Late outcomes of mitral valve repair for floppy valves: Implications for asymptomatic patients

Long-term mitral valve repair outcomes and hospital volume: 15 years' analysis of an administrative dataset

BACKGROUND

Procedural volume has been documented as an important contributor to operative outcomes for most complex surgical procedures. Mitral valve repair (MVRep) has been associated with excellent results, and it is increasingly adopted in many cardiac surgical centers. We sought to investigate if procedural volume is associated with better clinical long-term outcomes after MVRep.

METHODS

We analyzed the 10-year outcomes after MVRep by procedural volume for each cardiac surgery center in an Italian Region, Lazio, during the last 15 years, using a regional administrative dataset.

RESULTS

Between 2006 and 2020, 4961 patients were treated in seven cardiac surgery centers for an isolated mitral valve surgery (2677 underwent MVRep). At multivariate analysis, mitral valve replacement (MVR) (vs. MVRep) resulted one of the independent predictors of 30-day mortality [adjusted odds ratio (OR) 3.40; 95% confidence interval (CI) 1.96-5.90; P  < 0.0001]. Notably, a clear association between hospital volume of mitral valve surgery (>40 per year) and high rate of MVRep (>50%) was found. At 10 years, the incidence of mortality and the rate of death and rehospitalization for heart failure after MVRep were significantly lower in high-volume vs. low-volume hospitals.

CONCLUSION

Our data suggest that hospital volume is associated with a high rate of MVRep and long-term benefits in terms of mortality and recurrence of heart failure.

Clinical Outcomes of Mitral Valve Repair for Degenerative Mitral Regurgitation in Elderly Patients

OBJECTIVES

This study analyzes the safety and outcomes of mitral valve repair for degenerative mitral valve regurgitation in patients 75 years of age or older.

METHODS

We retrospectively reviewed the clinical results of 343 patients aged ≥75 years who underwent mitral valve repair for degenerative mitral valve regurgitation as a primary indication between January 1998 and June 2017.

RESULTS

The median (IQR) age of the patients was 79.4 (76.9, 82.9) years, and 132 (38.5%) patients were women. Concomitant procedures were performed in 123 patients: tricuspid surgery in 68 (19.8%) and a maze procedure or pulmonary vein isolation in 55 (16.0%). Operative mortality was 1.2%. Operative complications included atrial fibrillation in 37.9%, prolonged ventilation in 7.0%, pacemaker implantation in 3.8, renal failure requiring dialysis in 1.5, and troke in 3 (0.9%). Median follow-up was 7.4 years (IQR, 3.5-14.1 years). The cumulative incidence rates of mitral valve reoperation were 2.2%, 3.2%, and 3.2% at 1, 5, and 10 years, respectively. Overall survival at 1, 5, and 10 years were 95%, 83%, and 51%, respectively. Older age, smoking, and over and under weight were associated with increased risk of mortality, while higher left ventricular ejection fraction and hypertension were associated with reduced risk.

CONCLUSIONS

Mitral valve repair in elderly patients can be accomplished with low operative mortality and complications. Mitral valve repair in the elderly remains the preferred treatment for degenerative mitral regurgitation.

A Novel Plug-Based Vascular Closure Device for Percutaneous Femoral Artery Closure in Patients Undergoing Minimally-Invasive Valve Surgery

Objectives: Surgical exposure of groin vessels to establish cardiopulmonary bypass (CPB) for minimally-invasive valve surgery (MIS) is standard of care but may result in postoperative wound healing disorders or seroma formation. Therefore, adaption of transcatheter techniques for fully percutaneous insertion of CPB cannulae may improve clinical results. We herein analyze a single center experience with a novel plug-based vascular closure device for MIS.

