Moderate mitral regurgitation in aortic root replacement surgery: Comparing mitral repair with no mitral repair

Mid-term outcomes of surgical aortic valve replacement using a mosaic porcine bioprosthesis with concomitant mitral valve repair

This study retrospectively evaluated the mid-term outcomes of surgical aortic valve replacement (SAVR) using a stented porcine aortic valve bioprosthesis (Mosaic; Medtronic Inc., Minneapolis, MN, USA) with concomitant mitral valve (MV) repair. From 1999 to 2014, 157 patients (median [interquartile range] age, 75 [70-79] years; 47% women) underwent SAVR with concomitant MV repair (SAVR + MV repair), and 1045 patients (median [interquartile range] age, 76 [70-80] years; 54% women) underwent SAVR only at 10 centers in Japan as part of the long-term multicenter Japan Mosaic valve (J-MOVE) study. The 5-year overall survival rate was 81.5% ± 4.1% in the SAVR + MV repair group and 85.1% ± 1.4% in the SAVR only group, and the 8-year overall survival rates were 75.2% ± 5.7% and 78.1% ± 2.1%, respectively. Cox proportional hazards analysis showed no significant difference in the survival rates between the two groups (hazard ratio, 0.87; 95% confidence interval, 0.54-1.40; P = 0.576). Among women with mild or moderate mitral regurgitation who were not receiving dialysis, those who underwent SAVR + MV repair, were aged > 75 years, and had a preoperative left ventricular ejection fraction of 30-75% tended to have a lower mortality risk. In conclusion, this subgroup analysis of the J-MOVE cohort showed relevant mid-term outcomes after SAVR + MV repair.

Survival and repair durability in patients undergoing concomitant aortic valve reimplantation and mitral valve repair

Objective

The study objective was to determine repair durability and survival in patients with and without connective tissue disorders undergoing concomitant aortic valve reimplantation and mitral valve repair.

Methods

From 2002 to 2019, 68 patients underwent concomitant aortic valve reimplantation and mitral valve repair, including 27 patients with Marfan syndrome (39.7%). Follow-up echocardiograms were analyzed using nonlinear multiphase mixed-effects cumulative logistic regression. The regurgitation grade over time was estimated by averaging patient-specific profiles. Survival and freedom from reoperation were estimated by the Kaplan-Meier method.

Results

At 7 years, 11% of patients had aortic insufficiency greater than mild (severe in 2 patients). There was no difference in greater than mild aortic insufficiency between patients with or without Marfan syndrome (P = .37). Twenty percent of patients had progressed to mitral regurgitation greater than mild (severe in only 1 patient). The prevalence of recurrent mitral regurgitation was higher in those without Marfan syndrome, with greater than mild regurgitation increasing to 24% by 2 years and remaining constant thereafter (P = .04). Freedom from reoperation on the aortic valve or mitral valve was 83% at 10 years and did not differ between Marfan syndrome groups. There were no cases of perioperative mortality. Survival at 5 and 10 years was 94% and 87%, respectively, without a difference between those with and without Marfan syndrome.

Conclusions

Patients can undergo a total repair strategy using combined aortic valve reimplantation and mitral valve repair procedures with a low risk of mortality and complications, with favorable freedom from both residual valve regurgitation and reoperation.

Progression of Non-Significant Mitral and Tricuspid Regurgitation after Surgical Aortic Valve Replacement for Aortic Regurgitation

Little is known about the natural history of non-significant mitral and tricuspid regurgitation (MR and TR) following surgical aortic valve replacement (SAVR) for aortic regurgitation (AR). We retrospectively analyzed 184 patients (median age 64 (IQR, 55-74) years, 76.6% males) who underwent SAVR for AR. Subjects with significant non-aortic valvulopathies, prior/concomitant valvular interventions, or congenital heart disease were excluded. The cohort was evaluated for MR/TR progression and, based on the latter's occurrence, for echocardiographic and clinical indices of heart failure and mortality. By 5.8 (IQR, 2.8-11.0) years post-intervention, moderate or severe MR occurred in 20 (10.9%) patients, moderate or severe TR in 25 (13.5%), and either of the two in 36 (19.6%). Patients who developed moderate or severe MR/TR displayed greater biventricular disfunction and functional limitation and were less likely to be alive at 7.0 (IQR, 3.4-12.1) years compared to those who did not (47.2 vs. 79.7%, p < 0.001). The emergence of significant MR/TR was associated with preoperative atrial fibrillation/flutter, symptomatic heart failure, and above-mild MR/TR as well as concomitant composite graft use, but not with baseline echocardiographic measures of biventricular function and dimensions, aortic valve morphology, or procedural aspects. In conclusion, among patients undergoing SAVR for AR, significant MR/TR developed in one fifth by six years, correlated with more adverse course, and was anticipated by baseline clinical and echocardiographic variables.

