POINT: Efficacy of adding mitral valve restrictive annuloplasty to coronary artery bypass grafting in patients with moderate ischemic mitral valve regurgitation: a randomized trial

Best treatment option for secondary mitral regurgitation surgery: a network meta-analysis of randomized and non-randomized controlled studies

The objective of this study is to ascertain whether subvalvular papillary muscle repair in conjunction with restrictive mitral valve annuloplasty represents the most efficacious treatment for patients presenting with secondary ischemic mitral regurgitation, as compared to restrictive mitral valve annuloplasty alone and to mitral valve replacement. A network meta-analysis was conducted to investigate outcomes of randomized controlled trials, propensity-matched studies, and observational studies, comparing various treatments for secondary ischemic mitral regurgitation. The average follow-up duration for late mortality was 4.4 years. Coronary artery bypass grafting (CABG) without mitral valve surgery had a late mortality incidence of 3.7%. Restrictive mitral annuloplasty demonstrated a rate of 6.5%, while restrictive mitral annuloplasty + CABG resulted in a rate of 4.1%. Subvalvular papillary muscle repair plus restrictive mitral annuloplasty ± CABG and mitral valve replacement + CABG had rates of 4.4% and 5.1%. SUCRA analysis showed that CABG was the most effective treatment for reducing late mortality (70.0%). This was followed by subvalvular papillary muscle repair plus restrictive mitral annuloplasty with or without CABG (62.4%). The top strategy for decreasing early death, reoperation, and readmission to the hospital for heart failure is subvalvular papillary muscle repair plus restrictive mitral annuloplasty with or without CABG, based on SUCRA probabilities (84.6%, 85.54%, and 86.3%, respectively). Subvalvular papillary muscle repair plus restrictive mitral annuloplasty ± CABG has potential to reduce the risks associated with early mortality, reoperation, and re-hospitalization for heart failure. However, further research is required to substantiate these findings.

Secondary Mitral Regurgitation and Transcatheter Mitral Valve Therapies: Do They Have a Role in Advanced Heart Failure with Reduced Ejection Fraction?

Transcatheter mitral valve repair should be considered for patients with severe secondary mitral regurgitation with symptomatic heart failure with reduced ejection fraction for symptom improvement and survival benefit. Patients with a higher severity of secondary mitral regurgitation relative to the degree of left ventricular dilation are more likely to benefit from transcatheter mitral valve repair. A multidisciplinary Heart Team should participate in patient selection for transcatheter mitral valve therapy.

Management of secondary mitral regurgitation: from drugs to devices

Severe secondary mitral regurgitation carries a poor prognosis with one in five patients dying within 12 months of diagnosis. Fortunately, there are now a number of safe and effective therapies available to improve outcomes. Here, we summarise the most up-to-date treatments. Optimal guideline-directed medical therapy is the mainstay therapy and has been shown to reduce the severity of mitral regurgitation in 40-45% of patients. Rapid medication titration protocols reduce heart failure hospitalisation and facilitate earlier referral for device therapy. The pursuit of sinus rhythm in patients with atrial fibrillation has been shown to significantly reduce mitral regurgitation severity, as has the use of cardiac resynchronisation devices in patients who meet guideline-directed criteria. Finally, we highlight the key role of mitral valve intervention, particularly transcatheter edge-to-edge repair (TEER) for management of moderate-severe mitral regurgitation in carefully selected patients with poor left ventricular systolic function, with a number needed to treat of 3.1 to reduce heart failure hospitalisation and 5.9 to reduce all-cause death. To slow the rapid accumulation of morbidity and mortality, we advocate a proactive approach with accelerated medical optimisation, followed by management of atrial fibrillation and cardiac resynchronisation therapy if indicated, then, rapid referral to the Heart Team for consideration of mitral valve intervention in patients with ongoing symptoms and at least moderate-severe mitral regurgitation. Mitral TEER has been shown to be 'reasonably cost-effective' (but not cost-saving) in the UK in selected patients, although TEER remains underused with only 6.5 procedures per million population (pmp) compared with Germany (77 pmp), Switzerland (44 pmp) and the USA (32 pmp).

Moderate ischemic mitral regurgitation in ischemic heart disease: to operate or not? A meta-analysis

INTRODUCTION

Deciding whether to perform coronary artery bypass grafting (CABG) alone or in combination with mitral valve repair is a common dilemma encountered by surgeons when treating patients with ischemic mitral regurgitation, a common condition related to coronary artery disease. Although ischemic mitral regurgitation after CABG has been linked to unfavorable results, the benefits of including mitral valve repair are still unknown. This discrepancy led us to undertake a systematic review and meta-analysis to determine whether combining CABG with mitral valve surgery leads to better clinical results than CABG alone.

EVIDENCE ACQUISITION

Studies comparing the results of CABG versus CABG with mitral valve replacement were searched in the databases of PubMed and Google Scholar. There were six randomized clinical trials included in this study.

EVIDENCE SYNTHESIS

We analyzed 852 patients' data. There were no significant variations between patients who acquired CABG alone or CABG+(MVR) in terms of their risk of death at one year, stroke, atrial fibrillation, or hospitalization for heart failure. For recurrent/residual mitral regurgitation; it revealed an RR=5.42, 95% CI, 0.77 to 37.98, and a P value of =0.065. According to the analysis of study heterogeneity, no apparent heterogeneity was identified in the outcomes of death after one year, stroke, atrial fibrillation, or hospitalization for heart failure. However, the outcome of recurrent or residual mitral regurgitation showed significant variation (I2=66%).

CONCLUSIONS

Patients who underwent CABG alone versus CABG plus MVR did not differ significantly from one another. However, the comparison of CABG alone with CABG plus MVR underlines the need for customized treatment plans based on the unique characteristics of each patient.

Efficacy of mitral valve repair in combination with coronary revascularization for moderate ischaemic mitral regurgitation: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

The efficacy of mitral valve repair (MVR) in combination with coronary artery bypass grafting (CABG) for moderate ischaemic mitral regurgitation (IMR) remains unclear. To evaluate whether MVR + CABG is superior to CABG alone, the authors conducted a systematic review and meta-analysis of existing randomized controlled trials (RCTs).

METHODS

The authors searched PubMed, Web of Science, and the Cochrane Central Register of Controlled Trials for eligible RCTs from the date of their inception to October 2023. The primary outcomes were operative (in-hospital or within 30 days) and long-term (≥ 1 year) mortality. The secondary outcomes were postoperative stroke, worsening renal function (WRF), and reoperation for bleeding or tamponade. The authors performed random-effects meta-analyses and reported the results as risk ratios (RRs) with 95% CIs.

RESULTS

Six RCTs were eligible for inclusion. Compared with CABG alone, MVR + CABG did not increase the risk of operative mortality (RR, 1.244; 95% CI, 0.514-3.014); however, it was also not associated with a lower risk of long-term mortality (RR, 0.676; 95% CI, 0.417-1.097). Meanwhile, there was no difference between the two groups in terms of postoperative stroke (RR, 2.425; 95% CI, 0.743-7.915), WRF (RR, 1.257; 95% CI, 0.533-2.964), and reoperation for bleeding or tamponade (RR, 1.667; 95% CI, 0.527-5.270).

