Outcomes in Degenerative Mitral Regurgitation: Current State-of-the Art and Future Directions

Attaining competency and proficiency in minimally invasive mitral valve repair: a learning curve assessment using cumulative sum analysis

OBJECTIVE

To evaluate the learning curve of minimally invasive mitral valvuloplasty (MVP).

BACKGROUND

Minimally invasive MVP is characterized by minimal trauma, minimal bleeding, and short postoperative recovery time. The learning curve of any new procedure needs to be evaluated for learning and replication. However, minimally invasive mitral valve technique is a wide-ranging concept, no further analysis of the outcomes and learning curve of minimally invasive Mitral valvuloplasty has been performed.

METHODS

One hundred and fifty consecutive patients who underwent minimally invasive MVP alone without concurrent surgery were evaluated. Using cardiopulmonary bypass (CPB) time and aortic clamping (AC) time as evaluation variables, we visualized the learning curve for minimally invasive MVP using cumulative sum analysis. We also analyzed important postoperative variables such as postoperative drainage, duration of mechanical ventilation, ICU stay and postoperative hospital stay.

RESULTS

The slope of the fitted curve was negative after 75 procedures, and the learning curve could be crossed after the completion of the 75th procedure when AC and CPB time were used as evaluation variables. And as the number of surgical cases increased, CPB, AC, postoperative drainage, duration of mechanical ventilation, ICU stay and postoperative hospital stay all showed different degrees of decrease. The incidence of postoperative adverse events is similar to conventional Mitral valvuloplasty.

CONCLUSION

Compared to conventional MVP, minimally invasive MVP provides the same satisfactory surgical results and stabilization can be achieved gradually after completion of the 75th procedure.

Exercise-Induced Cardiovascular Adaptations and Approach to Exercise and Cardiovascular Disease: JACC State-of-the-Art Review

The role of the sports cardiologist has evolved into an essential component of the medical care of athletes. In addition to the improvement in health outcomes caused by reductions in cardiovascular risk, exercise results in adaptations in cardiovascular structure and function, termed exercise-induced cardiac remodeling. As diagnostic modalities have evolved over the last century, we have learned much about the healthy athletic adaptation that occurs with exercise. Sports cardiologists care for those with known or previously unknown cardiovascular conditions, distinguish findings on testing as physiological adaptation or pathological changes, and provide evidence-based and "best judgment" assessment of the risks of sports participation. We review the effects of exercise on the heart, the approach to common clinical scenarios in sports cardiology, and the importance of a patient/athlete-centered, shared decision-making approach in the care provided to athletes.

Impact of the introduction of percutaneous edge-to-edge mitral valve reconstruction on clinical practice in Germany compared to surgical valve repair

BACKGROUND

The introduction of percutaneous mitral valve (MV) repair had an effect on clinical practice in comparison with surgical MV repair. Complete nationwide data are useful in examining how the introduction of a new technique influences clinical practice.

METHODS

We analyzed procedural numbers, patient characteristics, and in-hospital outcomes for all percutaneous edge-to-edge and surgical MV reconstruction procedures performed in Germany between 2009 and 2015.

RESULTS

12,664 percutaneous edge-to-edge and 22,825 surgical MV reconstructions were recorded. Numbers increased steadily, albeit more rapidly in the percutaneous edge-to-edge group (108-4079 vs. 2923-3603 with surgical MV reconstruction). Patients with percutaneous edge-to-edge MV reconstruction were older (75.6 ± 8.8 vs 61.6 ± 13.4 years, P < 0.001) and at higher operative risk (estimated logistic EuroSCORE 13.2% vs. 4.7%, P < 0.001) compared to those undergoing surgery. However, in-hospital mortality did not differ (2.9% vs. 2.8%; P = 0.395). This was also true for the subset of 2103 patients at intermediate operative risk as defined by a logistic EuroSCORE ≥ 4% and ≤ 9%. Of note, complication rates (except acute kidney injury) were more favorable in patients undergoing percutaneous edge-to-edge reconstruction.