Methods: Between 03/2020 and 02/2021 MIS using the MANTA™ (Teleflex Medical Inc., Wayne, PA, USA) vascular closure device was performed in 28 consecutive patients (58.8 ± 10.6 years, 60.3% male, logEuroSCORE II 1.1 ± 0.8%) receiving mitral and/or tricuspid valve repair/replacement. Concomitant procedures were left atrial appendage occlusion and cryoablation for atrial fibrillation in 21.4% (6/28) and 10.7% (3/28) of patients, respectively. Data were retrospectively analyzed in accordance with standardized M-VARC definitions. MANTA™ device success and early safety was defined as absence of any access site or access related vascular injury and major and life-threatening bleeding complications.

Results: MANTA™ device success with immediate hemostasis and early safety were 96.4% (27/28). In one case, device failure necessitated surgical cut down without further complications. Mean aortic cross clamp time and cardiopulmonary bypass were 96.5 ± 24.2 min and 150.2 ± 33.6 min. Stroke, renal failure or myocardial infarction were not observed. Intensive care unit and total hospital stay were 1.7 ± 0.8 days and 10.1 ± 5.7 days. Overall 30-day mortality was 0%. Post-procedure echocardiography presented one case of residual moderate tricuspid regurgitation and competent valves in all other cases.

Conclusions: The MANTA™ device is safe and effective in MIS. Its ease of use and effectiveness to achieve immediate hemostasis have further simplified MIS.

The current diagnosis and treatment of high-risk patients with chronic primary and secondary mitral valve regurgitation

Mitral valve regurgitation (MR) is due primarily to either primary degeneration of the mitral valve with Barlow's or fibroelastic disease or is secondary to ischemic or nonischemic cardiomyopathies. Echocardiography is essential to assess MR etiology and severity, the remodeling of cardiac chambers and to characterize longitudinal chamber changes to determine optimal therapies. Surgery is recommended for severe primary MR if persistent symptoms are present or if left ventricle dysfunction is present with an EF <60% or a left ventricle end-systolic diameter ≥40 mm. For secondary MR, therapy of heart failure with vasodilators and diuretics improves forward cardiac output. Coronary artery bypass grafts (CABG) or percutaneous coronary intervention (PCI) should be considered for severe MR due to ischemia. This review summarizes the pathophysiology, the characteristics, the management and the different interventions for high risk patients with chronic primary and secondary MR.

Current status of the treatment of degenerative mitral valve regurgitation

Degenerative mitral valve disease (myxomatous degeneration or fibroelastic deficiency) is the most common indication for surgical referral to treat mitral regurgitation. Mitral valve repair is the procedure of choice whenever feasible and when the results are expected to be durable. Posterior leaflet prolapse is the commonest lesion, found in up to two-thirds of patients. It is the easiest to repair, particularly when limited to one segment. In these cases, rates of repairability and procedural success approach 100%, and there is now ample evidence that the immediate and long-term results are better than those of valve replacement. Notably, minimally invasive valvular procedures, surgical or interventional, have attracted increasing interest in the last decade. When performed by experienced groups, mitral valve repair is unrivaled irrespective of the severity of lesions, from simple to complex, which leaflets are involved, and the type of degenerative involvement (myxomatous or fibroelastic). Its results should be viewed as the benchmark for other present and future technologies. By contrast, percutaneous mitral valve repair is still in its infancy and its results so far fall short of those of surgical repair. Nevertheless, continued investment in transcatheter procedures is of great importance to enable development and improved accessibility, particularly for patients who are considered unsuitable for surgery. In this review, we analyze the current status of management of degenerative mitral valve disease, discussing mitral valve anatomy and pathology, indications for intervention, and current surgical and transcatheter mitral valve procedures and results.

