Influence of age on outcomes in patients undergoing mitral valve replacement

Mitral valve surgery in octogenarians: long-term and hemodynamic results

BACKGROUND

Octogenarians are often denied mitral valve (MV) surgery secondary to concerns over increased perioperative morbidity and mortality. The objective of this study was to examine the outcomes of octogenarians undergoing mitral valve repair (MVr) and replacement (MVR).

METHODS

The outcomes of 139 patients between the ages of 80-90 who underwent MVR/MVr between 2004-2018 at the Mazankowski Alberta Heart Institute (Edmonton, AB, Canada) were retrospectively analyzed. Follow-up was extended to a maximum of 15.8 years.

RESULTS

Following MVR, all-cause mortality at 30 days, 1 year, 5 years, 10 years, and the longest follow-up was 7%, 14%, 36.3%, 61.8%, and 67.7%, respectively. Post-MVr, all-cause mortality at the same time points was 1.9%, 7.6%, 22.5%, 55.5%, and 100%, respectively. During the Hospitalization Index, rates of new-onset atrial fibrillation, sepsis, acute kidney injury, superficial sternal wound infection, deep sternal wound infection, mediastinal bleeding, and permanent pacemaker insertion ranged from 22.1-34.0%, 3.8-11.0%, 7.6-22.0%, 1.9-2.4%, 0-1.2%, 0%, and 0-6.1%, respectively. Rates of overall rehospitalization, as well as readmission for heart failure, stroke, myocardial infarction, and MV reoperation ranged from 71.0-85.5%, 52.2-63.3%, 10.9-22.8%, 1.9-6.0%, and 0% during the follow-up period. There were significant reductions in peak MV gradient (P=0.042) and left ventricular internal diameter in diastole (LVIDd; P=0.008) post-MVR, as well as LVIDd (P<0.001) and Left Atrial (LA) Volume Index (P=0.019) post-MVr.

CONCLUSIONS

Octogenarians exhibit positive left atrial and left ventricular remodeling following MVR. Perioperative morbidity is low, late survival is reasonable, and long-term morbidity is considerable. Overall, these results add to the growing literature that MV surgery is relatively safe and effective in octogenarians.

Remimazolam for simultaneous percutaneous mitral valve clip and percutaneous left atrial appendage closure in an elderly patient with impaired cardiac function: A case report

Remimazolam is a short-acting benzodiazepine sedative with a short half-life and little circulatory depression. The safe use of remimazolam in the anesthetic management of an elderly patient with impaired cardiac function is reported. The patient's hemodynamics remained stable, and the patient was managed without serious complications. Remimazolam may be an option for sedation in elderly patients with reduced cardiac function.

Impact of Bariatric Surgery on Mortality of Mitral Valve Surgery: A National Analysis

OBJECTIVE

Obesity is a common comorbidity of cardiac surgery patients. The goal of this study is to determine if a lower weight achieved through bariatric surgery has any association with mitral valve (MV) replacement or repair surgery mortality.

METHODS

This study used a retrospective analysis of the National Inpatient Sample dataset from 2012 to 2020. Adult patients who underwent MV surgery with normal weight following bariatric surgery (n = 1,125) and patients with obesity (n = 48,555) were compared. The primary outcome was in-hospital mortality.

RESULTS

This study included 49,680 patients. The median age was 64 (55 to 71) years, and the majority were female (55%). Bariatric surgery was found to significantly decrease the odds of mortality, even after adjusting for important covariates, indicating a reduction of mortality risk by 54% (adjusted odds ratio = 0.46, p = 0.024). Other significant protective factors include isolated and elective surgery. Significant risk factors were older age, female sex, and diabetes mellitus. Patients who were obese demonstrated longer lengths of stay (LOS), greater transfers to other facilities, and higher hospital costs.

CONCLUSIONS

In patients receiving MV surgery, bariatric surgery demonstrated significant survival benefits during hospitalization, in addition to reducing LOS and cost. Our data support prior evidence of bariatric surgery improving cardiovascular outcomes. Therefore, bariatric surgery may be a meaningful method of weight loss to improve surgical patient outcomes in patients with obesity. However, longer-term data are needed.

Isolated Minimally Invasive Mitral Valve Surgery in Octogenarians: Perioperative Outcome

INTRODUCTION

Despite the feasibility, safety, and excellent outcomes of mitral valve surgery through a right mini-thoracotomy, there is data paucity about its use in octogenarians. In this study, we assess the outcomes of mitral valve surgery via right mini-thoracotomy in octogenarians.

METHODS

We performed a retrospective analysis of the in-hospital perioperative data of 38 octogenarian patients with severe mitral regurgitation undergoing isolated mitral valve surgery via right mini-thoracotomy from 2013 to 2021 in our institution.

RESULTS

The median patient age was 82 (81-83) years, and the median EuroSCORE II was 3.1% (2.3-4.9). A total of 19 (50%) patients underwent mitral valve repair. The median cardiopulmonary bypass duration was 78 (54-100) min and the median aortic cross-clamping duration was 57 (40-70) min. Two (5.3%) patients were converted to sternotomy, 1 (2.6%) underwent renal replacement therapy, 5 (13.2%) underwent reexploration for bleeding or tamponade, and 12 (31.6%) underwent permanent pacemaker implantation. The surgical repair success rate was 89.5%, with 2 (10.5%) patients requiring reoperation due to repair failure. No other patients required reoperation on the mitral valve. The median intensive care unit stay was 1 (1-2) day, and the median postoperative stay was 9.5 (8-14) days. There was no perioperative stroke or death.

CONCLUSION

Despite a relatively increased risk of pacemaker implantation and reexploration for bleeding, our data support the feasibility of mitral valve surgery via a right mini-thoracotomy in octogenarians, with short ischemic times, low overall in-hospital morbidity, and no mortality. Preferring replacement in mitral diseases with a high risk for repair failure could minimize reoperations in this high-risk subgroup.

Dexmedetomidine as an anesthetic adjunct is associated with reduced complications and cardiac intensive care unit length of stay after heart valve surgery

BACKGROUND

We sought to explore the relationship between dexmedetomidine as an anesthetic adjuvant in cardiac surgery and postoperative complications and length of stay (LOS) in the cardiac intensive care unit (CICU).

