Italy,Department of Electronics, Information and Bioengineering, Politecnico di Milano, Milan, Italy
| | - Sarah Ghulam Ali
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Anna Garlaschè
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, Milan, Italy
| | - Mauro Pepi
- Department of Cardiovascular Imaging, Centro Cardiologico Monzino IRCCS, Milan, Italy
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45
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Carino D, Lorusso R, Del Forno B, Lapenna E, Ascione G, Sala A, Ruggeri S, Schavi D, Bargagna M, Maisano F, Castiglioni A, Alfieri O, De Bonis M. Edge-to-Edge Technique Used as a Bailout for Suboptimal Mitral Repair: Long-term Results. Ann Thorac Surg 2023; 115:112-118. [PMID: 35987343 DOI: 10.1016/j.athoracsur.2022.08.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 06/02/2022] [Accepted: 08/01/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND For cases of initial suboptimal mitral valve repair, the edge-to-edge (EE) technique has been used as a bailout procedure. However the long-term durability of those rescued mitral valves is currently unknown. With this study we aim to evaluate the long-term clinical and echocardiographic results of the EE technique used to rescue patients with initial suboptimal conventional mitral valve repair. METHODS A retrospective review of our institutional database was done to query for patients who had undergone mitral valve repair with the EE technique used as a bailout procedure. The cumulative incidence function using death as a competing event was used to estimate cardiac death and redo for mitral valve replacement. To describe the time course of mitral regurgitation, we performed a longitudinal analysis using generalized estimating equations with random intercept for correlated data. RESULTS Eighty-one patients were selected. The median follow-up was 9.1 years (interquartile range, 6.7-12.1; maximum, 22.6 years). At 15 years the estimated Kaplan-Meier overall survival was 63.2% ± 8.69% (95% confidence interval, 43.76-77.46) and the predicted rate of moderate to severe mitral regurgitation recurrence was 16.67%. At 15 years the cumulative incidence function for redo for mitral valve replacement with death as a competing event was 2.5% (95% confidence interval, 0.48-7.84). No case of more than mild mitral stenosis was detected. CONCLUSIONS The EE technique can be effectively used as a bailout procedure in patients with suboptimal conventional mitral valve repair with satisfactory long-term results.
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Affiliation(s)
- Davide Carino
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific institute, Vita-Salute San Raffaele University, Milan, Italy.
| | - Roberto Lorusso
- Department of Cardio-Thoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre, Maastricht, The Netherlands; Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Benedetto Del Forno
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Elisabetta Lapenna
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Guido Ascione
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandra Sala
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Stefania Ruggeri
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Davide Schavi
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Marta Bargagna
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Francesco Maisano
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Alessandro Castiglioni
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Ottavio Alfieri
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific institute, Vita-Salute San Raffaele University, Milan, Italy
| | - Michele De Bonis
- Department of Cardiac Surgery, IRCCS San Raffaele Scientific institute, Vita-Salute San Raffaele University, Milan, Italy
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Xie H, Wang L, Tang Y, Zhao M, Wang Z, Liu M, Zhao Q, Zhou J, Wu Y. Functional analysis of differently expressed ferroptosis-related genes in patients with mitral valve prolapse. Front Genet 2022; 13:1062212. [DOI: 10.3389/fgene.2022.1062212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Accepted: 11/18/2022] [Indexed: 11/30/2022] Open
Abstract
Background: The prevalence of mitral valve prolapse (MVP) in heart valvular diseases is globally increasing. However, the understanding of its etiology and pathogenesis is limited. So far, the relationship between ferroptosis-related genes and long non-coding RNAs (lncRNAs) in MVP remains unexplored. This study investigates the potential pathogenesis of ferroptosis-related genes in MVP and provides a therapeutic target for the disease.Methods: Blood samples from patients with MVP and healthy volunteers were collected for transcriptomic sequencing to analyze the expression of ferroptosis-related differentially expressed genes (DEGs) and differentially expressed long non-coding RNAs (DElncRNAs Co-expression network of ferroptosis-related DEGs and DElncRNAs. Furthermore, this work conducted GO and KEGG enrichment analyses.Results:CDKN2A, SLC1A4, ATF3, and other core genes related to the mitral valve prolapse were screened out. CDKN2A, SLC1A4, and ATF3 genes were at the core position of the network, regulated by numerous lncRNAs. Notably, these genes are primarily involved in the extracellular region and p53 signaling pathway.Conclusion: In summary, CDKN2A, SLC1A4, and ATF3 regulate the pathophysiological process of MVP and are potential therapeutic targets.