Anticoagulation After Isolated Mitral Valve Repair: A Systematic Review and Meta-Analysis of Clinical Outcomes

Recommendations from international guidelines on optimal thromboprophylaxis after mitral repair are controversial and based on underpowered observational studies. This study aimed to evaluate the prophylactic use of warfarin after isolated mitral valve repair (MVr). A PubMed, EMBASE and Scopus search for studies in English on postoperative thromboprophylaxis for isolated MVr published to February 2020 was performed. The analysis excluded all studies with combined operations, mitral valve replacement and preoperative or postoperative atrial fibrillation. Clinical endpoints that were studied were thromboembolic events, bleeding complications and mortality. Random effects meta-analyses of the effect of postoperative warfarin use as compared with no warfarin use across all clinical endpoints was conducted. Warfarin use did not confer benefit in terms of thromboembolic prophylaxis after isolated MVr in patients without atrial fibrillation (OR, 0.97; 95% CI, 0.72-1.31). At the same time, it did not increase the risk of bleeding complications (OR, 1.10; 95% CI, 0.53-2.30) or affect overall survival during the follow-up period of the included studies (OR, 1.06; 95% CI, 0.28-4.05). To conclude, warfarin use is not necessary for patients after isolated MVr who remain in sinus rhythm. Recommendations from international guidelines may need to be revisited for this group of patients.

Early clinical outcomes of thoracoscopic mitral valvuloplasty: a clinical experience of 100 consecutive cases

Background

We reported our experience of 100 consecutive cases of thoracoscopic mitral valvuloplasty in the early period.

Methods

Between September 2017 and December 2019, 100 consecutive cases (aged 49.2±14.7 years; 56% male) of thoracoscopic mitral valvuloplasty had been completed in our institution. The safety and feasibility of this technique was evaluated by its early clinical outcomes.

Results

Mitral valve (MV) repair was performed by means of Carpentier techniques, including leaflet folding in 5 cases, cleft suture in 10, commissuroplasty in 15 including 2 commissurotomy, edge to edge in 1, artificial chordae implantation in 76 cases with an average of 2.5±1.6 (1 to 4) pairs, and prosthetic annuloplasty in all cases. Intraoperative transoesophageal echocardiography (TEE) revealed no mitral regurgitation (MR) in 95 cases and a mild in 2 cases with all coaptation length more than 5 mm. The rest 3 cases with moderate or more MR were successfully reconstructed during a second pump-run. The average cardiopulmonary bypass (CPB) time was 164.4±51.0 min and aortic clamping time was 119.7±39.1 min, and the latest 10 cases were 140.2±45.3 and 96.3±25.4 min, respectively (P<0.05). There was only one operative death from avulsion of left atrial suture after operation and 2 intraoperative re-exploration through a conversion to sternotomy for bleeding. Severe MR was observed in 2 patients 3 months after operation, and MV replacement (MVR) was performed through median sternotomy.

Conclusions

Totally thoracoscopic mitral valvuloplasty was technically feasible, safe, effective, and reproducible in clinical practice after crossing the learning curve.

Economic Analysis and Long-term Follow-up of Distant Referral for Degenerative Mitral Valve Repair

BACKGROUND

Despite the superiority of mitral valve repair (MVr) over replacement for degenerative disease, repair rates vary widely across centers. Traveling to a mitral reference center (MRC) is 1 way to increase the odds of MVr. This study assessed the economic value (quality/cost) and long-term outcomes of distant referral to an MRC.

METHODS

Among 746 mitral surgery patients between January 2011 and June 2013, low-risk patients with an ejection fraction greater than 40% undergoing isolated degenerative MVr were identified and included 26 out-of-state (DISTANT) and 104 in-state patients (LOCAL). Short- and long-term outcomes and institutional financial data (including travel expenses) were used to compare groups. National average and MRC-specific MVr rates, clinical outcomes, and marginal value of quality-adjusted life-years collected from The Society of Thoracic Surgeons database and Medicare estimates were used to perform a nationally representative cost-benefit analysis for distant referral.

