Re-repair of the failed mitral valve: insights into aetiology and surgical management

Reoperation after early and late failure of mitral valve repair for degenerative disease

OBJECTIVES

To determine mechanisms of early and late failure after mitral valve repair for degenerative disease, identify factors associated with re-repair, and evaluate durability of re-repair.

METHODS

From January 2008 to July 2020, 330 reoperations were performed for recurrent mitral valve dysfunction after initial valve repair for degenerative disease. Mechanisms of repair failure were determined by review of preoperative imaging and operative reports. Multivariable analysis was performed to identify factors associated with likelihood of re-repair or replacement. Durability of re-repair was assessed using longitudinal analysis of postoperative echo data.

RESULTS

Eighty-five of 330 (26%) reoperations were performed for early repair failure within 1 year and 245/330 (74%) for late failure thereafter. Suture/annuloplasty dehiscence, systolic anterior motion, hemolysis, and ventricular remodeling were more common mechanisms of early failure and disease progression and fibrosis late failure. Forty percent (34/85) of early failures were re-repaired versus 24% (59/245) of late failures. Re-repair was more common than replacement in recent years and was associated with earlier reoperation (median 1.5 vs 3.9 years; P = .0001). No in-hospital deaths occurred after re-repair; 2 patients (0.8%) died after valve replacement. Freedom from severe mitral regurgitation after re-repair was 93% at 7 years.

CONCLUSIONS

Mitral valve re-repair can be performed with low rates of mortality and morbidity for early and late valve dysfunction. Mechanisms of early repair failure differ from those of late failure and are generally more amenable to re-repair. In selected patients who present after failed repair, we prefer mitral re-repair to valve replacement whenever technically feasible.

Repeat crossclamp after failed initial degenerative mitral valve repair is safe and successful

Objective

Surgical risk and long-term outcomes when re-crossclamp is required during degenerative mitral valve repair are unknown. We examined the outcomes of patients who required re-crossclamp for mitral valve reintervention.

Methods

Adults undergoing mitral valve repair for degenerative mitral valve disease at a single center from 2007 to 2021 who required more than 1 crossclamp for mitral valve reintervention were included. Outcomes including major morbidity and 30-day mortality were collected. Kaplan-Meier analysis characterized survival and freedom from recurrent mitral regurgitation.

Results

A total of 69 patients required re-crossclamp for mitral valve reintervention. Of those, 72% (n = 50) underwent successful re-repair and the remaining underwent mitral valve replacement (28%, n = 19). Major morbidity occurred in 23% (n = 16). There was no 30-day mortality, and median long-term survival was 10.9 years for those undergoing re-repair and 7.2 years for those undergoing replacement (P = .79). Midterm echocardiography follow-up was available for 67% (33/50) of patients who were successfully re-repaired with a median follow-up of 20 (interquartile range, 7-37) months. At late follow-up, 90% of patients had mild or less mitral regurgitation. Of those re-repaired, 2 patients later required mitral valve reintervention.

Conclusions

Patients requiring re-crossclamp for residual mitral regurgitation had low perioperative morbidity and no mortality. Most patients underwent successful re-repair (vs mitral valve replacement) with excellent valve function and long-term survival. In the event of unsatisfactory repair at the time of mitral valve repair, attempt at re-repair is safe and successful with the appropriate valvar anatomy.

Re-repair vs. Replacement for Failed Mitral Valve Repair: A Systemic Review and Meta-Analysis

Objective

The objective of this study was to compare outcomes of re-repair with those of mitral valve replacement (MVR) for failed initial mitral valve repair (MVr).

Methods

We searched the Pubmed, Embase, and Cochrane Library databases for studies that compared mitral valve re-repair with MVR for the treatment of failed initial MVr. Data were extracted by two independent investigators and subjected to a meta-analysis. Odds ratio (OR), risk ratio (RR), hazard ratio (HR), ratio difference (RD), mean difference (MD), and 95% confidence interval (CI) were calculated with the Mantel-Haenszel and inverse-variance methods for mode of repair failure, perioperative outcomes, and follow-up outcomes.