CONCLUSIONS

Percutaneous edge-to-edge MV reconstruction has markedly changed clinical practice of MR therapy in Germany. Annual overall procedural numbers more than doubled, with a massive increase in percutaneous edge-to-edge procedures. Our data demonstrate its use mainly in high-risk patients and prove the favorable safety profile of this novel technique, with low in-hospital mortality and complication rates.

Clinical Outcomes after Mitral Valve Repair with the Physio II Annuloplasty Ring

BACKGROUND

 Mitral valve (MV) repair with annuloplasty is the standard of care in patients with primary degenerative mitral regurgitation (DMR). Newer generations of annuloplasty rings have been developed with the goals of closer reproduction of native annular geometry and easier implantation. This study investigates the short-term and 5-year clinical outcomes of MV repair with the Carpentier-Edwards (CE) Physio II annuloplasty ring.

METHODS

 This is an observational study including a total of 486 patients who underwent MV repair for DMR using the CE Physio II annuloplasty ring between 2011 and 2016.

RESULTS

 Mean age was 54.8 ± 12.1 years, 364 patients (74.9%) were males, and 84 patients (17.3%) presented with atrial fibrillation. Mean left ventricular ejection fraction was 62.3 ± 7.3%. Mean logistic EuroSCORE was 2.7 ± 2.4%. New York Heart Association functional class III-IV symptoms were present in 134 (27.6%) patients preoperatively. Isolated MV repair was performed via a right-sided mini-thoracotomy in 479 patients (98.6%). Concomitant procedures included ablation for atrial fibrillation in 83 patients (17.1%) and closure of atrial septum defect in 88 patients (18.1%). Median size of implanted annuloplasty rings was 34 mm (interquartile range: 34-38 mm). Mean cardiopulmonary bypass time was 116 ± 34 minutes and mean cross-clamp time was 74 ± 25 minutes. Thirty-day mortality was 0.4%. The Kaplan-Meier 4-year survival was 98.5%. Freedom from MV reoperation was 96.2 and 94.0% at 1 and 4 years.

CONCLUSION

 MV repair with the CE Physio II annuloplasty ring is associated with excellent midterm clinical outcome.

Transapical off-pump mitral valve repair with NeoChord implantation: A systematic review

INTRODUCTION

Mitral valve repair (MVr) is the gold standard for the treatment of degenerative mitral valve regurgitation (MR). The recently introduced NeoChord DS1000 has gained increasing recognition as a feasible, potentially safe, and effective procedure with minor complications and promising outcomes. This study aims to conduct a systematic review of the published literature that discusses the technical feasibility and outcome of transapical off-pump MVr with NeoChord DS1000 device implantation in the treatment of degenerative MR.

METHODS

This review was performed according to the PRISMA statement. Databases searched in this review included Pubmed, Web of Science, Scopus, and Cochrane databases for systematic reviews. All English articles on humans reporting isolated MVr using NeoChord DS1000 device were included provided that basic preoperative data, operative specifications, and postoperative mortality and morbidity were reported.

RESULTS

This review included six studies comprised 249 patients who had NeoChord mitral procedure. Almost all patients included had severe MR (243/249, 97.6%). Operative success was achieved in 241 out of the 249 patients (96.8%). No intraoperative mortality was reported. Intraoperative arrhythmia was reported in six patients (2.4%) and significant bleeding was reported in eight patients (3.2%).

CONCLUSION

Awaiting more evidence, NeoChord mitral procedure appears to be a promising procedure that can be considered in selected cases.

An analysis of the cost-effectiveness of transcatheter mitral valve repair for people with secondary mitral valve regurgitation in the UK

BACKGROUND AND AIMS

A proportion of chronic heart failure (CHF) patients will experience regurgitation secondary to ventricular remodeling in CHF, known as functional mitral (MR) or tricuspid (TR) regurgitation. Its presence adversely impacts the prognosis and healthcare utilization in CHF patients. The advent of interventional devices for both atrioventricular valves modifies both aspects. We present an economic model structure suitable for comparing interventions used in MR and TR, and assess the cost-effectiveness of transcatheter mitral valve repair (TMVr) plus guideline directed medical therapy (GDMT) compared with GDMT alone in people with MR.