RESULTS

Age, ejection fraction, operative time, blood transfusions, and annuloplasty ring size did not differ between groups. Median charges were $76,022 for LOCAL and $74,171 for DISTANT (P = .35), whereas median payments (including travel expenses) were $57,795 for LOCAL and $58,477 for DISTANT (P = .70). Short- and long-term outcomes were similar between groups and median follow-up was 7.1 years. Estimated 5-year survival was 97% (96% for LOCAL and 100% for DISTANT; P = .24). Cost-benefit analysis showed a net benefit through distant referral to an MRC ranging from $436 to $6078 to the payer and $22,163 to $30,067 to the patient, combining for an estimated $22,599 to $32,528 societal benefit.

CONCLUSIONS

These data suggest that distant referral to an MRC is achievable and reasonable.

Degenerative Mitral Valve Repair Restores Life Expectancy

BACKGROUND

Mitral valve repair (MVr) for severe, degenerative mitral regurgitation is the gold standard, because medical management carries poor prognosis. However, despite clear benefit of MVr, many eligible patients are untreated. This study investigated whether MVr restores patients to normal life expectancy, at any age of operation, by comparing long-term survival of patients after MVr with the life expectancy of the general United States population.

METHODS

This retrospective study investigated 1011 patients with degenerative mitral regurgitation who underwent isolated MVr between 2003 and 2017. Parametric distribution analysis was applied to long-term post-MVr mortality data, and Weibull probability plots provided the best-fit distribution by Anderson-Darling Goodness-of-Fit testing. Confidence intervals of the estimated distribution were used to compare additional life expectancy after MVr to the general US population across multiple decades of life. Patients after MVr were categorized by age into decade (range, 20-89 years).

RESULTS

The life expectancy of patients after MVr matched the life expectancy of the general US population at any age between 40 and 89 years. Lower-bound one-sided 95% confidence intervals for additional life expectancy were not appreciably different from corresponding median additional life expectancy of the general population. There were few deaths in the 20- to 39-year-old group, limiting predictability, but survival also appeared normative.

CONCLUSIONS

These findings suggest that degenerative MVr restores anticipated life expectancy to that of the general population, regardless of age. Although our findings underscore the importance of repair for degenerative mitral disease, larger studies with longer term follow-up are needed to reinforce this finding, particularly for younger patients.

Benefits of Early Surgery on Clinical Outcomes After Degenerative Mitral Valve Repair

BACKGROUND

This study aimed to evaluate the clinical trends of mitral valve repair for degenerative mitral regurgitation and the benefit of early surgical intervention on repair durability in a high-volume center.

METHODS

From January 2003 to December 2015, 1,903 consecutive patients with severe degenerative mitral regurgitation underwent mitral valve repair at our institution. The timing of surgical intervention was evaluated by guideline-related indications including symptoms, atrial fibrillation, left ventricular dysfunction, and pulmonary hypertension. Clinical outcomes and risk factors for recurrent mitral regurgitation were analyzed.

RESULTS

Over 13 years from 2003 to 2015, trends of preoperative characteristics demonstrated that the proportion of asymptomatic patients substantially increased. The 8-year overall survival, freedom from reoperation for mitral valve, and freedom from recurrent mitral regurgitation were 96%, 96%, and 85%, respectively. Ejection fraction less than 60%, left ventricular end-diastolic dimension greater than 60 mm, isolated anterior leaflet lesion, and intraoperative mild residual mitral regurgitation were independent predictive factors for recurrent mitral regurgitation. The incidence of recurrent mitral regurgitation was significantly lower in the early intervention group (3% versus 18%, p < 0.01). In subgroup analysis of asymptomatic patients, the incidence of recurrent mitral regurgitation was significantly lower in patients without guideline-related indications (3% versus 31%, p < 0.0001).

CONCLUSIONS

Early surgical intervention for severe degenerative mitral regurgitation before symptoms, atrial fibrillation, and ventricular dysfunction are associated with excellent clinical outcomes. Besides complexity of leaflet lesion and repair quality, surgical timing also significantly affects repair durability. Early surgical intervention should therefore be recommended to reduce recurrent mitral regurgitation.