CONCLUSIONS

The findings of this meta-analysis suggest that MVR + CABG fails to improve the clinical outcomes of patients with moderate IMR compared to CABG alone.

The high-risk features among patients undergoing mitral valve operation for ischemic mitral regurgitation: The 3-strike score

Objective

Ischemic mitral regurgitation is prevalent and associated with high surgical risk. With the less-invasive option of transcatheter edge-to-edge repair, the optimal patient selection for mitral valve operation for ischemic mitral regurgitation remains unclear. We sought to identify high-risk features in this group to guide patient selection.

Methods

Using the Cardiothoracic Surgery Trial Network's severe ischemic mitral regurgitation trial data, we identified patient and echocardiographic characteristics associated with an increased risk of 2-year mortality using the support vector classifier and Cox proportional hazards model. We identified 6 high-risk features associated with 2-year survival. Patients were categorized into 3 groups, each having 1 or less, 2, or 3 or more of the 6 identified high-risk features.

Results

Among the 251 patients, the median age was 69 (Q1 62, Q3 75) years, and 96 (38%) were female. Two-year mortality was 21% (n = 53). We identified 6 high-risk preoperative features: age 75 years or more (n = 69, 28%), prior sternotomy (n = 49, 20%), renal insufficiency (n = 69, 28%), gastrointestinal bleeding (n = 15, 6%), left ventricular ejection fraction less than 40% (n = 131, 52%), and ventricular end-systolic volume index less than 50 mL/m2 (n = 93, 37%). In patients who had 1 or less, 2, and 3 or more high-risk features, 90-day mortality was 4.2% (n = 5), 9.9% (n = 4), and 20.0% (n = 10), respectively (P = .006), and 2-year mortality was 10% (n = 12), 22% (n = 18), and 46% (n = 23) (P < .001), respectively.

Conclusions

We developed the 3-strike score by identifying high-risk preoperative features for mitral valve surgery for ischemic mitral regurgitation. Patients having 3 or more of such high-risk features should undergo careful evaluation for surgical candidacy given the high early and late mortality after mitral valve operations.

Should moderate ischemic mitral regurgitation be corrected during coronary artery bypass grafting? a systematic review and meta-analysis

OBJECTIVE

Ischemic mitral regurgitation (IMR) is associated with increased risks of mortality and heart failure. However, the optimal management of moderate IMR remains controversial. We conducted a meta-analysis to appraise whether moderate IMR should be corrected during coronary artery bypass grafting (CABG).

METHODS

We searched PubMed, Embase, and Cochrane databases from its inception up to 15 October 2022 for studies that assessed CABG alone versus CABG with mitral valve (MV) surgery in patients with moderate IMR. The primary outcome was perioperative mortality.

RESULTS

Four randomized controlled trials and three observational studies with propensity-matched data including 1209 patients assessing CABG alone (n = 598) versus CABG with MV surgery (n = 611) were included. Compared to CABG alone, the addition of MV surgery did not significantly increase perioperative mortality (RR, 1.01; 95% CI, 0.52-1.96; p = 0.98) and stroke (RR, 2.14; 95% CI, 0.97-4.72; p = 0.06), whereas a longer cardiopulmonary bypass duration (MD, 54.91; 95% CI, 42.13-67.68; p < 0.01) and an increased incidence of renal failure were observed in the combined-procedure group. At follow-up, the addition of MV surgery was significantly associated with reduced rates of residual MR (RR, 0.26; 95% CI, 0.13-0.51; p < 0.01) and NYHA class III-IV (RR, 0.54; 95% CI, 0.37-0.78; p < 0.01). However, there was no difference in either mid-term mortality (RR, 1.05; 95% CI, 0.65-1.70; p = 0.82) or late mortality (RR, 91; 95% CI, 0.49-1.71; p = 0.78) between the CABG alone group and the combined-procedure group.

CONCLUSIONS

In patients with moderate IMR, the addition of MV surgery to CABG did not increase perioperative mortality. Despite the reduced rates of moderate MR and NYHA class III-IV at follow-up, the addition of MV surgery did not translate in a reduction in mid-term or late mortality.

Restrictive annuloplasty on remodeling and survival in patients with end-stage ischemic cardiomyopathy

OBJECTIVES

To elucidate the influence of concomitant restrictive mitral annuloplasty (RMA) on postoperative left ventricular (LV) reverse remodeling and survival in patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting (CABG).

METHODS

This study comprised 157 patients with ischemic cardiomyopathy (LV ejection fraction ≤40%) who underwent CABG and completed echocardiographic examination at 1 year after surgery, with 84 (54%) undergoing concomitant RMA for clinically relevant ischemic mitral regurgitation. The primary end point was postoperative reduction in LV end-systolic volume index (LVESVI). The secondary end point was overall survival. Median follow-up was 5.1 years.

RESULTS

At baseline, patients who underwent CABG with RMA had a larger LVESVI (83 ± 23 vs 75 ± 24 mm; P = .046). One-year postoperatively, CABG with RMA reduced the LVESVI more than did CABG alone (37% vs 21% from baseline; P < .001), yielding nearly identical postoperative LVESVI (53 ± 27 vs 61 ± 26 mm; P = .065). In multivariable logistic regression analysis, concomitant RMA was associated with significant LV reverse remodeling (odds ratio, 2.79; 95% CI, 1.34-5.78; P = .006). The prevalence in moderate or severe mitral regurgitation was not different between the groups (7% vs 10%; P = .58). Survival rates were similar between the groups (5 years, 78% vs 83%; P = .35).

CONCLUSIONS

In patients with ischemic cardiomyopathy undergoing CABG, concomitant RMA was associated with significant reduction in LVESVI. The influence of LV reverse remodeling on survival remains undetermined.

Mitral Valve Intervention in Elderly or High-Risk Patients: A Review of Current Surgical and Interventional Management

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.

Does Sustained Reduction of Functional Mitral Regurgitation Impact Survival?

Functional mitral regurgitation (FMR) is associated with increased mortality and has been considered a marker for advanced heart disease, yet the value of mitral valve repair (MVr) in this population remains unclear. This study aims to evaluate the impact of reducing FMR burden through surgical MVr on survival. Patients with severe FMR who underwent MVr with an undersized, complete, rigid, annuloplasty between 2004 and 2017 were assessed (n = 201). Patients were categorized based on grade of recurrent FMR (0-4). Time-to-event Kaplan-Meier estimations of freedom from death or reoperation were performed using the log-rank test. Cox proportional hazards models evaluated all-cause mortality and reported in hazards ratios (HR) and 95% confidence intervals (CI). Patients were categorized by postoperative recurrent FMR: 45% (91/201) of patients had grade 0, 29% (58/201) grade 1, 20% (40/201) grade 2, 2% (4/201) grade 3%, and 4% (8/201) grade 4. The cumulative incidence of reoperation with death as a competing risk was higher in patients with grades ≥3 recurrent FMR compared to grades ≤2 (44.6% vs 14.6%, subhazard ratio 3.69 [95% CI, 1.17-11.6]; P = 0.026). Overall freedom from death or reoperation was superior for recurrent FMR grades ≤2 compared to grades ≥3 (log-rank P < 0.001). Increasing recurrent FMR grade was independently associated with mortality (HR 1.30 [95% CI, 1.07-1.59] P = 0.009). Reduced postoperative FMR grade resulted in an incrementally lower risk of death or reoperation after MVr. These results suggest that achieving a durable reduction in FMR burden improves long-term survival.