METHODS

We conducted a retrospective study of patients aged 18 years and older who underwent heart valve surgery between October 2020 and June 2022. The primary endpoint of the study was major postoperative complications (cardiac arrest, atrial fibrillation, myocardial injury/infarction, heart failure) and the secondary endpoint was prolonged CICU LOS (defined as LOS > 90th percentile). Multivariate logistic regression analysis was performed for variables that were significant in the univariate analysis.

RESULTS

A total of 856 patients entered our study. The 283 patients who experienced the primary and secondary endpoints were included in the adverse outcomes group, and the remaining 573 were included in the prognostic control group. Multivariate logistic regression analysis revealed that age > 60 years (odds ratio [OR], 1.68; 95% confidence interval [CI], 1.23-2.31; p < 0.01), cardiopulmonary bypass (CPB) > 180 min (OR, 1.62; 95% CI, 1.03-2.55; p = 0.04) and postoperative mechanical ventilation time > 10 h (OR, 1.84; 95% CI, 1.35-2.52; p < 0.01) were independent risk factors for major postoperative complications; Age > 60 years (OR, 3.20; 95% CI, 1.65-6.20; p < 0.01), preoperative NYHA class 4 (OR, 4.03; 95% CI, 1.74-9.33; p < 0.01), diabetes mellitus (OR, 2.57; 95% CI, 1.22-5.41; p = 0.01), Intraoperative red blood cell (RBC) transfusion > 650 ml (OR, 2.04; 95% CI, 1.13-3.66; p = 0.02), Intraoperative bleeding > 1200 ml (OR, 2.69; 95% CI, 1.42-5.12; p < 0.01) were independent risk factors for prolonged CICU length of stay. Intraoperative use of dexmedetomidine as an anesthetic adjunct was a protective factor for major complications (odds ratio, 0.51; 95% confidence interval, 0.35-0.74; p < 0.01) and prolonged CICU stay. (odds ratio, 0.37; 95% confidence interval, 0.19-0.73; p < 0.01).

CONCLUSIONS

In patients undergoing heart valve surgery, age, duration of cardiopulmonary bypass, and duration of mechanical ventilation are associated with major postoperative complication. Age, preoperative NYHA classification 4, diabetes mellitus, intraoperative bleeding, and RBC transfusion are associated with increased CICU length of stay. Intraoperative use of dexmedetomidine may improve such clinical outcomes.

Contemporary treatment of mitral valve disease with transcatheter mitral valve implantation

BACKGROUND

Transcatheter mitral valve implantation (TMVI) with self-expanding (SAV) or balloon-expandable (BAV) valves are rising as promising treatment options for high-risk patients with symptomatic mitral valve (MVD) disease unsuitable for alternative treatment options.

AIMS

The aim of this study was to examine the clinical, procedural and outcome parameters of patients undergoing SAV or BAV for MVD.

METHODS

In this observational and single-center case series, fifteen consecutive patients treated with the Tendyne Mitral Valve System (SAV) and thirty-one patients treated with SAPIEN prosthesis (BAV) were included.

RESULTS

The patients (aged 78 years [interquartile range (IQR): 65.5 to 83.1 years], 41% women, EuroSCORE II 10.3% [IQR: 5.5 to 17.0%] were similar regarding baseline characteristics, despite a higher rate of prior heart valve surgery and prevalence of MV stenosis in the SAV-group. At discharge, the SAV-group had a mean transvalvular gradient of 4.2 mmHg, whereas the BAV-group had a mean transvalvular gradient of 6.2 mmHg. None or trace paravalvular leakage (PVL) was assessed in 85% in SAV-group and 80% in the BAV-group. 320 day all-cause and cardiac mortality rates were comparable in both groups (SAV: 26.7% vs BAV: 20%, p = 0.60). Four deaths occurred early in the SAV-group until 32 days of follow-up.

CONCLUSIONS

In high-risk patients with MVD, TMVI presents a promising treatment option with encouraging mid-term outcomes and good valve durability. TMVI either with BAV or SAV may be developed to an established treatment option.

Contemporary outcomes of mitral valve replacement in octogenarians

AIM OF THE STUDY

We aimed to determine the outcomes of contemporary mitral valve replacement (MVR) in octogenarians, for rational treatment selection in a patient cohort.

METHODS

Between 2007 and 2018, 656 consecutive MVRs were performed. Among these cases, 109 patients were aged 80 years or older, and 547 patients were younger than 80 years. Isolated MVRs were performed in 211 patients, of whom 36 were aged 80 years or older. Perioperative mortality and complications were compared between the two groups, adjusted by propensity score.

RESULTS

In-hospital mortality of the entire MVR (<80: 26 [4.8%] vs. ≥80: 6 [5.5%], p = .81) and isolated MVR (<80: 6 [3.4%] vs. ≥80: 1 [2.8%], p > .99) groups were similar. Age >80 years did not influence in-hospital mortality (hazard ratio [HR], 1.07; 95% confidence interval [CI], 0.36-3.14, p = .9), stroke (HR, 1.12; 95% CI, 0.19-6.71, p = .9), hemodialysis (HR, 1.44; 95% CI, 0.45-4.66, p = .54), or prolonged ventilation (HR, 1.61; 95% CI, 0.81-3.23, p = .18), but influenced the incidence of reopening for bleeding (HR, 3.97; 95% CI, 1.11-14.19, p = .03). Cox proportional hazard model results showed that age >80 years did not affect cardiac death (HR, 1.45, 95% CI: 0.67-3.12, p = .35), bleeding events (HR, 1.89, 95% CI: 0.84-4.27, p = .13), or stroke (HR, 1.51, 95% CI: 0.54-4.21, p = .44) during the follow-up period.

CONCLUSIONS

The perioperative and follow-up outcomes of MVR in octogenarians were not inferior to those of younger patients. We should not hesitate to conduct MVR on the grounds of old age.

Mitral valve repair in chronic severe mitral regurgitation: short-term results and analysis of mortality predictors

Introduction

Mitral valve repair is the accepted treatment for mitral regurgitation (MR) but lack of resources and socioeconomic concerns delay surgical referral and intervention in developing countries. We evaluated immediate and short-term results of mitral valve repair for non-ischemic MR at our centre and aimed to identify the predictors of in-hospital and follow-up mortality.