Reference Values for Physical Stress Echocardiography in Asymptomatic Patients after Mitral Valve Repair

Background

Clinical decision-making in symptomatic patients after mitral valve (MV) repair remains challenging as echocardiographic reference values are lacking. In native MV disease intervention is recommended for mean transmitral pressure gradient (TPG) >15 mmHg or systolic pulmonary artery pressure (SPAP) >60 mmHg at peak exercise. Insight into standard stress echo parameters after MV repair may therefore aid to clinical decision-making during follow-up.

Hypothesis

Stress echocardiography derived parameters in asymptomatic patients after successful MV repair differ from current guidelines for native valves.

Material and methods

In 25 patients (NYHA I) after MV repair stress echocardiography was performed on a semi-supine bicycle. Doppler flow records and MV related hemodynamics at rest and peak were obtained. Linear regression analysis was performed for mean TPG and SPAP at peak, using predetermined variables and confounders.

Results

Mean TPG at rest (3.2 ± 1.4 mmHg) significantly increased at peak (15.0 ± 3.4 mmHg) but was always <25 mmHg. Mean SPAP at rest (21.4 ± 3.8 mmHg) significantly increased at peak (41.8 ± 8.9 mmHg) but was never >57 mmHg. Only the indexed MV ring diameter was inversely correlated to mean TPG at peak in a multivariable model.

Conclusion

In contrast to current recommendations in native MV disease, our data indicate that the standard value for mean TPG during stress echocardiography in asymptomatic patients after successful MV repair was above the guideline threshold of 15 mmHg in >50%, but always <25 mmHg. For SPAP, patients never reached the guideline cutoff (60 mmHg). Long-term follow-up data are needed to provide insight in clinical consequences. Baseline stress echocardiography may indicate individual reference values to compare with during follow-up.

Clinical trial registration

https://clinicaltrials.gov/ct2/show/NCT02371863?term=chamuleau+AND+Mitral&rank=1.

Mitral Valve Repair for Pure Mitral Regurgitation Followed Years Later by Mitral Valve Replacement for Mitral Stenosis

We describe herein 2 patients who developed severe mitral stenosis (MS) approximately two decades after a mitral valve repair operation for pure mitral regurgitation (MR) secondary to mitral valve prolapse. This report's purpose is to point out that use of a circumferential mitral annular ring during the repair has the potential to produce a transmitral pressure gradient just like that occurring after mitral valve replacement utilizing a mechanical prosthesis or a bioprosthesis in the mitral position.

Mitral valve repair for degenerative mitral valve disease: surgical approach, patient selection and long-term outcomes

Mitral valve repair (MVRepair) has become the procedure of choice to correct severe degenerative mitral regurgitation (MR), due to its documented superiority to valve replacement regarding long-term survival, freedom from valve-related adverse events and preservation of left ventricular (LV) function. The refinement of MVRepair techniques has rendered almost all valves (more than 95%) amenable to repair with a 15-year freedom from reoperation of 90%. The concept of 'centres of excellence for MVRepair' has emerged, encouraging referring doctors to select the most experienced institutions or individual surgeons to deal with the most complex cases, based on repair volume, appropriate peri-procedural imaging and data regarding expected outcomes (repair, mortality and durability of repair). Based on the good results, operating on asymptomatic patients with severe MR is now widely accepted, prophylactically avoiding the dire consequences of chronic MR, such as LV function deterioration/enlargement, and development of atrial fibrillation and pulmonary hypertension. In reference centres, where the repair rate is over 95% for all types of disease with <1% mortality, it has become standard practice in nearly 50%-60% of all patients submitted to MVRepair. Finally, recent advances in the surgical treatment with the purpose of reducing invasiveness and surgical trauma, through partial sternotomy or mini-thoracotomy (video-assisted with or without robotics), are now being increasingly performed in 20%-30% of centres, claiming comparable results to conventional surgery. In addition, transcatheter technology, particularly the MitraClip, is evolving and treading its way in the treatment of high-risk patients with severe MR, but the results are still short of ideal.