Secondary Mitral Regurgitation and Transcatheter Mitral Valve Therapies: Do They Have a Role in Advanced Heart Failure with Reduced Ejection Fraction?

Transcatheter mitral valve repair should be considered for patients with severe secondary mitral regurgitation with symptomatic heart failure with reduced ejection fraction for symptom improvement and survival benefit. Patients with a higher severity of secondary mitral regurgitation relative to the degree of left ventricular dilation are more likely to benefit from transcatheter mitral valve repair. A multidisciplinary Heart Team should participate in patient selection for transcatheter mitral valve therapy.

Effect of concurrent mitral valve surgery for secondary mitral regurgitation upon mortality after aortic valve replacement or coronary artery bypass surgery

Objectives

It is uncertain whether concurrent mitral valve repair or replacement for moderate or greater secondary mitral regurgitation at the time of coronary artery bypass graft or aortic valve replacement surgery improves long-term survival.

Methods

Patients undergoing coronary artery bypass graft and/or aortic valve replacement surgery with moderate or greater secondary mitral regurgitation were reviewed. The effect of concurrent mitral valve repair or replacement upon long-term mortality was assessed while accounting for patient and operative characteristics and mitral regurgitation severity.

Results

Of 1,515 patients, 938 underwent coronary artery bypass graft or aortic valve replacement surgery alone and 577 underwent concurrent mitral valve repair or replacement. Concurrent mitral valve repair or replacement did not alter the risk of postoperative mortality for patients with moderate mitral regurgitation (hazard ratio = 0.93; 0.75-1.17) or more-than-moderate mitral regurgitation (hazard ratio = 1.09; 0.74-1.60) in multivariable regression. Patients with more-than-moderate mitral regurgitation undergoing coronary artery bypass graft-only surgery had a survival advantage from concurrent mitral valve repair or replacement in the first two postoperative years (P = 0.028) that did not persist beyond that time. Patients who underwent concurrent mitral valve repair or replacement had a higher rate of later mitral valve operation or reoperation over the five subsequent years (1.9% vs. 0.2%; P = 0.0014) than those who did not.

Conclusions

These observations suggest that mitral valve repair or replacement for more-than-moderate mitral regurgitation at the time of coronary artery bypass grafting may be reasonable in a suitably selected coronary artery bypass graft population but not for aortic valve replacement, with or without coronary artery bypass grafting. Our findings are supportive of 2021 European guidelines that severe secondary mitral regurgitation "should" or be "reasonabl[y]" intervened upon at the time of coronary artery bypass grafting but do not support 2020 American guidelines for performing mitral valve repair or replacement concurrent with aortic valve replacement, with or without coronary artery bypass grafting.

Outcome of Surgery for Ischemic Mitral Regurgitation Depends on the Type and Timing of the Coronary Revascularization

OBJECTIVE

Long-term outcomes of mitral valve (MV) repair versus MV replacement for ischemic mitral regurgitation (IMR) in patients undergoing either prior (PCR) or concomitant coronary revascularization (CCR) by surgery (CABG) or intervention (PCI) are uncertain.

METHODS AND RESULTS

Of 446 patients receiving MV surgery for IMR between July 2006 and December 2010, 125 patients-87 CCR (69.1%) and 38 PCR (30.9%)-were eligible for inclusion in the study. Survival was higher in CCR versus PCR at long-term follow-up (78.83% vs. 57.9%, p = 0.016). The incidence of MACCE was lower in the CCR compared to PCR at both hospital discharge (34.11% vs. 63.57%, p = 0.003) and at follow-up (34.11% vs. 65.79%, p = 0.0008). Patients receiving CABG or CABG with PCI in PCR had higher mortality risks after MV surgery than CCR patients (X2 = 6.029, p = 0.014 and X2 = 6.466, p = 0.011, respectively). Whereas in the PCR group, MV repair and MV replacement achieved similar survival probability (X2 = 1.551, p = 0.213), MV repair in the CCR group led to improved survival compared to MV replacement (X2 = 3.921, p = 0.048). In MV replacement, LAD-CABG improved survival compared to LAD-PCI (U = 15,000.00, Z = -2.373 p = 0.018), and a substantial impact of arterial IMA-LAD grafting was revealed in the Cox-regression analysis (HR 0.334, CI: 0.113-0.989, p = 0.048) as opposed to venous-LAD grafting (HR 0.588, CI: 0.166-2.078, p = 0.410).

CONCLUSION

Early treatment of IMR concomitant to coronary revascularization enhances long-term survival compared to delayed MV surgery after PCR. MV repair is not superior to MV replacement when performed late after coronary revascularization; however, MV repair leads to better survival than MV replacement when performed concomitantly with CABG with arterial LAD revascularization.

Comparison of Coronary Artery Bypass Grafting Combined With Mitral Valve Repair Versus Coronary Artery Bypass Grafting Alone in Patients With Moderate Ischemic Mitral Regurgitation: A Meta-Analysis

The aim of this meta-analysis was to compare clinical outcomes between those who underwent coronary artery bypass grafting (CABG) alone and CABG with mitral valve repair (MVR) in patients with moderate ischemic mitral regurgitation. The present study was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Two authors performed a comprehensive search of international databases, including PubMed, EMBASE, and the Cochrane Library, for relevant studies published from inception to March 1, 2023. The search was performed again before the submission of the manuscript on March 20, 2023. Primary outcomes assessed in the present meta-analysis included early mortality and long-term mortality. Secondary outcomes assessed in the present meta-analysis included change in New York Heart Association (NYHA) score from baseline, change in ejection fraction (EF) from baseline (%), and major cardiovascular events (MACE). A total of 13 studies were included in the present meta-analysis. Out of 13 included studies, four were randomized control trials (RCTs) and nine were retrospective cohort studies. The pooled analysis showed that early mortality was significantly lower in patients in the CABG group compared to the CABG+MVR group (risk ratio [RR]: 0.47, 95% confidence interval [CI]: 0.31, 0.70). Long-term mortality was also lower in patients who underwent CABG compared to patients in the CABG+MVR group. However, the difference was statistically insignificant (RR: 0.88, 95% CI: 0.77, 1.02). No significant differences were reported in the EF score between patients who underwent CABG and patients who underwent CABG plus MVR (mean difference [MD]: 0.40, 95% CI: -1.90, 2.69). NYHA score was significantly lower in patients in the CABG+repair group compared to the CABG alone group (MD: 0.39, 95% CI: 0.06, 0.72). In conclusion, our meta-analysis suggests that concomitant MVR during CABG may not improve clinical outcomes in patients with moderate ischemic mitral regurgitation. Further clinical trials are needed to investigate this intervention in more detail.