Materials and methods

The study was conducted at a tertiary-level hospital in South India. All patients >18 years with severe non-ischemic MR who underwent mitral valve repair over a period of 6 years were included. Perioperative data was collected from hospital records and follow-up data was obtained by prospective methods.

Results

There were 244 patients (170 males). Most of the patients were in the age group 31-60 years (76.6%). Aetiology of MR was degenerative (n = 159; 65.2%), rheumatic (n = 34; 13.9%), structural (n = 42; 17.2%), or miscellaneous (n = 9; 3.7%). All patients underwent ring annuloplasty with various valve repair techniques. One hundred patients (44.7%) underwent additional cardiac procedures. At discharge, MR was moderate in 4 patients; the rest had no or mild MR. The mean hospital stay of survivors was 7.1 days (SD 2.52, range 5-25 days). There were 9 in-hospital deaths (3.68%) and 10 deaths during follow-up (4.2%). The mean follow-up period was 1.39 years, complete for 87.6%. Pre-operative left ventricle ejection fraction (LVEF) <60% (p = 0.04) was found to be significantly associated with immediate mortality. Logistic regression analysis detected age (p = 0.019), female sex (p = 0.015), and left ventricular (LV) dysfunction at discharge (p = 0.025) to be significantly associated with follow-up mortality.

Conclusion

Pre-operative LV dysfunction was identified as a significant risk factor for in-hospital mortality. Female sex, age greater than 45 years, and LV dysfunction at discharge were found to be significantly associated with follow-up mortality. Hence, it is important to perform mitral valve repair in severe regurgitation patients before significant LV dysfunction sets in for a better outcome.

Transcatheter mitral valve replacement: latest advances and future directions

Mitral regurgitation remains the most common form of valve disease worldwide and given an aging population with a significant proportion of secondary mitral regurgitation, a transcatheter approach to mitral valve replacement has become a major goal of the transcatheter therapeutics field. Mitral regurgitation can be caused by disease of the leaflets (primary) or by diseases of the left atrium or left ventricle (LV) (secondary or functional), and may involve overlap of the two (mixed disease). The location of the mitral valve (and large size), the approach to anchoring a valve replacement, and concerns about left ventricular outflow tract (LVOT) obstruction are all issues that have made the transcatheter delivery of a valve replacement challenging. Despite these challenges, both transapical and transseptal devices are currently being developed, with several in early feasibility trials and several entering pivotal trials. As the field of transcatheter mitral valve replacement (TMVR) improves and develops, a critical part of evaluating patients with mitral valve disease will be utilizing the heart team approach to identify and individualize the most appropriate treatment for each patient.

Transcatheter Mitral Valve Replacement: Rationale and Current Status

Mitral regurgitation (MR) is the most prevalent form of moderate or severe valve disease in the developed world. MR can result from impairment of any part of the mitral valve apparatus and is classified as primary (disease of the leaflets) or secondary (functional). The presence of at least moderate MR is associated with increased morbidity and mortality. With the goal of avoiding the risks of traditional surgery, transcatheter mitral valve therapies have been developed. The current transcatheter repair techniques are limited by therapeutic target and incomplete MR reduction, and thus transcatheter mitral valve replacement (TMVR) has been pursued. Several devices (both transapical and transseptal) are under development, with both early feasibility and pivotal trials under way. As this field develops, the decision to treat with TMVR will require a heart team approach that takes patient-, disease-, and device-specific factors into account.

Transcatheter or surgical repair for degenerative mitral regurgitation in elderly patients: A propensity-weighted analysis

OBJECTIVE

To compare the outcomes of MitraClip and surgical mitral repair in low-intermediate risk elderly patients affected by degenerative mitral regurgitation (DMR).

METHODS

We retrospectively selected patients aged ≥75 years, with Society of Thoracic Surgeons Predicted Risk Of Mortality (STS-PROM) <8%, submitted to MitraClip (n = 100) or isolated surgical repair (n = 206) for DMR at 2 centers between January 2005 and May 2017. To adjust for baseline imbalances, we used a propensity score model for average treatment effect on survival.

RESULTS

After weighting, MitraClip showed fewer postoperative complications (P < .05) but increased residual mitral regurgitation (MR) ≥2 (27.0% vs 2.8%, P < .001) compared with surgery. One-year survival was greater after MitraClip compared with surgery (97.6% vs 95.3%, hazard ratio [HR], 0.09; confidence interval [CI], 0.02-0.37, P = .001), whereas 5-year survival was lower (34.5% vs 82.2% respectively, HR, 4.12; CI, 2.31-7.34, P < .001). Greater STS-PROM (HR, 1.18; CI, 1.12-1.24, P < .001) and MR ≥3+ recurrence (HR, 2.18; CI, 1.07-4.48, P = .033) were associated with reduced survival. 5-year MR ≥3+ was more frequent after MitraClip compared with surgery: 36.9% versus 3.9%, odds ratio, 11.4; CI, 4.40-29.68, P < .001.

CONCLUSIONS

In elderly patients affected by DMR and STS-PROM <8%, the average effect of MitraClip resulted in lower acute postoperative complications and improved 1-year survival compared with surgery. However, MitraClip was associated with greater MR recurrence and reduced survival beyond 1 year. Long-term survival was impaired by patients' greater risk profile and MR recurrence. Early results are promising, but in the setting of operable patients with life expectancy beyond 1 year, the quality bar for transcatheter mitral repair needs to be raised.

Transcatheter mitral valve intervention: an emerging treatment for mitral regurgitation

Mitral regurgitation (MR) is a valvular heart disease associated with significant morbidity and mortality. Transcatheter mitral valve intervention (TMVI) repairs or replaces the mitral valve through small arterial and venous entry sites and so avoids risks associated with open heart surgery. Transcatheter devices targeting components of the mitral apparatus are being developed to repair or replace it. Numerous challenges remain including developing more adaptable devices and correction of multiple components of the mitral annulus to attain durable results. The mitral valve apparatus is a complex structure and understanding of the mechanisms of MR is essential in the development of TMVI. There will likely be a complementary role between surgery and TMVI in the near future.