Mitral Valve Repair: Is There Still a Place for Suture Annuloplasty?

Prosthetic ring annuloplasty is considered the gold standard technique for mitral valve repair, but it has been associated with some drawbacks. Suture annuloplasty is less expensive and may have some physiopathologic advantages. We reviewed the literature to assess clinical results of mitral suture annuloplasty. Thirteen series, each reporting more than 50 patients and published in the last 10 years, were included in the analysis. They comprised 1,648 patients with cumulative follow-up of 5,607 patient-years. Our review suggests that suture annuloplasty is a safe procedure, but a trend toward recurrence of annular dilatation with time was reported. In selected cases, suture annuloplasty is effective, and its mid-term clinical results are encouraging and compare well with those of prosthetic ring repair series. The quality of the results varies according to the particular annuloplasty technique used and to the mitral valve pathology treated. Recent technical modifications have been found to decrease the incidence of repair failure and promise to improve the reproducibility of the procedure. Further investigations are warranted to better assess the long-term results of suture annuloplasty, and to determine whether its theoretical functional advantages translate into a real clinical benefit.

Long-term outcomes of mitral valve repair versus replacement for degenerative disease: a systematic review

The short-term advantage of mitral valve repair versus replacement for degenerative disease has been extensively documented. These advantages include lower operative mortality, improved survival, better preservation of left-ventricular function, shorter post-operative hospital stay, lower total costs, and fewer valve-related complications, including thromboembolism, anticoagulation-related bleeding events and late prosthetic dysfunction. More recent written data are available indicating the long-term advantage of repair versus replacement. While at some institutions, the repair rate for degenerative disease may exceed 90%, the national average in 2007 was only 69%. Making direct comparisons between mitral valve repair and replacement using the available studies does present some challenges however, as there are often differences in baseline characteristics between patient groups as well as other dissimilarities between studies. The purpose of this review is to systematically summarize the long-term survival and reoperation data of mitral valve repair versus replacement for degenerative disease. A PubMed search was done and resulted in 12 studies that met our study criteria for comparing mitral valve repair versus replacement for degenerative disease. A systematic review was then conducted abstracting survival and reoperation data.

Standards for heart valve surgery in a 'Heart Valve Centre of Excellence'

Surgical centres of excellence should include multidisciplinary teams with specialist expertise in imaging, clinical assessment and surgery for patients with heart valve disease. There should be structured training programmes for the staff involved in the periprocedural care of the patient and these should be overseen by national or international professional societies. Good results are usually associated with high individual and centre volumes, but this relationship is complex. Results of surgery should be published by centre and should include rates of residual regurgitation for mitral repairs and reoperation rates matched to the preoperative pathology and risk.

Mitral valve analysis adding a virtual semi-transparent annulus plane for detection of prolapsing segments

Background

We hypothesized that a novel three-dimensional virtual semi-transparent annulus plane (3D VSAP) presented on a holographic screen can be used to visualize the prolapsing tissue in degenerative mitral valve disease and furthermore, provide us with geometrical data of the mitral valve apparatus. Phantom and patient studies were designed to demonstrate the feasibility of creating a semi-automatic, semi-transparent mitral annulus plane visualized on a holographic display.

Methods

Ten pipe cleaners mimicking the mitral annulus with different shapes and three types of annuloplasty rings served as phantoms. We obtained 3D transoesophageal examination of the phantoms in a special designed box filled with water. Recordings were converted to the holographic display and a 3D VSAP was created. The ratio of the major and minor axes as well as the non-planar angles were calculated and compared with direct measures of the phantoms. Forty patients with degenerative mitral valve disease were then analyzed with 3D transthoracic echocardiography (TTE) and a 3D VSAP was created on the holographic display. A total of 240 segments were analyzed by two independent observers, one echo expert (observer I), and the other novice with limited echo experience (observer II). The two observers created the 3D VSAP in each patient before suggesting the valve pathology.