Results

Eight retrospective cohort studies were included, with a total of 938 patients, and mean/median follow-up ranged from 1.8 to 8.9 years. Pooled incidence of technical failure was 41% (RD: 0.41; 95% CI: 0.32 to 0.5; P = 0.00; I2 = 86%; 6 studies, 846 patients). Pooled mitral valve re-repair rate was 36% (RD: 0.36; 95% CI: 0.26–0.46; P = 0; I2 = 91%; 8 studies, 938 patients). Pooled data showed significantly lower perioperative mortality (RR: 0.22; 95% CI: 07 to 0.66; I2 = 0%; P = 0.008; 6 studies, 824 patients) and significantly lower long-term mortality (HR:0.42; 95% CI: 0.3 to 0.58; I2 = 0%; P = 0; 7 studies, 903 patients) in the re-repair group compared with MVR.

Conclusions

Mitral valve re-repair was associated with better immediate and sustained outcomes for failed MVr and should be recommended if technically feasible.

Clinical Impact of Computational Heart Valve Models

This paper provides a review of engineering applications and computational methods used to analyze the dynamics of heart valve closures in healthy and diseased states. Computational methods are a cost-effective tool that can be used to evaluate the flow parameters of heart valves. Valve repair and replacement have long-term stability and biocompatibility issues, highlighting the need for a more robust method for resolving valvular disease. For example, while fluid-structure interaction analyses are still scarcely utilized to study aortic valves, computational fluid dynamics is used to assess the effect of different aortic valve morphologies on velocity profiles, flow patterns, helicity, wall shear stress, and oscillatory shear index in the thoracic aorta. It has been analyzed that computational flow dynamic analyses can be integrated with other methods to create a superior, more compatible method of understanding risk and compatibility.

Mitral Valve Annuloplasty Failure and Percutaneous Treatment Options

PURPOSE OF REVIEW

Mitral valve repair is a common surgical procedure for both primary and secondary mitral regurgitation. With operations performed earlier in disease progression and increased patient longevity, the need for a repeat intervention is not infrequent. With the associated risks of reoperation and patient comorbidities, percutaneous techniques for acute or delayed failure after ring annuloplasty are emerging.

RECENT FINDINGS

Current commercially available devices, used in "off-label" ways, such as the MitraClip, may be effective in repairing recurrent mitral regurgitation after annuloplasty. Similarly, a valve-in-ring transcatheter mitral valve replacement can be considered in patients at high risk for surgical reoperation. These procedures are not without risk, for example, resultant mitral stenosis in the setting of edge-to-edge repair or left ventricular outflow tract (LVOT) obstruction with valve-in-ring transcatheter mitral valve replacement. Newer devices are emerging to permit more options for this subset of patients, which include transcatheter valves that are specifically designed for the mitral position. Undoubtedly, surgical reoperation has increased risk as compared to primary operation. Though percutaneous options are evolving, use in this patient population is currently limited to "off-label" use and is also associated with procedural complexities and risk. It is prudent for cardiologists, surgeons, and anesthesiologists to weigh risks, benefits, and limitations when considering patients for surgical reoperation, percutaneous repair, or transcatheter replacement after failed mitral annuloplasty.

Mitral Valve Surgery in Patients With Rheumatic Heart Disease: Repair vs. Replacement

Background: High morbidity and mortality caused by rheumatic heart disease (RHD) are global burdens, especially in low-income and developing countries. Whether mitral valve repair (MVP) benefits RHD patients remains controversial. Thus, we performed a meta-analysis to compare the perioperative and long-term outcomes of MVP and mitral valve replacement (MVR) in RHD patients. Methods and Results: A systematic literature search was conducted in major databases, including Embase, PubMed, and the Cochrane Library, until 17 December 2020. Studies comparing MVP and MVR in RHD patients were retained. Outcomes included early mortality, long-term survival, freedom from reoperation, postoperative infective endocarditis, thromboembolic events, hemorrhagic events, and freedom from valve-related adverse events. Eleven studies that met the inclusion criteria were included. Of a total of 5,654 patients, 1,951 underwent MVP, and 3,703 underwent MVR. Patients who undergo MVP can benefit from a higher long-term survival rate (HR 0.72; 95% CI, 0.55-0.95; P = 0.020; I ² = 44%), a lower risk of early mortality (RR 0.62; 95% CI, 0.38-1.01; P = 0.060; I ² = 42%), and the composite outcomes of valve-related adverse events (HR 0.60; 95% CI, 0.38-0.94; P = 0.030; I ² = 25%). However, a higher risk of reoperation was observed in the MVP group (HR 2.60; 95% CI, 1.89-3.57; P<0.001; I ² = 4%). Patients who underwent concomitant aortic valve replacement (AVR) in the two groups had comparable long-term survival rates, although the trend still favored MVP. Conclusions: For RHD patients, MVP can reduce early mortality, and improve long-term survival and freedom from valve-related adverse events. However, MVP was associated with a higher risk of reoperation. Systematic Review Registration: https://www.crd.york.ac.uk/PROSPERO/display_record.php?RecordID=228307.