Role of MDCT Imaging in Planning Mitral Valve Intervention

PURPOSE OF REVIEW

Recent advancements in transcatheter valvular interventions have resulted in a growing demand for advanced cardiac imaging to help guide these procedures.

RECENT FINDINGS

Both echocardiography and multi-detector computed tomography have played essential roles in the maturation of transcatheter aortic valve replacement and are now building on these experiences and helping inform the nascent field of transcatheter mitral interventions. Advanced imaging is essential to aid in the diagnosis and determination of the mechanism of mitral regurgitation. In addition, they are integral to annular sizing, determination of the suitability of patient anatomy for specific devices and increasingly important in the determination of the risk of left ventricular outflow tract obstruction and providing appropriate patient-specific fluoroscopic angulation in advance of the procedure.

Outcomes and Predictors of Mortality After Mitral Valve Surgery in High-Risk Elderly Patients: The Heidelberg Experience

Background

Overall, life expectancy at the age of 80 has significantly increased in the industrialized world and the proportion of this age class undergoing cardiac surgery has also grown. In this context, we have analyzed a contemporary series of octogenarians undergoing mitral valve surgery at our institution.

Material/Methods

We performed a retrospective analysis of 138 consecutive octogenarians receiving mitral valve surgery between January 2006 and April 2017. Preoperative comorbidities, early mortality, postoperative clinical course, and predictors of mortality were examined.

Results

The mean age was 82.4±2.0 years and 50% (n=69) were male. Preoperative comorbidities included history of heart infarction (24.6%, n=34), chronic renal failure (37.7%, n=52), and COPD (27.5%, n=38). A total of 52.9% (n=73) had a history of previous cardiac decompensation, while 20 (14.5%) presented with cardiogenic shock or cardiac arrest. In all, 33 patients (23.9%) underwent emergency surgery. There were only 39 isolated mitral valve procedures, while 99 patients (71.7%) underwent various concomitant procedures. The intensive care unit average length of stay was 5.3±7.5 days. Respiratory complications and sepsis were the most frequent postoperative complications. Emergency surgery and concomitant coronary artery bypass grafting were the most important predictors of early mortality. The overall 30-day mortality was 18.1% (n=25). The mean follow-up time was 1.7±2.3 years.

Conclusions

Octogenarians are increasingly represented in cardiac surgery and combined procedures. Prudent patient selection is necessary for optimizing postoperative outcomes among the elderly. In our seriously ill octogenarian cohort, mitral valve surgery was associated with moderate but acceptable mid-term survival.

Predictors of survival in octogenarians after mitral valve surgery for degenerative disease: The Mitral Surgery in Octogenarians study

OBJECTIVES

An increasing number of octogenarians are referred to undergo mitral valve surgery for degenerative disease, and percutaneous approaches are being increasingly used in this subgroup of patients. We sought to determine the survival and its predictors after Mitral Valve Surgery in Octogenarians (MiSO) in a multicenter UK study of high-volume specialized centers.

METHODS

Pooled data from 3 centers were collected retrospectively. To identify the predictors of short-term composite outcome of 30 days mortality, acute kidney injury, and cerebrovascular accident, a multivariable logistic regression model was developed. Multiple Cox regression analysis was performed for late mortality. Kaplan-Meier curves were generated for long-term survival in various subsets of patients. Receiver operating characteristic analysis was done to determine the predictive power of the logistic European System for Cardiac Operative Risk Evaluation.

RESULTS

A total of 247 patients were included in the study. The median follow-up was 2.9 years (minimum 0, maximum 14 years). A total of 150 patients (60.7%) underwent mitral valve repair, and 97 patients (39.3%) underwent mitral valve replacement. Apart from redo cardiac surgery (mitral valve repair 6 [4%] vs mitral valve replacement 11 [11.3%], P = .04) and preoperative atrial fibrillation (mitral valve repair 79 [52.6%] vs mitral valve replacement 34 [35.1%], P < .01), there was no significant difference in terms of any other preoperative characteristics between the 2 groups. Patient operative risk, as estimated by logistic European System for Cardiac Operative Risk Evaluation, was lower in the mitral valve repair group (10.2 ± 11.8 vs 13.7 ± 15.2 in mitral valve replacement; P = .07). No difference was found between groups for duration of cardiopulmonary bypass and aortic crossclamp times. The 30-day mortality for the whole cohort was 13.8% (mitral valve repair 4.7% vs mitral valve replacement 18.6%; P < .01). No differences were found in terms of postoperative cerebrovascular accident (2% vs 3.1%; P = .9), acute kidney injury requiring dialysis (6.7% vs 13.4%; P = .12), and superficial or deep sternal wound infection (10% vs 16.5%, P = .17; 2% vs 3.1%, P = .67, respectively). The final multiple regression model for short-term composite outcome included previous cardiac surgery (odds ratio [OR], 4.47; 95% confidence interval [CI], 1.37-17.46; P = .02), intra-aortic balloon pump use (OR, 4.77; 95% CI, 1.67-15.79; P < .01), and mitral valve replacement (OR, 7.7; 95% CI, 4.04-14.9; P < .01). Overall survival for the entire cohort at 1, 5, and 10 years was 82.4%, 63.7%, and 45.5% (mitral valve repair vs mitral valve replacement: 89.9% vs 70.7% at 1 year, 69.6% vs 54% at 5 years, and 51.8% vs 35.5% at 10 years; P = .0005). Cox proportional hazard model results showed mitral valve replacement (hazard ratio, 1.88; 95% CI, 1.22-2.89; P < .01) and intra-aortic balloon pump use (hazard ratio, 2.54; 95% CI, 1.26-5.13; P < .01) to be independent predictor factors affecting long-term survival. Logistic European System for Cardiac Operative Risk Evaluation did not perform well in predicting early mortality (area under the curve, 0.57%).

CONCLUSIONS

In octogenarians, mitral valve repair for degenerative disease is associated with good survival and remains the gold standard, whereas mitral valve replacement is still associated with significant mortality. Logistic European System for Cardiac Operative Risk Evaluation was unable to predict early mortality in our cohort of patients. Larger international multicenter registries are required to optimize the decision-making process in such a high-risk subgroup.