Results

The major/minor axes ratio and non-planar angles by 3D VSAP correlated with direct measurements by r = 0.65, p < 0.02 and r = 0.99, p < 0.0001, respectively. The sensitivity and specificity of the 3D VSAP method in patients was 81 and 97 %, respectively (observer I) and for observer II 77 and 96 %, respectively. The accuracy and precisions were 93.9 and 89.4 %, respectively (observer I), 92.3 and 85.1 % (observer II). Mitral valve analysis adding a 3D VSAP was feasible with high accuracy and precision, providing a quick and less subjective method for diagnosing mitral valve prolapse. This novel method may improve preoperative diagnostics and may relieve a better understanding of the pathophysiology of mitral valve disease. Thus, based on the specific findings in each patient, a tailored surgical repair can be planned and hopefully enhance long-term repair patency in the future.

Computational mitral valve evaluation and potential clinical applications

The mitral valve (MV) apparatus consists of the two asymmetric leaflets, the saddle-shaped annulus, the chordae tendineae, and the papillary muscles. MV function over the cardiac cycle involves complex interaction between the MV apparatus components for efficient blood circulation. Common diseases of the MV include valvular stenosis, regurgitation, and prolapse. MV repair is the most popular and most reliable surgical treatment for early MV pathology. One of the unsolved problems in MV repair is to predict the optimal repair strategy for each patient. Although experimental studies have provided valuable information to improve repair techniques, computational simulations are increasingly playing an important role in understanding the complex MV dynamics, particularly with the availability of patient-specific real-time imaging modalities. This work presents a review of computational simulation studies of MV function employing finite element structural analysis and fluid-structure interaction approach reported in the literature to date. More recent studies towards potential applications of computational simulation approaches in the assessment of valvular repair techniques and potential pre-surgical planning of repair strategies are also discussed. It is anticipated that further advancements in computational techniques combined with the next generations of clinical imaging modalities will enable physiologically more realistic simulations. Such advancement in imaging and computation will allow for patient-specific, disease-specific, and case-specific MV evaluation and virtual prediction of MV repair.

Review of mitral valve insufficiency: repair or replacement

Mitral valve (MV) dysfunction is the second-most common clinically significant form of valvular defect in adults. MV regurgitation occurs with the increasing frequency of degenerative changes of the aging process. Moreover, other causes of clinically significant MV regurgitation include cardiac ischemia, infective endocarditis and rhematic disease more frequently in less developed countries. Recent evidence suggests that the best outcomes after repair of severe degenerative mitral regurgitation (MR) are achieved in asymptomatic or minimally symptomatic patients, who are selected for surgery soon after diagnosis on the basis of echocardiography. This review will focus on the surgical management of mitral insufficiency according to its aetiology today and will give insight to some of the perspectives that lay in the future.

Clinical outcomes through 12 months in patients with degenerative mitral regurgitation treated with the MitraClip® device in the ACCESS-EUrope Phase I trial

OBJECTIVES

Percutaneous treatment with the MitraClip device represents an alternative option for selected patients with degenerative mitral regurgitation (DMR) considered ineligible for surgery due to contraindications or high surgical risk by an inter-disciplinary heart team. We describe 12-month outcomes following treatment with the MitraClip device in DMR patients.

METHODS

The MitraClip Therapy Economic and Clinical Outcomes Study Europe (ACCESS-EU) Study has completed the enrolment of 567 patients as of April 2011, 117 of whom were DMR. Baseline demographics, procedural and acute safety results at 30 days and survival at 12 months were evaluated in the DMR subset. Effectiveness results, defined by a reduction in MR, and improvement in clinical outcomes based on changes in New York Heart Association (NYHA) functional Class, 6-min walk test (6MWT) and quality-of-life data were also assessed. Furthermore, DMR patients were stratified into high- and low-risk subgroups (logistic European System of Cardiac Operative Risk Evaluation I (logEuroSCORE I ≥20% or <20%, respectively) and differentially evaluated.