Predictors of Outcomes After Coronary Artery Bypass Grafting: The Effect of Concomitant Mitral Repair

Background Ischemic mitral regurgitation (IMR) or functional MR intensity with or without repair increases the risk of coronary artery bypass grafting (CABG), and if the contaminant is undertaken, it doubles the risk of the surgery. This study aimed to characterize patients with concomitant CABG and mitral valve repair (MVR) and assess the surgical and long-term outcomes. Methods We conducted a cohort study from 2014 to 2020 on 364 patients who underwent CABG. A total of 364 patients were enrolled and divided into two groups. Group I (n= 349) included patients with isolated CABG, and Group II included patients who underwent CABG with concomitant mitral valve repair (MVR) (n= 15). Results Regarding preoperative presentation, most patients were male: 289 (79.40%), hypertensive 306 (84.07%), diabetic 281 (77.20%), dyslipidemic 246 (67.58%), presenting with NYHA classes III-IV: 200 (54.95%), and upon angiography, found to have the three-vessel disease: 265 (73%). Regarding their age mean± SD and Log EuroSCORE median (Q1-Q3), they had a mean age of 60.94± 10.60 years and a median score of 1.87 (1.13-3.19). The most prevalent postoperative complications were low cardiac output 75 (20.66%), acute kidney injury (AKI) 63 (17.45%), respiratory complications 55 (15.32%), and atrial fibrillation (AF) 55 (15.15%). Regarding long-term outcomes, most patients reported class I NYHA 271 (83.13%) and an echocardiographic decrease in MR severity. Patients with a CABG + MVR were significantly younger (53.93± 15.02 vs. 61.24± 10.29 years; P= 0.009), had a lower ejection fraction (33.6 [25-50] vs. 50 [43-55] %; p= 0.032), and had a higher prevalence of LV dilation (32 [9.17%]). EuroSCORE was significantly higher in patients with mitral repair (3.59 [1.54-8.63] vs. 1.78 (1.13-3.11); P= 0.022). The mortality percentage was higher with MVR but did not attain statistical significance. Intraoperative CPB and ischemic durations were longer in the CABG + MVR group. Furthermore, neurological complications were higher in patients with mitral repair (4 (28.57%) vs. 30 (8.65%), P= 0.012). The study's follow-up duration median was 24 (9-36) months. The composite endpoint occurred more frequently in older patients (HR: 1.05 [95% CI: 1.02-1.09]; 0.001), patients with low ejection fraction (HR: 0.96 [95% CI: 0.93-0.99]; P= 0.006) and in patients with preoperative myocardial infarction (MI) (HR: 2.3 [95%: 1.14- 4.68]; P= 0.021). Conclusion Most IMR patients benefited from CABG and CABG + MVR, as evident by NYHA class and echocardiographic follow-up. CABG + MVR had a higher Log EuroSCORE risk with increased intraoperative cardiopulmonary bypass (CPB) and ischemic durations, which may have played a role in increasing the incidence of postoperative neurological complications. On follow-up, no differences were reported between the two groups. However, age, ejection fraction, and a history of preoperative MI were identified as factors affecting the composite endpoint.

Impact of Mitral Regurgitation Recurrence on Mitral Valve Repair for Secondary Ischemic Mitral Regurgitation

OBJECTIVES

The current guidelines still do not include specific recommendations on the use of subvalvular repair (SV-r) for treatment of ischemic mitral regurgitation (IMR). Therefore, the objective of our study was to evaluate the clinical impact of mitral regurgitation (MR) recurrence and ventricular remodeling on long-term outcomes after SV-r combined with restrictive annuloplasty (RA-r).

METHODS

We performed a subanalysis of the papillary muscle approximation trial, studying 96 patients with severe IMR and coronary artery disease undergoing restrictive annuloplasty alongside subvalvular repair (SV-r + RA-r group) or restrictive annuloplasty alone (RA-r group). We analyzed treatment failure differences, the influence of residual MR, left ventricular remodeling, and clinical outcomes. The primary endpoint was treatment failure (composite of death; reoperation; or recurrence of moderate, moderate-to-severe, or severe MR) within 5 years of follow-up after the procedure.

RESULTS

A total of 45 patients showed failure of the treatment within 5 years, of which 16 patients underwent SV-r + RA-r (35.6%) and 29 underwent RA-r (64.4%, p = 0.006). Patients with significant residual MR presented with a higher rate of all-cause mortality at 5 years compared with trivial MR (HR 9.09, 95% CI 2.08-33.33, p = 0.003). MR progression occurred earlier in the RA-r group, as 20 patients in the RA-r group vs. 6 in SV-r + RA-r group had a significant MR 2 years after surgery (p = 0.002).

CONCLUSIONS

RA-r remains a surgical mitral repair technique with an increased risk of failure and mortality at 5 years compared with SV-r. The rates of recurrent MR are higher, and recurrence occurs earlier, with RA-r alone compared to SV-r. The addition of the subvalvular repair increases the durability of the repair, thus extending all of the benefits of preventing MR recurrence.

Comparative study of coronary artery bypass grafting combined with off-pump mitral valvuloplasty versus coronary artery bypass grafting alone in patients with moderate ischemic mitral regurgitation

INTRODUCTION

Whether mitral surgery should be performed simultaneously with coronary artery bypass grafting (CABG) in patients with moderate ischemic mitral regurgitation (MIMR) is controversial. This study was performed to introduce a method of off-pump mitral valvuloplasty after off-pump CABG (OPCABG) and compare it with OPCABG alone.

METHODS

Eighty-three patients with MIMR underwent OPCABG. Among them, 21 patients (Group A) underwent posterior mitral annuloplasty without cardiopulmonary bypass, and 62 patients (Group B) underwent OPCABG alone. The primary endpoint of follow-up was the mitral regurgitation area.

RESULTS

The mean mitral regurgitant area in Group A and B was 6.42 ± 1.02 and 5.49 ± 1.24 cm² preoperatively (p = .479), 2.93 ± 1.35 and 3.28 ± 1.93 cm² at 1 week postoperatively (p = .516), 3.06 ± 2.16 and 3.09 ± 1.85 cm² at 3 months postoperatively (p = .839), and 3.02 ± 1.60 and 3.7 cm² (median) at 1 year postoperatively (p = .043). There was less regurgitation in Group A at the mid-term. Intragroup comparison showed significant differences between the preoperative and postoperative values in both groups, with no difference in the regurgitant area at each postoperative time point in Group A but a significant difference between 3 months and 1 year postoperatively in Group B (p = .042). Multiple linear regression showed that the mid-term mitral regurgitant area changes were negatively correlated with graft flow and positively correlated with age.

CONCLUSION

In patients with MIMR who underwent OPCABG plus off-pump mitral valve annuloplasty, the mitral regurgitant area was smaller and mitral regurgitation recurrence was less frequent at the mid-term follow-up.

Concomitant Mitral Valve Surgery Versus No Intervention in Patients with Moderate Ischemic Mitral Regurgitation Undergoing Coronary Artery Bypass Grafting: A Propensity Score Analysis

Objectives

Ischemic mitral valve regurgitation (IMR) in patients undergoing coronary artery bypass grafting (CABG) is associated with worse long-term outcomes. This study aimed to assess the impact of mitral valve repair with CABG in patients with moderate IMR.