Carotid artery stenosis as an independent risk factor for perioperative strokes following mitral valve surgical intervention

OBJECTIVE

To examine the role of carotid stenosis (CS) and other independent risk factors of perioperative stroke following either mitral valve repair or replacement.

METHODS

Using data from the National Inpatient Sample (NIS) database for analysis, all patients who underwent either mitral valve repair or replacement were identified using ICD-9 codes.

RESULTS

A total of 79,583 patients who underwent either mitral valve replacement or repair were studied. 3.39% of the total cohort developed perioperative stroke. With a mean age of 62.78±0.23, there was a statistically significant amount of stroke cases in age ranges 65-74 and 75-84 (p<0.05). Risk stratification was done using Van Walraven (VWR) scoring and the cohort had a mean of 2.73±0.06. The following independent predictors were found to be significant: age, female gender, moderate and high VWR risk, both symptomatic and asymptomatic CS, atrial fibrillation, previous h/o smoking, and other cardiac valve procedures performed, and congestive heart failure (CHF).

CONCLUSION

CS is a significant risk factor for perioperative strokes following mitral valve surgery. Further prospective clinical studies are needed that look into risk stratification of patients for better patient selection and the question of whether carotid revascularization procedures will be beneficial in reducing stroke rates.

Initial surgery versus conservative management of symptomatic severe mitral regurgitation in the elderly

OBJECTIVE

In elderly patients, the benefit of surgical correction of severe mitral regurgitation (MR) may not be greater than the operative risk. This study sought to compare the long-term clinical outcomes between initial surgery and conservative management in elderly patients (≥70 years of age) with severe MR.

METHODS

We prospectively evaluated 157 consecutive patients (75 men, 74±4 years of age) with severe degenerative MR and mild symptoms. Mitral valve surgery was performed on 79 (initial surgery group), whereas the conservative strategy was chosen for 78 patients (conservative management group). We compared the overall and cardiac mortality and cardiac event between strategies in the overall and propensity-matched cohort (46 pairs).

RESULTS

During the median follow-up of 5.4 years, overall death occurred less in the initial surgery group (16 vs 37 patients). This group showed reduced cardiac mortality (HR 0.31; 95% CI 0.13 to 0.73; p=0.007), overall mortality (HR 0.39; 95% CI 0.21 to 0.74; p=0.004) and cardiac event (HR 0.26; 95% CI 0.13 to 0.53; p<0.001). A significant reduction in cardiac mortality (HR 0.18; 95% CI 0.05 to 0.63; p=0.007), overall mortality (HR 0.36; 95% CI 0.15 to 0.86; p=0.022) and cardiac event (HR 0.20; 95% CI 0.07 to 0.52; p=0.001) in the initial surgery group was also observed in the propensity-matched cohort.

CONCLUSIONS

In elderly patients with severe degenerative MR and mild symptoms, initial surgical strategy was associated with significant long-term reductions in cardiac and overall mortality compared with conservative management.

Transapical mitral valve implantation after unclipping of a MitraClip: a glimpse into the future and treatment considerations in mitral regurgitation

AIMS

Transcatheter mitral valve implantation (TMVI) is a novel approach that may enable a less invasive effective reduction of mitral regurgitation (MR). A limitation of the MitraClip is that definitive implantation of a clip precludes future therapy with TMVI. The purpose of this paper is to describe contemporary treatment considerations in patients with mitral valve regurgitation.

METHODS AND RESULTS

In this report we describe an attempted MitraClip implantation which resulted in no reduction of MR severity. There was a consensus that additional clips would probably not be effective. MitraClip implantation was therefore abandoned and the clip was removed, allowing subsequent successful TMVI with the Tiara™ system three weeks later. Echocardiography revealed secure seating of the prosthesis with good mitral valve function, trivial paravalvular leakage and transvalvular gradient of 3 mmHg. The patient recovered rapidly and was discharged four days post implant.

CONCLUSIONS

The clinical approach towards high-risk patients with significant MR may change in the next few years. In selected patients, in whom an initial attempt with MitraClip implantation results in only limited efficacy, the clip may be retrieved during the index procedure to allow subsequent TMVI.

Cardiovascular Surgery in the Elderly

The elderly population is the fastest growing demographic in Western countries. As the population ages, the incidence of age-related comorbidities such as diabetes mellitus, chronic obstructive pulmonary disease, peripheral vascular disease, renal disease, cerebrovascular disease, and cardiovascular disease increases. With cardiovascular disease occurring in approximately one-quarter of the population over the age of 75 years and more than half of all cardiac procedures performed on this age group, the number of potential elderly surgical candidates is increasing. However, data suggest that old age is associated with increased morbidity and mortality following cardiac surgery. Over the past 2 decades, improvements in myocardial protection, extracorporeal circulation, anesthesia, and surgical techniques have significantly reduced the morbidity and mortality associated with cardiac surgery. Although most prospective studies exclude elderly patients, data from large retrospective studies and subgroup analyses suggest that cardiac surgery is a viable option for many elderly patients with cardiovascular disease, with good outcomes observed in reasonable-risk candidates; moreover, there are a growing number of available less-invasive options for them when surgical risk becomes prohibitive. In this article, we discuss the current state of cardiovascular surgery in the elderly as well as emerging technologies on the horizon.

The role of age and comorbidities in postoperative outcome of mitral valve repair: A propensity-matched study

The average age of patients undergoing mitral valve repair is increasing each year. This retrospective study aimed to compare postoperative complications of mitral valve repair (known to be especially high-risk) between 2 age groups: under and over the age of 80.Patients who underwent mitral valve repair were divided into 2 groups: group 1 (<80 years old) and group 2 (≥80 years old). Baseline characteristics, pre- and postoperative hemodynamic data, surgical characteristics, and postoperative follow-up data until hospital discharge were collected.A total of 308 patients were included: 264 in group 1 (age 63 ± 13 years) and 44 in group 2 (age 83 ± 2 years). Older patients had more comorbidities (atrial fibrillation, history of cardiac decompensation, systemic hypertension, pulmonary hypertension, and chronic kidney disease) and they presented more postoperative complications (50.0% vs 33.7%; P = 0.043), with a longer hospital stay (8.9 ± 6.9 vs 6.6 ± 4.6 days; P = 0.005). To assess the burden of age, a propensity score was awarded to postoperative complications. Active smoking, chronic pulmonary disease, chronic kidney disease, associated ischemic heart disease, obesity, and cardio pulmonary by-pass duration were described as independent risk factors. When matched on this propensity score, there was no difference in morbidity or mortality between group 1 and group 2.Older patients suffered more postoperative complications, which were related to their comorbidities and not only to their age.