RESULTS

One hundred and seventeen DMR patients underwent the MitraClip procedure with a 94.9% rate (111 of 117) of successful clip implantation. Baseline characteristics and comorbidities included NYHA Class III/IV (74%), left ventricular ejection fraction (LVEF) <40% (9%), prior cardiac surgery (24%) and prior myocardial infarction (MI) (22%). Mean logEuroSCORE I was 15.5 ± 13.3%. Mortalities at 30 days and 12 months were 6.0 and 17.1%, respectively. At 12 months, 74.6% (53 of 71) of patients in follow-up achieved MR ≤grade 2+ and 80.8% (63 of 78) were in NYHA functional class I/II. Both Minnesota Living with Heart Failure questionnaire (MLHFQ) scores and 6MWT distance improved significantly at 12 months compared with baseline (P = 0.03 and P < 0.0001, respectively).

CONCLUSIONS

The MitraClip procedure resulted in significant reductions in MR and improvements in clinical outcomes at 12 months in selected patients with severe DMR. MitraClip therapy may serve as a complementary non-surgical therapeutic option for DMR patients who are considered at high risk or ineligible for surgery by an inter-disciplinary dedicated heart team. Interventional treatment should be indicated following the discussion of patients in an inter-disciplinary conference of cardiologists and cardiac surgeons as suggested by current international guidelines.

Percutaneous Mitral Valve Repair in the Initial EVEREST Cohort

Background—

Percutaneous repair of mitral regurgitation (MR) permits examination of the effect of MR reduction without surgery and cardiopulmonary bypass on left ventricular (LV) dimensions and function. The goal of this analysis was to determine the extent of reverse remodeling at 12 months after successful percutaneous reduction of MR with the MitraClip device.

Methods and Results—

Of 64 patients with 3 and 4+ MR who achieved acute procedural success after treatment with the MitraClip device, 49 patients had moderate or less MR at 12-month follow-up. Their baseline and 12-month echocardiograms were compared between the group with and without LV dysfunction. In patients with persistent MR reduction and pre-existing LV dysfunction, there was a reduction in LV wall stress, reduced LV end-diastolic volume, LV end-systolic volume and increase in LV ejection fraction in contrast to those with normal baseline LV function, who showed reduction in LV end-diastolic volume, LV wall stress, no change in LV end-systolic volume, and a fall in LV ejection fraction.

Conclusions—

Patients with pre-existing LV dysfunction demonstrate reverse remodeling and improved LV ejection fraction after percutaneous mitral valve repair.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov . Unique identifiers: NCT00209339, NCT00209274.

Surgical RF ablation of atrial fibrillation in patients undergoing mitral valve repair for Barlow disease

OBJECTIVES

At present, limited experience exists on the treatment of atrial fibrillation (AF) in patients undergoing mitral valve repair (MVR) for Barlow disease. The aim of this investigation was to prospectively evaluate the radiofrequency ablation of AF in patients undergoing MVR for severe regurgitation due to Barlow disease.

METHODS

From January 1, 2007 to December 31, 2010, out of 85 consecutive patients with Barlow disease, 27 with AF underwent RF ablation associated with MVR. They were examined every 4 months in the first year after surgery and thereafter twice yearly.

RESULTS

At follow-up, AF was observed in 4/25 (16.0%). NYHA (New York Heart Association) functional class improved significantly, with no patients in class III or IV (before surgery, 81.5% had been). Otherwise, among 58 patients in sinus rhythm, 6 (11%) developed AF during follow-up. No clinical or echocardiographic predictive factor was found in this subgroup.

CONCLUSIONS

Results from our investigation suggest that radiofrequency ablation of AF in patients with Barlow disease undergoing MVR for severe regurgitation is effective and should be considered in every patient with Barlow disease and AF undergoing valve surgical repair.