Materials

This observational study enrolled 3,215 consecutive patients from the Juntendo CABG registry with moderate IMR and multivessel coronary artery disease who underwent CABG between 2002 and 2017.

Methods

The CABG alone and CABG with mitral valve surgery (MVs) groups were compared. The propensity score was calculated for each patient. Long-term all-cause death, cardiac death, and major adverse cardiac and cerebrovascular events (MACCEs) were compared.

Results

Our database had 101 patients who underwent CABG with moderate IMR. Propensity score matching selected 40 pairs for final analysis. MVs was associated with increased risks of postoperative atrial fibrillation, blood transfusion, and longer hospitalization. Long-term outcomes, including all-cause mortality, cardiac mortality, and the incidence of MACCEs were similar.

Conclusion

Surgical treatment of moderate IMR combined with CABG was related to increased risk of several non-fatal short-term complications when compared to CABG alone, with similar long-term outcomes. Further studies are needed to determine the effects of MVs in patients with moderate IMR and severe coronary artery disease.

Contemporary Management of Ischemic Mitral Regurgitation at Coronary Artery Bypass Grafting

BACKGROUND

Recent guidelines for the treatment of moderate or severe ischemic mitral regurgitation (IMR) in patients undergoing coronary artery bypass grafting (CABG) have changed. This study assessed the real-world impact of changing guidelines on the management of IMR during CABG over time. We hypothesized that the utilization of mitral valve repair for IMR would decrease over time, whereas mitral valve replacement for severe IMR would increase.

METHODS

Patients undergoing CABG in a statewide collaborative database (2011-2020) were stratified by severity of IMR. Trends in mitral valve repair or replacement were evaluated. To account for differences of the patients, propensity score-matched analyses were used to compare patients with and without mitral intervention.

RESULTS

A total of 11,676 patients met inclusion criteria, including 1355 (11.6%) with moderate IMR and 390 (3.3%) with severe IMR. The proportion of patients undergoing mitral intervention for moderate IMR decreased over time (2011, 17.7%; 2020, 7.5%; P_trend = .001), whereas mitral replacement for severe IMR remained stable (2011, 11.1%; 2020, 13.3%; P_trend = .14). Major morbidity was higher for patients with moderate IMR who underwent mitral intervention (29.1% vs 19.9%; P = .005). In a propensity analysis of 249 well-matched pairs, there was no difference in major morbidity (29.3% with mitral intervention vs 23.7% without; P = .16) or operative mortality (1.2% vs 2.4%; P = .5).

CONCLUSIONS

Consistent with recent guideline updates, patients with moderate IMR were less likely to undergo mitral repair. However, the rate of replacement for severe IMR did not change. Mitral intervention during CABG did not increase operative mortality or morbidity.

NT-proBNP increase during stress echocardiography predicts significant changes in ischemic mitral regurgitation severity in patients qualified for surgical revascularization

BACKGROUND

In many patients, significant changes in ischemic mitral regurgitation (IMR) severity during exercise can be observed independent of the degree of IMR at rest. This study aimed to investigate the correlations between N-terminal fragment B-type natriuretic peptide (NT-proBNP) and echocardiography measurements at rest and at peak exercise in patients with moderate IMR who qualified for surgical revascularization.

METHODS

A total of 100 patients eligible for coronary artery bypass grafting, were included in this prospective study. All patients underwent exercise echocardiography. Additionally, the levels of NT-proBNP were measured at rest and after peak exercise.

RESULTS

A positive correlation of absolute NT-proBNP levels with effective regurgitant orifice area (EROA) were observed and with tricuspid regurgitant peak gradient (TRPG) at peak exercise. Absolute ΔNT-proBNP during exercise and the tenting area at rest were independent predictors of severe IMR at peak exercise. The level of absolute ΔNT-proBNP during exercise and coaptation height at rest were the most important predictors of significant increases in TRPG. The best cutoff value for ΔNT-proBNP as a predictor for increases in EROA at peak exercise was 68.9 pg/mL and to predict an increase in TRPG ≥ 50 mmHg at peak exercise was 68 pg/mL.

CONCLUSIONS

The level of ΔNT-proBNP during exercise was the most important parameter in predicting significant changes in IMR severity and pulmonary pressure. Based on the present data, it can be speculated that integration of the assessment of NT-proBNP at rest and at exercise might improve patient selection for valve surgery.

Isolated OPCABG in moderate chronic ischemic mitral regurgitation: is it a justifiable alternative approach ?

OBJECTIVE

Current evidence does not allow a consensus on the management of moderate chronic ischemic mitral regurgitation (CIMR). We compared moderate CIMR patients undergoing off-pump CABG (OPCABG) alone and CABG + MV repair for early mortality, major adverse systemic events (MASE) and mid-term functional outcomes.

METHODS

210 patients with moderate CIMR who underwent off-pump coronary artery bypass grafting (OPCABG) Group I (n = 106) or CABG + mitral valve repair (MV rep) Group II (n = 104) were followed prospectively. For comparison, patients were further sub-divided based on the product of regurgitant fraction and ejection fraction "RFEF"(Good/Bad) and MR jet direction (Central/Eccentric). The primary end point of the study was mortality and secondary end points were MASE, percentage improvements in indexed left ventricle end-systolic volume (LVESVI %), MR grade and functional outcomes of the patients.

RESULTS

In-hospital and overall mortality was significantly lower in Group I (1.89% vs. 13.46%, p < 0.001 and 5.66% vs. 15.38%; p = 0.024 respectively). Group II had significantly higher MASE, ventilation time, mean ICU and hospital stay. At 36 months, LVESVI% (17.56% ± 9.12% vs. 18.81% ± 7.48%; p = 0.279), MR grade improvement (80.18% vs. 83.50%; p = 0.544), NYHA class and MLHF scores were also similar in both groups. On subgroup analysis, Good RFEF with Central jet subgroup had comparable improvement in LVESVI% and MR grade with either procedure, while Bad Eccentric subgroup showed a significantly higher improvement in LVESVI% and MR grade with CABG + MV repair.

CONCLUSION

OPCABG is associated with significantly reduced mortality and MASE with comparable improvement in LVEDVI% and MR grade. CABG + MV Rep results in significant improvement in LVEDVI% and MR grade in patients with bad eccentric MR. The recommended procedures in the "Good Central" and "Bad Eccentric" subsets are CABG and CABG + Mvrepair, respectively.

Effect of left ventricular hyperenhancement in magnetic resonance imaging on reverse remodeling after mitral valve repair for moderate ischemic mitral regurgitation

We aimed to investigate cardiac magnetic resonance imaging (MRI)-derived predictors of a lack of left ventricular (LV) reverse remodeling after undersized mitral annuloplasty (uMAP) for moderate ischemic mitral regurgitation (IMR). We retrospectively reviewed 31 patients who underwent uMAP for moderate IMR and cardiac MRI evaluation between 2004 and 2017. Cardiac MRI evaluation included cine MRI LV and right ventricular volumetric measurements and gadolinium-enhanced MRI assessment of myocardial scarring. LV dimensions were assessed preoperatively, postoperatively, and at follow-up using serial transthoracic echocardiography, and the mid-term (median, 49 months) predictors of a lack of LV reverse remodeling were analyzed. At the mid-term follow-up (mean follow-up period: 85 ± 40 months), 15 patients exhibited reverse LV remodeling. The relative reduction in LV dimension at follow-up was negatively correlated with the preoperative number of LV segments with myocardial infarction (MI) (defined as an LV segment with >25% enhancement). The optimal cut-off for predicting a lack of reverse LV remodeling at follow-up was >5 LV segments with MI, with a sensitivity and specificity of 92% and 92%, respectively. This cut-off value also predicted all-cause mortality at follow-up, with a sensitivity and specificity of 88% and 67%, respectively. The presence of >5 LV segments with MI on gadolinium-enhanced MRI might be a useful predictor of lack of reverse LV remodeling and all-cause mortality outcomes after undersized mitral annuloplasty for moderate IMR.