Transcatheter mitral valve implantation with Tiara bioprosthesis

Mitral valve surgery is the gold standard therapy for severe mitral regurgitation, but can be associated with significant morbidity and mortality. Percutaneous mitral leaflet repair has recently been established as a viable alternative to surgery, but many patients are ineligible and repair may not be optimal. Transcatheter mitral valve implantation may be an alternate therapeutic option, particularly for high-risk patients. We outline the initial preclinical and first-in-human experience with the Tiara transapical mitral valve implantation system, highlighting the ease of implantation, proven feasibility and excellent haemodynamic performance.

A systematic review and meta-analysis of surgical outcomes following mitral valve surgery in octogenarians: implications for transcatheter mitral valve interventions

AIMS

To evaluate the outcomes of mitral valve surgery in octogenarians with severe symptomatic mitral regurgitation (MR).

METHODS AND RESULTS

We performed a systematic review and meta-analysis of data on octogenarians who underwent mitral valve replacement (MVR) or mitral valve repair (MVRpr). Our search yielded 16 retrospective studies. Using Bayesian hierarchical models, we estimated the pooled proportion of 30-day mortality, postoperative stroke, and long-term survival. The pooled proportion of 30-day postoperative mortality was 13% following MVR (10 studies, 3,105 patients, 95% credible interval [CI] 9-18%), and 7% following MVRpr (six studies, 2,642 patients, 95% CI: 3-12%). Furthermore, pooled proportions of postoperative stroke were 4% (six studies, 2,945 patients, 95% CI: 3-7%) and 3% (three studies, 348 patients, 95% CI: 1-8%) for patients undergoing MVR and MVRpr, respectively. Pooled survival rates at one and five years following MVR (four studies, 250 patients) were 67% (95% CI: 50-80%) and 29% (95% CI: 16-47%), and following MVRpr (three studies, 333 patients) were 69% (95% CI: 50-83%) and 23% (95% CI: 12-39%), respectively.

CONCLUSIONS

Surgical treatment of MR in octogenarians is associated with high perioperative mortality and poor long-term survival with an uncertain benefit on quality of life. These data highlight the importance of patient selection for operative intervention and suggest that future transcatheter mitral valve therapies such as transcatheter mitral valve repair (TMVr) and/or transcatheter mitral valve implantation (TMVI), may provide an alternative therapeutic approach in selected high-risk elderly patients.

Percutaneous mitral valve repair with the MitraClip system according to the predicted risk by the logistic EuroSCORE: preliminary results from the German Transcatheter Mitral Valve Interventions (TRAMI) Registry

OBJECTIVE

To evaluate in-hospital and short-term outcomes of percutaneous mitral valve repair according to patients' logistic EuroSCORE (logEuroSCORE) in a multicenter registry

BACKGROUND

The logEuroSCORE is an established tool to predict the risk of mortality during cardiac surgery. In high-risk patients percutaneous mitral valve repair with the MitraClip system represents a less-invasive alternative

METHODS

Data from 1002 patients, who underwent percutaneous mitral valve repair with the MitraClip system, were analyzed in the German Transcatheter Mitral Valve Interventions (TRAMI) Registry. A logEuroSCORE (mortality risk in %) ≥ 20 was considered high risk

RESULTS

Of all patients, 557 (55.6%) had a logEuroSCORE ≥ 20. Implantation of the MitraClip was successful in 95.5 % (942/986) patients. Moderate residual mitral valve regurgitation was more often detected in patients with a logEuroSCORE ≥ 20 (23.8% vs. 17.1%, respectively, P < 0.05). In patients with a logEuroSCORE ≥ 20 the procedural complication rate was 8.9% (vs. 6.4, n.s.) and the in-hospital MACCE rate 4.9% (vs. 1.4% P < 0.01). The in-hospital mortality rate in patients with a logEuroSCORE ≥ 20 and logEuroSCORE < 20 was 4.3 and 1.1%, respectively (P ≤ 0.01) CONCLUSION: Percutaneous mitral valve repair with the MitraClip system is feasible in patients with a logEuroSCORE ≥ 20 with similar procedural results compared to patients with lower predicted risk. Although mortality was four times higher than in patients with logEuroSCORE < 20, mortality in high risk patients was lower than predicted. In those with a logEuroSCORE ≥ 20, moderate residual mitral valve regurgitation was more frequent.

Percutaneous edge-to-edge repair in high-risk and elderly patients with degenerative mitral regurgitation: midterm outcomes in a single-center experience

OBJECTIVE

The study objective was to report the midterm outcomes of MitraClip implantation in inoperable or high-risk surgical candidates with degenerative mitral regurgitation.

METHODS

From October 2008, data of all high-risk or elderly patients with severe degenerative mitral regurgitation who underwent MitraClip implantation were prospectively collected.

RESULTS

Forty-eight high-risk consecutive patients with severe degenerative mitral regurgitation underwent MitraClip implantation (mean age, 78.5 ± 10.8 years; 56.6% of the patients were aged ≥ 80 years). Mean Society of Thoracic Surgeons score was 12% ± 10%, and 71% were in New York Heart Association class III or IV. Mean left ventricular ejection fraction was 57% ± 11%. The device was successfully implanted in 47 of 48 patients (98%). In-hospital mortality was 2%. The median intensive care unit stay was 22 hours; patients were discharged from the hospital in an average of 4.5 ± 2.4 days. Predischarge echocardiography showed a mitral regurgitation reduction to grade 2+ or less in 43 of 47 patients (91.5%). Actuarial survival was 89% ± 5.2% and 70.2% ± 9% at 1 and 2 years, respectively (82% ± 9% in patients aged <80 years and 95% ± 4.4% in patients aged ≥ 80 years at 1 year; P = .9). Freedom from mitral regurgitation 3+ or greater was 80% ± 7% at 1 year and 76.6% ± 7% at 2 years. At 1 year, 93% of survivors were in New York Heart Association class I or II (100% of patients aged <80 years and 88% of patients aged ≥ 80 years; P = .4). Significant quality of life improvements were documented. A significant improvement in 6-minute walk test performance was observed.