Early Mitral Valve Repair Failure in the Setting of Endocarditis: When to Reoperate?

Surgery is recommended for endocarditis complicated by annular abscess or destruction of the native valve. Guidelines also recommend valvular repair over replacement for endocarditis when feasible. Guidance on management of early repair failure is not well described. (Level of Difficulty: Intermediate.)

Reoperative Mitral Surgery Versus Transcatheter Mitral Valve Replacement: A Systematic Review

Bioprosthetic mitral structural valve degeneration and failed mitral valve repair (MVr) have traditionally been treated with reoperative mitral valve surgery. Transcatheter mitral valve-in-valve (MVIV) and valve-in-ring (MVIR) replacement are now feasible, but data comparing these approaches are lacking. We sought to compare the outcomes of (1) reoperative mitral valve replacement (redo-MVR) and MVIV for structural valve degeneration, and (2) reoperative mitral valve repair (redo-MVr) or MVR and MVIR for failed MVr. A literature search of PubMed, Embase, and the Cochrane Library was conducted up to July 31, 2020. Thirty-two studies involving 25 832 patients were included. Redo-MVR was required in ≈35% of patients after index surgery at 10 years, with 5% to 15% 30-day mortality. MVIV resulted in >95% procedural success with 30-day and 1-year mortality of 0% to 8% and 11% to 16%, respectively. Recognized complications included left ventricular outflow tract obstruction (0%-6%), valve migration (0%-9%), and residual regurgitation (0%-6%). Comparisons of redo-MVR and MVIV showed no statistically significant differences in mortality (11.3% versus 11.9% at 1 year, P=0.92), albeit higher rates of major bleeding and arrhythmias with redo-MVR. MVIR resulted in 0% to 34% mortality at 1 year, whereas both redo-MVr and MVR for failed repairs were performed with minimal mortality and durable long-term results. MVIV is therefore a viable alternative to redo-MVR for structural valve degeneration, whereas redo-MVr or redo-MVR is preferred for failed MVr given the suboptimal results with MVIR. However, not all patients will be candidates for MVIV/MVIR because anatomical restrictions may preclude transcatheter options from adequately addressing the underlying pathology.

Contemporary Reoperative Mitral Valve Surgery: Technical Considerations and Clinical Outcomes

As patients with cardiac disease live longer, reoperative mitral valve surgery has become more common. Although these operations are technically challenging and of high risk, outcomes continue to improve. Minimally invasive techniques, better cardioprotective strategies, and advanced perioperative care have contributed to this. In this review, we discuss surgical approaches, intraoperative strategies, novel catheter-directed devices, and clinical outcomes of contemporary reoperative mitral valve surgery.

The Neochord Procedure After Failed Surgical Mitral Valve Repair

Surgical mitral valve reintervention is associated with significant morbidity and mortality, and repeat repair is not always feasible. We examine the clinical outcomes of the NeoChord procedure after failed conventional mitral valve repair. A total of 312 patients were treated with the NeoChord repair procedure between January 2014 and December 2018 at 5 European centers. Clinical and echocardiographic data were reviewed to identify patients who had a prior surgical mitral valve repair procedure. The primary endpoint (Patient Success) was a composite of placement of at least 2 neochordae and end-procedure mitral valve regurgitation (MR) ≤ mild, freedom from death, stroke, structural or functional procedure failure (MR > moderate), procedure or device-related unplanned procedures, cardiac-related rehospitalization, or worsening NYHA functional class at 1 and 2-year FU. Fifteen (15) patients were identified who required reoperation for failed surgical mitral valve repair. Mean time-to-reoperation was 2.7 years (2.2-6.1). Median intensive care unit stay was 24 hours and median hospitalization time was 7 days (6-8). No in-hospital deaths were observed. At discharge, mitral regurgitation was ≤ mild in 13 patients (86.7%). Patient success and freedom from more than mild MR were 92.3 ± 7.4% and 83.9 ± 10.4% at 1 and 2-year follow-up respectively. One high-risk patient presented with severe recurrent MR and died during surgical reintervention due to an acute aortic dissection. Selected patients can be successfully treated with the NeoChord procedure after failed surgical mitral valve repair. These results support a wider adoption of the NeoChord procedure as a first-line minimally invasive, alternative therapy to treat failed mitral valve repair.