METHODS

An economic model with a lifetime time horizon was developed based on extrapolated survival data and using New York Heart Association classifications to describe disease severity in people with functional MR at high risk of surgical mortality or deemed inoperable. Cost and utility values (describing health-related quality-of-life) were assigned to patients dependent on their disease severity. The analysis was conducted from a UK National Health Service perspective. An incremental cost per additional quality-adjusted life year (QALY) was estimated, and sensitivity (one-way and probabilistic) and scenario analyses conducted.

RESULTS AND CONCLUSIONS

Compared with GDMT, the use of TMVr results in an additional 1.07 QALYs and an increase in costs of £32,267 per patient over a lifetime time horizon. The estimated incremental cost per QALY gained is £30,057 and would therefore be on the threshold of cost-effectiveness at £30,000 per quality adjusted life year. Thus, from a UK reimbursement perspective, in patients with severe functional MR who are at high risk of surgical mortality or deemed inoperable with conventional surgery, TMVr plus medical therapy is likely to represent a cost-effective treatment option compared with GDMT alone. The choice of device (MitraClip or PASCAL) will need to be confirmed once further clinical data are reported.

Cardiac Surgery: Beyond Conventional Sternotomy With Cardiopulmonary Bypass

Minimally invasive cardiac surgery options, which originated with off-pump coronary artery bypass grafting and aortic valve procedures, continue to evolve in order to address complex conditions, including those requiring mitral and tricuspid valve repair. Although these procedures are primarily indicated for high-risk patient populations, favorable patient outcomes have resulted in recommendations being expanded to include intermediate-risk groups. This article increases nursing-related knowledge of minimally invasive cardiac procedures, providing an overview of current minimally invasive cardiac surgeries and their associated risks and benefits.

Mitral valve leaflet repair with the new PASCAL system: early real-world data from a German multicentre experience

AIMS

To examine the clinical experience and practical use of the PASCAL transcatheter valve repair system (Edwards Lifesciences, Irvine, CA, USA) and to report some of the first clinical results.

METHODS AND RESULTS

A total of 18 consecutive patients with severe, symptomatic mitral regurgitation (MR) were included in this German multicentre registry. All patients underwent clinical, echocardiographic, and laboratory assessment prior to the PASCAL procedure and before hospital discharge. MR was classified as functional in 6 patients, degenerative in 2, and combined in 10. All except one received a single PASCAL implant. The preprocedural severe MR present in all patients was reduced: grade 0 in 4 (22.2%), grade I in 11 (61.1%), grade II in 3 (16.7%). The v-wave was significantly reduced from 31.7 ± 9.5 to 18 ± 7.7 mmHg (p < 0.001). Independent leaflet capture, performed in 4 (22.2%) of the patients, wide clasps, and the 10-mm central spacer are features of the PASCAL device to optimize mitral leaflet repair. There were no periprocedural complications.

CONCLUSION

PASCAL is a safe and effective mitral valve repair device for the treatment of severe MR. Device-specific features allow valve repair tailored to the individual anatomy of the underlying mitral pathology in each patient.

Repair of bileaflet prolapse in Barlow syndrome: The 4-chord technique

Barlow syndrome is a form of degenerative mitral valve (MV) disease found in a subset of patients with bileaflet prolapse. The hallmark of Barlow's disease includes excessive and billowing leaflet tissue caused by myxomatous tissue proliferation, elongated chordae, and pronounced annular dilatation. Surgical repair of patients with Barlow's disease is challenging due to the extent of the leaflet and annular abnormalities. Several techniques have been described to repair Barlow's MV including currently popular "non-resectional" approaches. Repair with neochordae has been associated with excellent results and includes the advantage of preserved leaflet mobility and a large surface of coaptation. We describe a simple approach to the use of neochordae to repair bileaflet prolapse in patients with Barlow syndrome and avoid systolic anterior motion.