CONCLUSIONS

MitraClip therapy is a valuable alternative to surgery in high-risk and elderly patients with degenerative mitral regurgitation. Clinical benefits also are obtained in octogenarians.

Outcomes of cardiac surgery in the elderly

The elderly represent a rapidly growing and substantially under-treated sector in industrialized countries, with coronary artery disease and degenerative aortic stenosis rampant. The proportion of elderly patients undergoing cardiac surgery is rising steadily and outcomes continue to improve with the refinement of operative techniques and perioperative care. Advanced risk stratification models, such as the logistic European System for Cardiac Operative Risk Evaluation now offer validated prediction of operative mortality in these high-risk patients. Current trends towards off-pump coronary artery surgery, hybrid revascularization and mitral repair may have advantages in the elderly, who often have more diffuse cardiovascular disease and a lower tolerance to intervention. Recent advances may also provide surgical options for the emerging epidemics of cardiovascular disease affecting the elderly, atrial fibrillation and heart failure.

Echocardiographic guidance for diagnostic and therapeutic percutaneous procedures

Echocardiographic guidance has an important role in percutaneous cardiovascular procedures and vascular access. The advantages include real time imaging, portability, and availability, which make it an effective imaging modality. This article will review the role of echocardiographic guidance for diagnostic and therapeutic percutaneous procedures, specifically, transvenous and transarterial access, pericardiocentesis, endomyocardial biopsy, transcatheter pulmonary valve replacement, pulmonary valve repair, transcatheter aortic valve implantation, and percutaneous mitral valve repair. We will address the ways in which echocardiographic guidance provides these procedures with detailed information on anatomy, adjacent structures, and intraprocedural instrument position, thus resulting in improvement in procedural efficacy, safety and patient outcomes.

Pooled estimates of immediate and late outcome of mitral valve surgery in octogenarians: a meta-analysis and meta-regression

OBJECTIVE

The authors evaluated the outcome of patients≥80 years undergoing mitral valve (MV) surgery.

DESIGN

Systematic review of the literature and meta-analysis.

SETTING

None.

PARTICIPANTS

None.

INTERVENTIONS

None.

MAIN RESULTS

Twenty-four studies reporting on 5,572 patients ≥80 years of age who underwent MV surgery were included in this analysis. Pooled proportion of operative mortality was 15.0% (95% confidence interval [CI] 11.9-18.1), stroke was 3.9% (95% CI 2.6-5.2), and dialysis was 2.7% (95% CI 0.5-4.9). Early date of study (p = 0.014), increased age (p = 0.006), MV replacement (p = 0.008), procedure other than isolated MV surgery (p = 0.010), MV surgery associated with coronary artery surgery (p = 0.029), aortic cross-clamping time (p<0.001), and cardiopulmonary bypass time (p<0.001) were associated significantly with increased operative mortality. MV repair had lower operative mortality compared with MV replacement (7.3% v 14.2%, relative risk 0.573, 95% CI 0.342-0.962). Random-effects metaregression showed that prolonged aortic cross-clamping time (p = 0.005) was the only determinant of increased operative mortality, even when adjusted (p<0.001) for date of study (p = 0.004). Operative mortality was significantly higher in studies reporting a mean cross-clamp time >90 minutes (17.0% v 7.4%, p<0.001). Survival rates at 1, 3, and 5 years were 76.1%, 67.7%, and 56.5%, respectively.

CONCLUSIONS

MV surgery in patients ≥80 years of age is associated with operative mortality, which has decreased significantly during recent years. Prolonged aortic cross-clamp time is a major determinant of operative mortality. MV repair may achieve better results than MV replacement in the very elderly. Five-year survival of these patients is good and justifies surgical treatment of MV diseases in octogenarians.

Mitral transcatheter technologies

Mitral valve regurgitation (MR) is often diagnosed in patients with heart failure and is associated with worsening of symptoms and reduced survival. While surgery remains the gold standard treatment in low-risk patients with degenerative MR, in high-risk patients and in those with functional MR, transcatheter procedures are emerging as an alternative therapeutic option. MitraClip(®) is the device with which the largest clinical experience has been gained to date, as it offers sustained clinical benefit in selected patients. Further to MitraClip implantation, several additional approaches are developing, to better match with the extreme variability of mitral valve disease. Not only repair is evolving, initial steps towards percutaneous mitral valve implantation have already been undertaken, and initial clinical experience has just started.

Mortality and complications in elderly patients undergoing cardiac surgery

PURPOSE

The purpose of the study was to analyze postoperative complications, mortality, and related factors of elderly patients undergoing cardiac surgery.

METHODS

An observational, retrospective, and multicenter study of cardiac surgery patients, obtained from the ARIAM registry, was performed between 2008 and 2011. Clinical-surgical data, postoperative complications, and mortality were analyzed in a group of patients older than 75 years and in a younger group.

RESULTS

A total of 4548 patients were analyzed, with 882 (19.4%) patients at least 75 years old. Elderly patients had worse functional status (New York heart Association class) and comorbidities. The complication rate was higher in the elderly group (40.4% and 33.5%, respectively; P = .0001). Mortality in the elderly was 1.1%, 12%, and 15.1% (during surgery, intensive care unit [ICU], and 30-day mortality, respectively). Thirty-day mortality in elderly patients was higher when adjusted for EuroSCORE (European System for Cardiac Operative Risk Evaluation) and cardiopulmonary bypass time. The interaction between multiorgan dysfunction syndrome (MODS) and age more than 75 years was assessed by logistic regression, obtaining an odds ratio of 9.27 (5.88-14.60) for younger patients and 29.44 (12.22-70.94) for elderly patients who died during the ICU stay.

