1
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Drake DH, Zhang P, Zimmerman KG, Morrow CD, Sidebotham DA. Anatomic, stage-based repair of secondary mitral valve disease. J Thorac Cardiovasc Surg 2024; 167:1733-1744. [PMID: 36775783 DOI: 10.1016/j.jtcvs.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 12/20/2022] [Accepted: 01/05/2023] [Indexed: 01/12/2023]
Abstract
OBJECTIVE Intervention for repair of secondary mitral valve disease is frequently associated with recurrent regurgitation. We sought to determine if there was sufficient evidence to support inclusion of anatomic indices of leaflet dysfunction in the management of secondary mitral valve disease. METHODS We performed a systematic review and meta-analysis of published reports comparing anatomic indices of leaflet dysfunction with the complexity of valve repair and the outcome from intervention. Patients were stratified by the severity of leaflet dysfunction. A secondary analysis was performed comparing outcomes when procedural complexity was optimally matched to severity of leaflet dysfunction and when intervention was not matched to dysfunction. RESULTS We identified 6864 publications, of which 65 met inclusion criteria. An association between the severity of leaflet dysfunction and the procedural complexity was highly predictive of satisfactory freedom from recurrent regurgitation. Patients were categorized into 4 groups based on stratification of leaflet dysfunction. Satisfactory results were achieved in 93.7% of patients in whom repair complexity was appropriately matched to severity of leaflet dysfunction and in 68.8% in whom repair was not matched to dysfunction (odds ratio, 0.148; 95% confidence interval, 0.119-0.184; P < .0001). CONCLUSIONS For patients with secondary mitral valve disease, satisfactory outcome from valve repair improves when procedural complexity is matched to anatomic indices of leaflet dysfunction. Anatomic indices of leaflet dysfunction should be considered when planning interventions for secondary mitral regurgitation. Routine inclusion of anatomic indices in trial design and reporting should facilitate comparison of results and strengthen guidelines. There are sufficient data to support anatomic staging of secondary mitral valve disease.
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Affiliation(s)
- Daniel H Drake
- Department of Cardiac Surgery, University of Michigan Medical School, Ann Arbor, Mich; Department of Surgery, Munson Medical Center, Traverse City, Mich.
| | - Peng Zhang
- Department of Surgery, University of Michigan Medical School, Ann Arbor, Mich
| | | | - Cynthia D Morrow
- Health Systems, Management & Policy, Colorado School of Public Health, Aurora, Colo
| | - David A Sidebotham
- Department of Cardiothoracic Anaesthesia and Cardiothoracic Intensive Care, Auckland City Hospital, Auckland, New Zealand
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2
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Girdauskas E, Pausch J, Reichenspurner H, Kempfert J, Kuntze T, Owais T, Holubec T, Krane M, Vitanova K, Borger M, Eden M, Hachaturyan V, Bramlage P, Falk V. Subannular repair for functional mitral regurgitation with reduced systolic ventricle function: rationale and design of REFORM-MR registry. J Cardiothorac Surg 2022; 17:343. [PMID: 36581901 PMCID: PMC9801540 DOI: 10.1186/s13019-022-02045-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 11/27/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Functional mitral regurgitation (FMR) is one of the most common heart valve diseases that is a sequel of left ventricular remodelling. Although mitral valve annuloplasty is a standard treatment of FMR, the recurrence of FMR is a major drawback and occurs in 10-50% of patients. The REFORM-MR registry aims to investigate the effectiveness of standardized papillary muscle relocation and ring annuloplasty and to identify the risk factors associated with recurrent FMR. METHODS REFORM-MR is a prospective, multicenter registry that enrols consecutive FMR patients across five sites in Germany. All patients with FMR and restricted movement of leaflets during systole (i.e., type IIIb mitral regurgitation) undergoing standardized subannular repair in combination with mitral valve annuloplasty are included in the study. The primary objective is to examine the effect of combined papillary muscle relocation and ring annuloplasty on the recurrence of FMR at 2 years postoperatively. The secondary objectives are MACCE rate, reinterventions on the mitral valve and cardiac-related mortality in the study cohort. Echocardiography core-lab and MRI core-lab will provide anonymized analysis of the imaging data in the REFORM-MR registry. Student's t-test or Mann-Whitney U test for continuous variables and the Chi-Square or Fisher exact test for categorical variables are used for group comparisons. Kaplan-Meier analyses is performed for survival and safety outcomes. RESULTS As of May 2021, a total of 97 patients were enrolled across five sites in Germany. CONCLUSIONS The results of this study will help define the outcomes of combined papillary muscle relocation and ring annuloplasty in the FMR treatment in a multicentre setting and to improve the understanding of the limitations of subannular repair procedures while treating patients with type III FMR. Trial registration clinicaltrials.gov Identifier: NCT03470155.