Echocardiographic indices and severity of mitral regurgitation in dogs with preclinical degenerative mitral valve disease

Background

Describing severity of mitral regurgitation (MR) in dogs with degenerative mitral valve disease (DMVD) is challenging.

Hypothesis/Objectives

Mitral regurgitant fraction (RF), effective regurgitant orifice area (EROA), and the ratio of mitral regurgitant to aortic flow (Q_MR:Q_Ao) can be calculated from routine echocardiographic measurements and provide additional information regarding MR severity.

Animals

Fifty‐seven dogs with preclinical DMVD including 36 without and 21 with cardiomegaly.

Methods

Prospective observational study. The expected relationships among RF, EROA, and Q_MR:Q_Ao and 1‐dimensional measurements including left atrium to aortic root diameter ratio (LA:Ao) and normalized left ventricular internal dimension at end‐diastole (LVIDdN) were mathematically derived and calculated using echocardiographic data from the study population. Nonlinear goodness of fit was determined by calculation of the root mean standard error. The correlations between 1‐dimensional and multidimensional indices were analyzed using receiver operating characteristic curves.

Results

The relationships among RF, EROA, Q_MR:Q_Ao, and both LA:Ao and LVIDdN were curvilinear, and the multidimensional indices differentiated MR of variable severity. By contrast, 1‐dimensional measurements were insensitive to MR severity until RF equaled or exceeded 50%. Regurgitant fraction ≥50%, EROA to body surface area ≥0.347 and Q_MR:Q_Ao ≥0.79 were strongly associated with LA:Ao ≥1.6 and LVIDdN ≥1.7.

Conclusions and Clinical Importance

Regurgitant fraction, EROA, and Q_MR:Q_Ao quantify MR severity in dogs with preclinical DMVD in a manner that 1‐dimensional measurements do not.

Exercise recommendations in patients with valvular heart disease

Valvular heart disease affects 1%-2% of young individuals, many of whom aspire to partake in competitive sport or high intensity recreational exercise. There are limited reports on the impact of intensive physical activity on the progression of valvular heart disease; therefore, current recommendations are based on consensus opinion. The management of exercising individuals with valvular heart disease requires a structured approach that incorporates several key factors including symptomatic status, functional capacity, type and nature of the valvular lesion, impact on ventricular structure and function and effect on pulmonary artery pressure. Asymptomatic individuals with minor valvular abnormalities may engage in all forms of competitive sport, whereas those with lesions of moderate severity may exercise intensively if an exercise stress test tailored to the relevant physical activity reveals good functional capacity without myocardial ischaemia, haemodynamic disturbances or arrhythmia. Symptomatic athletes and those with severe valvular heart disease, impaired ventricular function, pulmonary hypertension and arrhythmias should refrain from most competitive sports. Athletes with a bicuspid aortic valve and aortic root diameter >40 mm should avoid sport with a strong isometric component even with minimal valvular dysfunction. There is an association between mitral valve prolapse and sudden cardiac death in the general population; however, there is limited evidence of increased risk with competitive sport. Athletes undergoing corrective surgery may return to exercise after 3 months if ventricular function and exercise capacity are preserved. Individuals anticoagulated for mechanical bioprosthetic valves should avoid contact or collision sport to minimise the risk of bleeding.

The aging heart

As the elderly segment of the world population increases, it is critical to understand the changes in cardiac structure and function during the normal aging process. In this review, we outline the key molecular pathways and cellular processes that underlie the phenotypic changes in the heart and vasculature that accompany aging. Reduced autophagy, increased mitochondrial oxidative stress, telomere attrition, altered signaling in insulin-like growth factor, growth differentiation factor 11, and 5'- AMP-activated protein kinase pathways are among the key molecular mechanisms underlying cardiac aging. Aging promotes structural and functional changes in the atria, ventricles, valves, myocardium, pericardium, the cardiac conduction system, and the vasculature. We highlight the factors known to accelerate and attenuate the intrinsic aging of the heart and vessels in addition to potential preventive and therapeutic avenues. A greater understanding of the processes involved in cardiac aging may facilitate our ability to mitigate the escalating burden of CVD in older individuals and promote healthy cardiac aging.