CONCLUSIONS

Age more than 75 years is an independent risk factor for ICU mortality when adjusted for EuroSCORE and cardiopulmonary bypass time. Elderly patients also have a higher rate of complications during ICU stay. Elderly patients develop MODS more frequently and present a higher mortality rate than younger patients with MODS.

Mitral valve surgery: wait and see vs. early operation

Mitral valve repair represents the optimal surgical treatment for severe degenerative mitral regurgitation. According to the current guidelines, mitral repair is indicated in the presence of symptoms and/or signs of left ventricular (LV) dysfunction. In asymptomatic patients with preserved LV function, surgery should be considered in the presence of atrial fibrillation (AF) and/or pulmonary hypertension. In asymptomatic patients with preserved LV function, normal pulmonary artery pressure, and no episodes of AF, surgical timing is still an object of debate. The controversial issue is whether, in those circumstances, a 'wait and see (watchful waiting)' approach should be followed or an 'early repair' policy should be preferred. Indeed, a randomized trial comparing the two strategies has never been performed. In the absence of evidence-based arguments definitely supporting any particular course of action, advantages, drawbacks, and requirements for both strategies will be discussed in this review on the basis of the most significant observational studies which have focused on this issue.

Risk stratification and prognostic effects of internal thoracic artery grafting during acute myocardial infarction

OBJECTIVE

Surgeons are occasionally requested to perform coronary artery bypass grafting during acute myocardial infarction. We intended to test the safety of coronary artery bypass grafting and internal thoracic artery grafting early after myocardial infarction using the Society of Thoracic Surgeons database.

METHODS

The database was queried for isolated coronary artery bypass grafting less than 24 hours after a myocardial infarction from 2002 to 2008. By using multivariable logistic regression and classification trees, risk models were created to stratify this group of patients. The independent prognostic effect of internal thoracic artery grafting was examined using standard risk-adjusted mortality comparisons.

RESULTS

A total of 44,141 patients were identified, with an overall operative mortality of 7.9%. Cardiogenic shock occurred in 21%, percutaneous coronary intervention within 6 hours before surgery was performed in 11%, myocardial infarction within 6 hours before surgery occurred in 37%, preoperative intra-aortic balloon pump was used in 50%, and internal thoracic artery grafting was performed in 79% of the patients. Myocardial infarction in less than 24 hours was associated with higher operative mortality (odds ratio, 3.25) and major morbidity (odds ratio, 2.54). Emergency/salvage status (odds ratio, 6.43), age more than 80 years (odds ratio, 4.07), dialysis (odds ratio, 3.08), and cardiogenic shock (odds ratio, 2.79) were independent mortality predictors. Patients with nonemergence salvage status, absence of cardiogenic shock, creatinine less than 1.5 mg/dL, and age less than 70 years represented 48% of the population and exhibited a lower mortality rate of 2%. Internal thoracic artery grafting was independently associated with a lower risk of mortality (odds ratio, 0.52; P < .0001) and did not seem to compromise outcomes.

CONCLUSIONS

Coronary artery bypass grafting less than 24 hours after myocardial infarction carries a higher operative risk but can be performed safely in selected patients. Although confounding variables may exist, internal thoracic artery grafting was associated with improved outcomes. Internal thoracic artery use in this setting is less than ideal, and taking time to harvest internal thoracic artery grafts in patients with acute myocardial infarction might be encouraged.

Watchful waiting for severe mitral regurgitation

Watchful waiting is an established treatment strategy for asymptomatic patients with severe organic mitral regurgitation. It is based on indications for surgery that are based on current European Society of Cardiology and American Heart Association/American College of Cardiology guideline recommendations, which are defined by symptom onset, impairment of left ventricular function, and left ventricular enlargement. Excellent outcome is achieved when patients are periodically followed with clinical and echocardiographic examinations and when surgery is performed in expert centers. The strategy is based on the recognition of mitral regurgitation at an early symptomatic stage, avoiding a delayed referral of these patients. There is an ongoing debate about whether surgery should be performed in asymptomatic patients with preserved ventricular function. Ultimately, decision-making needs to be individualized and to take individual patient-related factors and local resources (including the natural history of the disease, the risk of surgery, and the likelihood of successful mitral valve repair) into consideration to obtain an optimal outcome with medical and surgical management.

A propensity score-adjusted retrospective comparison of early and mid-term results of mitral valve repair versus replacement in octogenarians

AIMS

Feasibility and efficacy of mitral repair in the elderly remain controversial. This study aims to compare outcomes of mitral repair and replacement in octogenarians.

METHODS AND RESULTS

We compared the outcomes of 322 consecutive octogenarian patients (mean age 82.6 ± 2.2 years) who underwent mitral repair (n = 227, 70%) or replacement (n = 95, 30%) at Mount Sinai Medical Center and Leipzig Herzzentrum between 1998 and 2008 using propensity score adjustment and univariate and multivariate analyses. Patients undergoing aortic valve replacement were excluded. Coronary bypass was performed in 47.5% (n = 153), and 31.1% (n = 100) required tricuspid repair. Propensity score adjustment yielded comparable groups. Thirty-day mortality in patients undergoing primary elective mitral repair for degenerative disease was 5.1% (2/39). Overall 90-day mortality was 18.9% (43/227) for repair compared with 31.6% (30/95) for replacement (P = 0.014). Pre-discharge echocardiography revealed less than moderate residual regurgitation in 99% of patients (231/232). Adjusted 1-, 3-, and 5-year survival for patients undergoing mitral repair was 71 ± 3, 61 ± 4, and 59 ± 4%, respectively, compared with 56 ± 5, 50 ± 6, and 45 ± 6% for patients undergoing mitral replacement (P = 0.046). Multivariate analysis demonstrated emergency surgery, previous myocardial infarction, concomitant coronary artery bypass surgery, and mitral replacement to be strong independent predictors of early mortality; mitral valve replacement was an independent predictor of reduced survival in degenerative patients.

CONCLUSION

Elective mitral repair can be performed with low operative mortality and good long-term outcomes in selected octogenarians with degenerative mitral disease, and is associated with better long-term survival than mitral replacement. The survival benefit associated with surgery for non-degenerative disease is more questionable.