MitraClip implantation in real-world: clinical relevance of different patterns of left ventricular remodeling

OBJECTIVES

The role of left ventricular (LV) volumes and ejection fraction (EF) in the selection of patients candidates to MitraClip procedure remains matter of debate. To assess the pattern of LV remodeling and its clinical implications after MitraClip procedures, and to evaluate the role of LV ejection fraction (EF) in patient selection.

METHODS

Complete echocardiography was performed before, at discharge,1,6, and 12-month in 45 patients treated with MitraClip for severe mitral regurgitation (MR) [age 78.2±8.3 yrs, NYHA 3.74±0.44, EF 36.5±12.8%]. From baseline to 6-month reverse and adverse LV-R was defined as ≥15 % decrease and ≥10% increase in LV end-systolic volume, respectively.

RESULTS

At 6-month, sustained reduction of MR≤2 was observed in all patients, but 2; reverse, adverse and no LV-R occurred in 51% (N=23), 18% (N=8) and 31% (N=14) patients. Baseline LV end-diastolic volume was an independent predictor of reverse LV-R [P=0.004], whereas EF was not. During follow-up (17.5±9.3 months), freedom from the composite endpoint (mortality and hospitalization for heart failure) was observed in 50% of adverse/no LV-R vs. 95.7% of reverse LV-R patients (P=0.006). At Cox analysis, adverse LV-R and adverse/no LV-R were associated with composite endpoint with adjusted hazard ratio of 5.6 (95% CI 1.65-19.00) and 10.08 (95% CI 1.29-78.6), respectively.

CONCLUSIONS

After MitraClip implantation, sustained adverse or no LV-R occurred in one-in-two patients and was associated with poor prognosis. Large LV volumes may help us to avoid futility of procedure.

The association between myocardial scar and the response of moderate ischemic mitral regurgitation to isolated coronary artery bypass grafting

Background

The factors that associated with the response of moderate ischemic mitral regurgitation (IMR) to isolated coronary artery bypass grafting (CABG) remain unclear. This study aims to evaluate whether left ventricular (LV) myocardial scar assessed by cardiovascular magnetic resonance (CMR) is associated with the outcome of moderate IMR after isolated CABG.

Methods

Forty-six patients with coronary artery disease (CAD) and moderate IMR who underwent isolated CABG between January 2014 and February 2019 in Anzhen Hospital Affiliated to Capital Medical University were enrolled in this case-control study. All patients underwent CMR and echocardiography before surgery. Patients were classified into two groups according to the severity of IMR 1 year after CABG: an improved group (no or mild IMR) and an unimproved group (moderate or severe IMR). Univariate and multivariate logistic regression analyses were used to assess the association between individual variables and unimproved IMR at 1-year post-CABG.

Results

Compared to patients in the improved group, the patients in the unimproved group had a significantly greater amount of LV myocardial scar (18.0%±9.5% vs. 30.8%±11.2%, P<0.001). In the multiple logistic regression model, after adjustment for age, sex, and body mass index, only LV myocardial scar (OR: 0.89, 95% CI: 0.83–0.96, P=0.001) was independently associated with unimproved IMR after isolated CABG. Furthermore, there was no difference in the 3-year overall survival rates between the two groups (92.3% vs. 90.3%, P=0.46). In addition, patients in the unimproved group had a higher New York Heart Association (NYHA) classification (P=0.01) and more major adverse cardiac events such as MI, angina pectoris, and readmission for heart failure (P=0.03).

Conclusions

A greater amount of preoperative LV myocardial scar was associated with unimproved moderate IMR after isolated CABG. Measuring preoperative LV myocardial scar is helpful to predict post-operative outcome and determine optimal surgery in patients with moderate IMR.

Clinical Outcomes Following Durable Mitral Valve Repair for Ischemic Mitral Regurgitation

BACKGROUND

This study aimed to clarify the incidence and determinants of postoperative adverse events in patients with ischemic cardiomyopathy who achieved long-term durable mitral valve repair.

METHODS

Between 1999 and 2015, 166 patients with chronic ischemic mitral regurgitation (MR) and left ventricular (LV) ejection fraction ≤40% underwent restrictive mitral annuloplasty. During follow-up (65±34 months), echocardiographic assessments were performed 809 times (mean, 4.9±2.4 times) and 20 patients who had developed postoperative recurrent MR (≥moderate) were excluded. Finally, 146 patients (68±9 years) whose MR was well controlled over time were included.

RESULTS

A total of 61 mortalities and/or 27 readmissions for heart failure were observed in 76 patients (52%). Among hospital survivors, age (adjusted hazard ratio: 1.05; P=0.001), and estimated glomerular filtration rate (adjusted hazard ratio: 0.61; P=0.001) were identified as independent predictors of long-term mortality and/or readmission for heart failure. The degree of LV function recovery after surgery was comparable between patients with and without adverse events. However, the former group showed greater values for systolic pulmonary artery pressure, tricuspid regurgitation severity, inferior vena cava dimension, and plasma brain natriuretic peptide level throughout the follow-up period (group effect p<0.05 for all).

CONCLUSIONS

Approximately 50% of patients died or were hospitalized for heart failure even in the absence of recurrent mitral regurgitation during the 5-year follow-up, indicating that durable mitral repair does not always lead to favorable clinical outcomes. The adverse events might be related to volume overload secondary to impaired renal function and less favorable pulmonary hemodynamics.

Left ventricle restoration. Keep the door open

Surgical left ventricle restoration (SVR) was first by Cooley in 1958 with the "linear suture technique," and three decades later, Dor used a circular patch to reconstruct the left ventricle excluding the scarred parts of the septum and ventricular wall. It gained popularity and eventually almost abandoned after the contrasting literature evidence. Hassanabad et al. presented a comprehensive review of current literature on SVR techniques and clinical outcomes, trying to understand if SVR has still a substantial role in the modern medicine.

Joint preoperative transthoracic and intraoperative transoesophageal echocardiographic assessment of functional mitral regurgitation severity provides better association with long-term mortality

OBJECTIVES

Functional mitral regurgitation (MR) is observed with ischaemic heart disease or aortic valve disease. Assessing the value of mitral valve repair or replacement (MVR/P) is complicated by frequent discordance between preoperative transthoracic echocardiographic (pTTE) and intraoperative transoesophageal echocardiographic (iTOE) assessment of MR severity. We examined the association of pTTE and iTOE with postoperative mortality in patients with or without MR, at the time of coronary artery bypass grafting (CABG) and/or aortic valve replacement without MVR/P.