Modified Transventricular and Transaortic Mitral Valve Edge-to-Edge Repair Mimicking MitraClip Overcorrection

Objective

In the current study, we present our mid-term experience with modified edge-to-edge repair technique through a transventricular and transaortic route in patients requiring left ventricular remodeling or aortic root/valve surgery.

Methods

From December 2006 through April 2015, 49 high-risk patients (median age: 69 years; median European System for Cardiac Operative Risk Evaluation II: 11.4 [6.54-14.9]) underwent transventricular (N = 7; 14%) or transaortic (N = 42; 86%) edge-to-edge mitral valve repair. The Alfieri stitch technique was modified by MitraClip type overcorrection and solid buttressing behind the posterior leaflet. Indication was grade 2+ functional mitral valve incompetence and dilated or impaired left ventricle (N = 25; 52%), or grade 3+ (N = 22; 45%) and grade 4+ functional mitral valve regurgitation (N = 2; 4%). Surgical procedure included aortic root surgery in 65%, aortic valve replacement with surgical revascularization in 18%, and Dor-plasty with surgical revascularization in 14%.

Results

Intraoperative mortality and early neurologic complications were absent in our series. Ninety-day mortality was 12.2% (N = 6). Median clinical and echocardiographic follow-up-time was 50.7 (21.5-44.1) and 39.2 (33.7-44.1) months, respectively. Median postoperative transvalvular gradient was low (2.72 [1.91-4.22] mm Hg) and did not increase during follow-up (P = .268), although peak gradient rose slightly from 7.41 to 8.12 mm Hg (P = .071). The actuarial reoperation free rate at the index valve was 96.8%.

Conclusions

Transventricular or transaortic Alfieri mitral repair mimicking mitral clip overcorrection represents a quick and safe technique in the setting of high-risk patients undergoing left ventricular remodeling or aortic root/valve surgery and can be performed with low risk of creating mitral stenosis at midterm. The technique is straightforward, with reliable identification of the center of the valve leaflets being the limitation.

Mitral Regurgitation in Patients With Coexisting Chronic Aortic Regurgitation: An Evidence-Based Narrative Review

Chronic aortic regurgitation (AR) frequently leads to significant downstream changes to the left ventricle and pulmonary vasculature; these structural and physiologic changes result in lower- than expected patient survival. Progressive, uncorrected AR can lead to left ventricle dilation and subsequent mitral valve leaflet tethering, as well as mitral annular dilation, resulting in secondary mitral regurgitation (MR) in up to 45% of patients. Surgical aortic valve replacement (AVR) improves secondary MR in most patients, but survival is significantly lower in those patients who do not show improvement in MR after AVR. Thus, there is considerable debate on whether the mitral valve should be intervened upon at the time of the AVR. In this review, the authors address the long-term outlook for patients with chronic AR and concurrent MR. The authors also review the available evidence on concomitant mitral valve surgery in patients undergoing AVR for AR. Lastly, this narrative review examines the recent advances in transcatheter mitral valve repair and replacement, and explores the potential role of transcatheter mitral therapies in patients with secondary MR due to AR.

Echocardiographic evaluation of non-surgically treated mild-to-moderate mitral dysfunction in patients undergoing aortic valve replacement

Background

Surgical management of the mitral valve (MV) in patients with mild-to-moderate mitral dysfunction undergoing aortic valve replacement is still controversial. We investigated the echocardiographic data from patients with mild-to-moderate mitral dysfunction who did not undergo MV surgery.

Materials and methods

From January 1989 to June 2012, a total of 2731 patients underwent aortic valve replacement. Among these, 560 patients with mild-to-moderate mitral dysfunction were screened. Of these, 292 patients (61.9 ± 13.0 years; 113 females) who had not undergone MV surgery formed our study cohort. Survival, valve-related complication, and echocardiographic data were evaluated.