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47
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Kitahara H, Balkhy HH. Minimally invasive mitral valve surgery with or without robotics: Examining the evidence. J Card Surg 2022; 37:3276-3278. [PMID: 35989500 PMCID: PMC9543420 DOI: 10.1111/jocs.16854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 08/03/2022] [Indexed: 11/26/2022]
Abstract
Minimally invasive mitral valve surgery can be performed with or without robotic assistance. In this issue of the journal, Zheng et al. compare between these two approaches in a propensity‐matched study over a 5‐year period and show that the two techniques have similar successful short and mid‐term outcomes. Although we are proponents of the robotic approach, we agree with their conclusions and discuss in this commentary some of the previously published studies that have shown similar findings.
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Affiliation(s)
- Hiroto Kitahara
- Department of Surgery, Section of Cardiac Surgery, University of Chicago Medicine, Chicago, Illinois, USA
| | - Husam H Balkhy
- Department of Surgery, Section of Cardiac Surgery, University of Chicago Medicine, Chicago, Illinois, USA
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48
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Yoon SH, Makar M, Kar S, Chakravarty T, Oakley L, Sekhon N, Koseki K, Nakamura M, Hamilton M, Patel JK, Singh S, Skaf S, Siegel RJ, Bax JJ, Makkar RR. Outcomes After Transcatheter Edge-to-Edge Mitral Valve Repair According to Mitral Regurgitation Etiology and Cardiac Remodeling. JACC Cardiovasc Interv 2022; 15:1711-1722. [PMID: 36075642 DOI: 10.1016/j.jcin.2022.07.004] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 06/29/2022] [Accepted: 07/05/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND Transcatheter edge-to-edge repair (TEER) has been increasingly used for selected patients with mitral regurgitation (MR), but limited data are available regarding clinical outcomes in patients with varied etiology and mechanism of MR. OBJECTIVES The aim of this study was to evaluate the outcomes of TEER according to etiology and left ventricular (LV) and left atrial remodeling. METHODS Consecutive patients who underwent TEER between 2007 and 2020 were included in the analysis. Among patients with functional MR (FMR), those with predominant LV remodeling were classified as having ventricular FMR (v-FMR), whereas those without LV remodeling but predominant left atrial remodeling were classified as having atrial FMR (a-FMR). The primary outcome was a composite of all-cause mortality and heart failure hospitalization at 2 years and was compared among patients with degenerative MR (DMR), a-FMR, and v-FMR. RESULTS A total of 1,044 patients (11% with a-FMR, 48% with v-FMR, and 41% with DMR) with a mean Society of Thoracic Surgeons score of 8.6 ± 7.8 underwent TEER. Patients with a-FMR had higher rates of atrial fibrillation and severe tricuspid regurgitation with larger left and right atria, whereas patients with v-FMR had lower LV ejection fractions with larger LV dimensions. Residual MR more than moderate at discharge was not significantly different among the 3 groups (5.2% vs 3.2% vs 2.6%; P = 0.37). Compared with patients with DMR, 2-year event rates of the primary outcome were significantly higher in patients with a-FMR and v-FMR (21.6% vs 31.5% vs 42.3%; log-rank P < 0.001). CONCLUSIONS Despite excellent procedural outcomes, patients with a-FMR and v-FMR had worse clinical outcomes compared with those with DMR.
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Affiliation(s)
- Sung-Han Yoon
- Cedars-Sinai Medical Center, Smidt Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Moody Makar
- Cedars-Sinai Medical Center, Smidt Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Saibal Kar
- Cedars-Sinai Medical Center, Smidt Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Tarun Chakravarty
- Cedars-Sinai Medical Center, Smidt Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Luke Oakley
- Cedars-Sinai Medical Center, Smidt Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Navjot Sekhon
- Cedars-Sinai Medical Center, Smidt Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Keita Koseki
- Cedars-Sinai Medical Center, Smidt Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Mamoo Nakamura
- Cedars-Sinai Medical Center, Smidt Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Michele Hamilton
- Cedars-Sinai Medical Center, Smidt Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Jignesh K Patel
- Cedars-Sinai Medical Center, Smidt Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Siddharth Singh
- Cedars-Sinai Medical Center, Smidt Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Sabah Skaf
- Cedars-Sinai Medical Center, Smidt Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Robert J Siegel
- Cedars-Sinai Medical Center, Smidt Cedars-Sinai Heart Institute, Los Angeles, California, USA
| | - Jeroen J Bax
- Leiden University Medical Center, Leiden, the Netherlands
| | - Raj R Makkar
- Cedars-Sinai Medical Center, Smidt Cedars-Sinai Heart Institute, Los Angeles, California, USA.