METHODS

Medical records of 6629 patients undergoing CABG and/or aortic valve replacement surgery with or without functional MR and who did not undergo MVR/P were reviewed. MR severity assessed by pTTE and iTOE were examined for association with postoperative mortality using proportional hazards regression while accounting for patient and operative characteristics.

RESULTS

In 72% of 709 patients with clinically significant (moderate or greater) functional MR detected by pTTE, iTOE performed after induction of anaesthesia demonstrated a reduction in MR severity, while 2% of patients had increased severity of MR by iTOE. iTOE assessment of MR was better associated with long-term postoperative mortality than pTTE in patients with moderate MR [hazard ratio (HR) 1.31 (1.11-1.55) vs 1.02 (0.89-1.17), P-value for comparison of HR 0.025] but was not different for more than moderate MR [1.43 (0.96-2.14) vs 1.27 (0.80-2.02)].

CONCLUSIONS

In patients undergoing CABG and/or aortic valve replacement without MVR/P, these findings support intraoperative reassessment of MR severity by iTOE as an adjunct to pTTE in the prediction of mortality. Alone, these findings do not yet provide evidence for an operative strategy.

Exploring the Operative Strategy for Secondary Mitral Regurgitation: A Systematic Review

Background

Mitral valve disease surgery is an evolving field with multiple possible interventions. There is an increasing body of evidence regarding the optimal strategy in secondary mitral regurgitation where the pathology lies within the ventricle. We conducted a systematic review to identify the benefits and limitations of each surgical option.

Methods

A systematic review of the literature was performed to identify pertinent randomized controlled trials (RCTs), propensity-matched observational series, and meta-analyses which were considered initially and followed by unmatched observational series using the MEDLINE, Ovid EMBASE, and Cochrane Library.

Results

We identified 6 different strategies for treating secondary mitral valve regurgitation: mitral valve replacement, restrictive mitral annuloplasty, surgical revascularization (with and without mitral annuloplasty), subvalvular procedures (papillary muscle approximation, papillary muscle relocation, ring and string procedure), and procedures directly targeting the mitral valve (edge-to-edge repair and anterior leaflet enlargement) alongside transcatheter heart valve therapy. We also highlighted the role of left ventricular assist devices in the management of this condition. The benefits and limitations of each intervention are highlighted.

Conclusion

There is currently no unanimous and shared strategy for the optimal treatment of patients with secondary IMR. The management of patients with secondary mitral regurgitation must be entrusted to a multidisciplinary Heart Team to ensure ideal intervention and patient matching for the best outcomes.

10-Year Results of Mitral Repair and Coronary Bypass for Ischemic Regurgitation: A Randomized Trial

BACKGROUND

The decision to treat moderate ischemic mitral regurgitation (IMR) at the time of coronary artery bypass surgery (CABG) remains controversial. We previously conducted a prospective randomized trial that showed a benefit of adding restricted annuloplasty to bypass surgery (CABG-Ring group) in terms of IMR grade, New York Heart Association classification, and left ventricle reverse remodeling. Here, we present the long-term (>10 years) follow-up data from this randomized trial.

METHODS

The original trial arms accounted for 54 patients in the CABG-alone and 48 in the CABG-Ring group; patients were re-contacted for follow-up to obtain relevant clinical and echocardiographic information.

RESULTS

The mean follow-up was 160.4 ± 45.5 months. Survival probabilities in the CABG-alone and CABG-Ring groups were 96% vs 93% at 3 years, 85% vs 89% at 6 years, 79% vs 85% at 9 years, 77% vs 83% at 12 years, and 72% vs 80% at 15 years, respectively (P = .18) Freedom from at least moderate IMR or reintervention at last follow-up was also higher in the CABG-Ring group (P < .001). Compared with the CABG-alone group, the CABG-Ring group had a higher degree of left ventricular reverse remodeling (54.7 ± 6.9 mm vs 51.6 ± 6 mm, respectively; P = .03), lower New York Heart Association class (P < .001), and a lower rate of rehospitalization (P = .002).

CONCLUSIONS

Long-term follow-up data from our randomized trial further support the utility of performing restricted annuloplasty at the time of CABG to prevent further progression of IMR, mitral reintervention, and left ventricle remodeling. Untreated IMR was associated with significantly higher New York Heart Association class and rehospitalization.

Treatment of type A dissection: Searching for the Holy Grail

Current principles of surgical treatment of type A dissections are for the most part based on best evidence practice for the lack of controlled randomized studies providing definitive scientific evidence. Despite its widespread use, axillary cannulation still remains a debated topic as the preferred method of cannulation and perfusion strategy in the treatment of this complex condition.

2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

This executive summary of the valvular heart disease guideline provides recommendations for clinicians to diagnose and manage valvular heart disease as well as supporting documentation to encourage their use.

METHODS

A comprehensive literature search was conducted from January 1, 2010, to March 1, 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from PubMed, EMBASE, Cochrane, Agency for Healthcare Research and Quality Reports, and other selected database relevant to this guideline. Structure: Many recommendations from the earlier valvular heart disease guidelines have been updated with new evidence and provides newer options for diagnosis and treatment of valvular heart disease. This summary includes only the recommendations from the full guideline which focus on diagnostic work-up, the timing and choice of surgical and catheter interventions, and recommendations for medical therapy. The reader is referred to the full guideline for graphical flow charts, text, and tables with additional details about the rationale for and implementation of each recommendation, and the evidence tables detailing the data considered in developing these guidelines.

Transcatheter reshaping of the mitral annulus in patients with functional mitral regurgitation: one-year outcomes of the MAVERIC trial

AIMS

The aim of this study was to assess the one-year safety and efficacy of the transcatheter ARTO system in the treatment of functional mitral regurgitation (FMR).

METHODS AND RESULTS

MAVERIC is a multicentre, prospective, non-randomised pre-commercial study. Eligible patients were on guideline-recommended therapy for NYHA Class II-IV systolic heart failure and had an FMR grade ≥2+. The ARTO system was implanted in forty-five (100%) patients. The primary safety composite endpoint (death, stroke, myocardial infarction, device-related surgery, cardiac tamponade, renal failure) at 30 days and one year was 4.4% (95% CI: 1.5-16.6) and 17.8% (95% CI: 9.3-32.4), respectively. Periprocedural complications occurred in seven patients (15.5% [95% CI: 6.5-29.5]), and five patients (11.1% [95% CI: 4.9-24.0]) died during one-year follow-up. Paired results for 36 patients demonstrated that 24 (66.7%) had grade 3+/4+ mitral regurgitation at baseline; however, only five (13.9%) and three (8.3%) patients remained at grade 3+/4+ 30 days and one year post procedure (p<0.0001). Echocardiographic parameters such as anteroposterior annulus diameter decreased from 41.4 mm (baseline) to 36.0 and 35.3 mm at 30 days and one year, respectively (p<0.0001). Twenty-five patients (69.4%) had baseline NYHA Class III/IV symptoms decreasing significantly to nine (25.0%) at 30 days and eight (22.2%) at one year post procedure (p<0.0001).