Results

There were three early deaths. During the mean follow-up period of 56.9 ± 46.5 months, there were 23 late deaths and 28 valve-related complications. Valve-related event-free survival at 5 years was 85.9% ± 2.4%. In serial postoperative echocardiographic evaluations (mean follow-up duration: 40.8 ± 44.5 months), 21 patients experienced a progression in late mitral dysfunction. At 5 years, 88.8% ± 2.7% of patients did not suffer from late mitral dysfunction. Based on multivariate analysis, rheumatic pathology of MV (Hazard Ratio: 3.88, 95% confidence intervals 1.60–9.39, p = 0.003) was an independent predictor of late mitral dysfunction.

Conclusions

Conservatively treated patients with mild-to-moderate mitral dysfunction exhibited acceptable clinical outcomes. Rheumatic pathology of MV is associated with a higher risk of progressive native MV dysfunction.

Outcomes of aortic root replacement after previous aortic root replacement: the "true" redo root

BACKGROUND

Aortic reoperations are technically challenging. This study evaluated outcomes after "true" redo root replacement (previous full root replacement) stratified by cause of prosthesis failure.

METHODS

Data were compared for 793 patients who underwent a first-time sternotomy (de novo group) and 120 patients who had previously undergone full aortic root replacement (redo group), of which 76 underwent reoperation due to structural valve deterioration (degenerative group), and 44 due to endocarditis (infection group).

RESULTS

Overall mortality was 4% (n = 28) in the de novo group and 5% (n = 6) in the redo group (p = 0.43) (degenerative group, 3%, infection group, 9%; p = 0.19). The infection group had an increased incidence of renal failure, sternal infection, prolonged ventilation, reoperation for bleeding, multisystem failure, and sepsis, and an increased hospital length of stay. The degenerative group and the de novo group had a similar risk of perioperative death and major complications. The 5-year survival was 86.3% ± 1.3% for the de novo group and 77.3% ± 4.6% for the redo group (p ≤ 0.01; degenerative, 86.3% ± 5%; infection, 65.3% ± 7.7%; p < 0.01; p = 0.98 for de novo vs degenerative). Multivariate analysis demonstrated that reoperation for degenerative failure did not increase the risk of perioperative or late death.

CONCLUSIONS

Redo aortic root replacement can be performed with low perioperative morbidity and death. The presence of infection increases the risk of complications and worsens survival. However, redo root replacement for degenerative failure can be performed with similar short-term complication risk and midterm survival as de novo root replacement.

Aortic and mitral valve replacement versus transcatheter aortic valve replacement in propensity-matched patients

BACKGROUND

Recent studies have suggested that transcatheter aortic valve replacement (TAVR) may have superior outcomes compared with aortic valve replacement (AVR) for high-risk patients with significant mitral regurgitation (MR). Considering significant MR is frequently addressed with a mitral valve repair or replacement (MVR) at the time of open aortic valve replacement, this study compares TAVR and AVR/MVR in propensity-matched pairs of patients with significant MR.

METHODS

We evaluated all patients presenting with moderate or greater MR undergoing either TAVR or AVR/MVR at a single institution from 2002 to 2012. Patients who underwent other cardiac operations or had preoperative endocarditis were excluded. Of 306 patients in the AVR/MVR group and 147 patients in the TAVR group, propensity analysis matched 40 pairs of patients. Standard univariate, logistic regression, and propensity matching techniques were used.

RESULTS

There was no significant difference between TAVR patients and AVR/MVR patients, respectively, in preoperative average age (76 ± 7.4 versus 78 ± 6.9 years, p = 0.68), ejection fraction (53 ± 15 versus 51 ± 17, p = 0.68), The Society of Thoracic Surgeons score (9.9 ± 3.1 versus 9.3 ± 3.4, p = 0.61), or 30-day mortality (7.5% versus 2.5%, p = 0.6). Postoperative MR was significantly improved for both TAVR and AVR/MVR, but AVR/MVR showed significantly greater improvement (-2.33 ± 1.23 versus -0.88 ± 0.79, p < 0.001). Among 30-day survivors, midterm survival was significantly better in the AVR/MVR group compared with the TAVR group (log rank p = 0.04).

CONCLUSIONS

In a propensity-matched analysis of patients with significant MR, AVR/MVR and TAVR had equivalent perioperative outcomes, but AVR/MVR had more reduction in MR and may have superior midterm survival when compared with TAVR among 30-day survivors.