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Mitral Annuloplasty Ring Design and Selection: Flexible Bands Are (Mostly) All You Need. J Thorac Cardiovasc Surg 2022:S0022-5223(22)00820-0. [DOI: 10.1016/j.jtcvs.2022.06.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2022] [Revised: 06/06/2022] [Accepted: 06/17/2022] [Indexed: 11/18/2022]
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50
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Campos-Arjona R, Rodríguez-Capitán J, Martínez-Carmona JD, Lavreshin A, Fernández-Romero L, Melero-Tejedor JM, Jiménez-Navarro M. Prognosis for Mitral Valve Repair Surgery in Functional Mitral Regurgitation. Ann Thorac Cardiovasc Surg 2022; 28:342-348. [PMID: 35851568 PMCID: PMC9585337 DOI: 10.5761/atcs.oa.22-00051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Purpose: Our aim was to evaluate the development of new significant mitral regurgitation and long-term survival after mitral repair surgery in functional mitral regurgitation. Methods: A retrospective observational analysis of the recurrence of functional mitral regurgitation (ischemic and nonischemic) and global mortality during follow-up of 176 patients who underwent mitral repair surgery between 1999 and 2018 in our center was conducted. Results: The etiology of functional mitral regurgitation was ischemic in 55.7% of cases. After surgery, mitral regurgitation was 0-I in 92.3% of cases. We conducted a long-term clinical follow-up of a mean 42.2 months and an echocardiographic follow-up of a mean 41.8 months. We observed mitral regurgitation of at least grade II in 52 patients (36.9%). Survival at 1, 3, and 5 years was 78.8%, 66.7%, and 52.3%, respectively. Predictive factors for global mortality were age (hazard ratio = 1.038, p = 0.01) and a depressed preoperative ejection fraction. After a competing risk analysis, we found the only predictive factor for the recurrence of mitral regurgitation in our series to be age (sub-hazard ratio = 1.03, 95% confidence interval = 1.01–1.06, p = 0.016). Conclusion: Repair surgery for functional mitral regurgitation shows age as the only independent predictor of recurrence. Age and depressed ejection fraction were predictors of mortality.
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Affiliation(s)
- Rafael Campos-Arjona
- Department of Heart and Cardiovascular Pathology, Virgen de la Victoria University Hospital, Malaga, Spain.,Department of Medicine and Dermatology, University of Malaga, Malaga, Spain.,Malaga Biomedical Research Institute (IBIMA), Malaga, Spain.,CIBERCV Cardiovascular Diseases. Carlos III Health Institute, Madrid, Spain
| | - Jorge Rodríguez-Capitán
- Department of Heart and Cardiovascular Pathology, Virgen de la Victoria University Hospital, Malaga, Spain.,Department of Medicine and Dermatology, University of Malaga, Malaga, Spain.,Malaga Biomedical Research Institute (IBIMA), Malaga, Spain.,CIBERCV Cardiovascular Diseases. Carlos III Health Institute, Madrid, Spain
| | - José D Martínez-Carmona
- Department of Heart and Cardiovascular Pathology, Virgen de la Victoria University Hospital, Malaga, Spain.,Department of Medicine and Dermatology, University of Malaga, Malaga, Spain.,Malaga Biomedical Research Institute (IBIMA), Malaga, Spain.,CIBERCV Cardiovascular Diseases. Carlos III Health Institute, Madrid, Spain
| | - Alexey Lavreshin
- Department of Heart and Cardiovascular Pathology, Virgen de la Victoria University Hospital, Malaga, Spain.,Department of Medicine and Dermatology, University of Malaga, Malaga, Spain.,Malaga Biomedical Research Institute (IBIMA), Malaga, Spain.,CIBERCV Cardiovascular Diseases. Carlos III Health Institute, Madrid, Spain
| | - Loudes Fernández-Romero
- Department of Heart and Cardiovascular Pathology, Virgen de la Victoria University Hospital, Malaga, Spain.,Department of Medicine and Dermatology, University of Malaga, Malaga, Spain.,Malaga Biomedical Research Institute (IBIMA), Malaga, Spain.,CIBERCV Cardiovascular Diseases. Carlos III Health Institute, Madrid, Spain
| | - José M Melero-Tejedor
- Department of Heart and Cardiovascular Pathology, Virgen de la Victoria University Hospital, Malaga, Spain.,Department of Medicine and Dermatology, University of Malaga, Malaga, Spain.,Malaga Biomedical Research Institute (IBIMA), Malaga, Spain.,CIBERCV Cardiovascular Diseases. Carlos III Health Institute, Madrid, Spain
| | - Manuel Jiménez-Navarro
- Department of Heart and Cardiovascular Pathology, Virgen de la Victoria University Hospital, Malaga, Spain.,Department of Medicine and Dermatology, University of Malaga, Malaga, Spain.,Malaga Biomedical Research Institute (IBIMA), Malaga, Spain.,CIBERCV Cardiovascular Diseases. Carlos III Health Institute, Madrid, Spain
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