CONCLUSIONS

The ARTO transcatheter mitral valve repair system is both safe and effective in decreasing FMR up to one year post procedure.

Ischemic functional mitral regurgitation: from pathophysiological concepts to current treatment options. A systemic review for optimal strategy

OBJECTIVE

The current treatment of ischemic functional mitral regurgitation (FMR) remains debated due to differences in inclusion criteria of randomized studies and baseline characteristics. Also, the role of left ventricular pathophysiology and the role of subvalvular apparatus have not been thoroughly investigated in recent literature.

METHODS

A literature search was performed from PubMed inception to June 2020.

RESULTS

Novel concepts of pathophysiology, such as the proportionate/disproportionate conceptual framework, the role of papillary muscles and left ventricular dysfunction, the impact of myocardial ischemia and revascularization, left ventricular remodeling, and the effect of restrictive annuloplasty or subvalvular procedures have been reviewed.

CONCLUSIONS

The clinical benefits associated with the use of MitraClip is more evident in patients with disproportionate FMR with greater and sustained left ventricular reverse remodeling. Importantly, in the absence of myocardial revascularization, expansion of myocardial scar tissue and non-perfused areas of ischemic myocardium occur with time, and this impact on outcomes with a longer follow-up period cannot be quantified. In advanced phases of FMR, neither mitral ring annuloplasty nor percutaneous therapies could significantly modify the established pathoanatomic alterations.

The treatment of mitral insufficiency in refractory heart failure

Secondary mitral insufficiency (SMI) is caused by dilatation and left ventricular dysfunction and is a frequent finding in patients with heart failure (HF). It is associated with a mortality of between 40% and 50% at 3 years. The first-line treatment is represented by medical therapy, possibly associated, when indicated, with cardiac re-synchronization. If the patient remains symptomatic, corrective action should be considered. Surgery is indicated in cases of severe SMI with ejection fraction >30% and the need for myocardial revascularization. The management of patients in whom revascularization is not an option remains extremely complex and the evidence in this field is extremely limited. Percutaneous transcatheter therapies, reparative or replacement, are rapidly emerging as valid alternatives in cases of patients at high surgical risk. In particular, edge-to-edge repair (MitraClip) has proven effective in improving symptoms and reducing hospitalizations for HF. However, neither transcatheter nor surgical mitral repair or replacement has been shown to significantly improve prognosis, with mortality remaining high (14–20% at 1 year). Randomized trials aimed at assessing the effect of these treatments and establishing their long-term outcomes are urgently required.

Mitral valve surgery combined with on-pump versus off-pump myocardial revascularization: A prospective randomized analysis with midterm follow-up

BACKGROUND

The aim of the study was to compare results off-pump coronary artery bypass (OPCAB) combined mitral valve reconstruction (MVR) with standard on-pump approach.

METHODS

From January 2014 to December 2017, a total of 53 patients received a combined myocardial revascularization and MVR for multivessel coronary artery disease (CAD) complicated by severe ischemic mitral regurgitation (IMR). All the subjects were divided into two groups: group I: 27 patients, received OPCAB + MVR, and group II (control group): 26 patients with on-pump myocardial revascularization (ONCAB) + MVR.

RESULTS

The aortic cross-clamp (ACC) and cardio-pulmonary bypass (CPB) times were longer in group II, 47.0 (44.0; 55.0) vs 94.5 (89.75; 105.5) minutes, P < .05 and 70.0 (63.0; 77.0) vs 138.5 (127.0; 157.5) minutes, P < .05, respectively. Evaluation of major clinical events showed that the implementation of the off-pump stage of myocardial revascularization in patients with severe IMR did not lead to significant changes in the mortality and postoperative complications. Furthermore, its use did not affect the volume of blood loss and need for blood transfusion, the duration of mechanical ventilation, the need for inotropic therapy, as well as the duration of the patient's resuscitation and the total duration of hospitalization, with the one exception: the troponin-T level increase in the OPCAB + MVR group was less than in the ONCAB + MVR group.

CONCLUSION

OPCAB combined MVR in patients with CAD and severe IMR can be performed with shorter CPB and ACC times, and lower troponin-T level after surgery, without reducing the risk of surgical complications.

An observational, prospective study on surgical treatment of secondary mitral regurgitation: The SMR study. Rationale, purposes, and protocol

The natural history of secondary mitral regurgitation (MR) is unfavorable. Nevertheless, there are no evidence that its correction can improve the outcome. If from one side the original cause of secondary MR can be such to limit the possibilities of improvement, from the other side it is possible that the surgical technique widely applied to repair, restrictive mitral annuloplasty, is not adequate to correct the regurgitation. The addition of valvular and/or subvalvular techniques has been considered a possible technical solution. However, we do not know the prevalence of each technique, how many times mitral replacement is used to correct secondary MR. This aspect is of particular importance, as we know that a successful mitral repair causes a better left ventricular systolic remodeling than a unsuccessful repair or replacement. This study is a prospective, observational registry, conceived to understand what is done in the real world. Any surgeon will use the technique he thinks the most suitable for the patient. Every year, for 5 years, patients will have a clinical and echocardiographic follow-up, to evaluate the risk factors for a worse result (death, rehospitalization for heart failure, reoperation for MR return, moderate, or more MR return). This knowledge will give us the possibility to understand which is the technique, or the strategy, more efficient to treat this disease and the real efficacy of the surgical treatment.

Valvular Heart Disease in Pregnancy: Anticoagulation and the Role of Percutaneous Treatment

Valvular heart disease is present in about 1% of pregnancies, and it poses a management challenge as both fetal and maternal lives are at risk of complications. Pregnancy is associated with significant hemodynamic changes, which can compromise the cardiac status in women with underlying valvular disorders. Management of valvular heart diseases has undergone considerable innovation and advancement with newer techniques, approaches and devices being employed. The decision regarding the management of anticoagulation, especially in patients with prosthetic valves, raises distinct questions and challenges. In this review, we describe the management of common valvular heart diseases encountered during pregnancy, role of percutaneous catheter based therapeutic interventions, the importance of a team-based approach, and the challenges given existing gaps in the literature.

The most influential papers in mitral valve surgery; a bibliometric analysis

This study is an analysis of the 100 most cited articles in mitral valve surgery. A bibliometric analysis is a tool to evaluate research performance in a given field. It uses the number of times a publication is cited by others as a proxy marker of its impact. The most cited paper Carpentier et al. discusses mitral valve repair in terms of restoring the geometry of the entire valve rather than simply narrowing the annulus (Carpentier, J Thorac Cardiovasc Surg 86:23–37, 1983). The first successful mitral valve repair was performed by Elliot Cutler at Brigham and Women’s Hospital in 1923 (Cohn et al., Ann Cardiothorac Surg 4:315, 2015). More recently percutaneous and minimally invasive techniques that were originally designed as an option for high risk patients are being trialled in other patient groups (Hajar, Heart Views 19:160–3, 2018). Comparison of percutaneous method with open repair represents an expanding area of research (Hajar, Heart Views 19:160–3, 2018). This study will analyse the top 100 cited papers relevant to mitral valve surgery, identifying the most influential papers that guide current management, the institutions that produce them and the authors involved.