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Affiliation(s)
- Evaldas Girdauskas
- grid.13648.380000 0001 2180 3484Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany ,grid.419801.50000 0000 9312 0220Department of Cardiovascular and Thoracic Surgery, University Hospital Augsburg, Augsburg, Germany
| | - Jonas Pausch
- grid.13648.380000 0001 2180 3484Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Hermann Reichenspurner
- grid.13648.380000 0001 2180 3484Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Hamburg, Germany
| | - Jörg Kempfert
- grid.418209.60000 0001 0000 0404Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany ,grid.452396.f0000 0004 5937 5237German Center for Cardiovascular Research, Partner Site Berlin, Berlin, Germany
| | - Thomas Kuntze
- Department of Cardiology, Central Hospital Bad Berka, Bad Berka, Germany
| | - Tamer Owais
- grid.419801.50000 0000 9312 0220Department of Cardiovascular and Thoracic Surgery, University Hospital Augsburg, Augsburg, Germany ,Department of Cardiology, Central Hospital Bad Berka, Bad Berka, Germany
| | - Tomas Holubec
- grid.7839.50000 0004 1936 9721Department of Cardiovascular Surgery, University Hospital Frankfurt, Johann Wolfgang Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Markus Krane
- grid.472754.70000 0001 0695 783XGerman Heart Center Munich, Munich, Germany
| | - Keti Vitanova
- grid.472754.70000 0001 0695 783XGerman Heart Center Munich, Munich, Germany
| | - Michael Borger
- grid.411339.d0000 0000 8517 9062Department Cardiac Surgery, Leipzig Heart Center, University Clinic Leipzig, Leipzig, Germany
| | - Matthias Eden
- grid.412468.d0000 0004 0646 2097Department for Internal Medicine III, Molecular Cardiology and Angiology, University Hospital Schleswig-Holstein, Kiel, Germany
| | - Violetta Hachaturyan
- grid.476473.50000 0004 8389 0378Institute for Pharmacology and Preventive Medicine, Bahnhofstrasse 20, 49661 Cloppenburg, Germany
| | - Peter Bramlage
- grid.476473.50000 0004 8389 0378Institute for Pharmacology and Preventive Medicine, Bahnhofstrasse 20, 49661 Cloppenburg, Germany
| | - Volkmar Falk
- grid.418209.60000 0001 0000 0404Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany ,grid.452396.f0000 0004 5937 5237German Center for Cardiovascular Research, Partner Site Berlin, Berlin, Germany ,grid.7468.d0000 0001 2248 7639Department of Cardiovascular Surgery, Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt Universität zu Berlin, Berlin, Germany ,grid.5801.c0000 0001 2156 2780Department of Health Sciences and Technology, ETH Zürich, Zurich, Switzerland
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Pausch J, Bhadra OD, Sequeira Gross TM, Hua X, Conradi L, Reichenspurner H, Girdauskas E. Early Outcomes of Endoscopic Papillary Muscle Relocation for Secondary Mitral Regurgitation Type IIIb in Patients With Severe Left Ventricular Dysfunction. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2022; 17:317-323. [PMID: 35983699 PMCID: PMC9403379 DOI: 10.1177/15569845221115419] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Objective: Subannular mitral valve (MV) repair techniques have been
developed to address increased rates of recurrent mitral regurgitation (MR) in
patients with secondary MR (SMR) type IIIb. Endoscopic papillary muscle
relocation (PMR) is feasible via minithoracotomy. Nevertheless, the
periprocedural outcome of patients with severe left ventricular (LV) dysfunction
remains unknown. Methods: A total of 98 consecutive patients with
SMR type IIIb underwent PMR at our institution. Due to concomitant coronary
artery bypass grafting, 62 patients underwent sternotomy and were excluded from
the current analysis, whereas 36 patients were treated by a minimally invasive
technique using 3-dimensional endoscopy. Of these, 18 patients had severely
depressed LV ejection fraction (LVEF) ≤35% (study group) and were compared to
the remaining 18 patients with LVEF >35% (control group). Periprocedural
outcome was retrospectively analyzed. Results: Although LVEF was
significantly worse in the study group (30% ± 4% vs 43% ± 6%,
P < 0.001), the severity of SMR and the degree of MV leaflet
tethering were similar. The prevalence of concomitant procedures and the
duration of surgery, cardiopulmonary bypass, and aortic cross-clamp were
comparable. Periprocedural low cardiac output syndrome was favorably low in both
groups (16.7% vs 5.6%, P = 0.29). Postoperative ventilation
time (5.7 h [4.2 to 8.7 h] vs 6.0 h [4.6 to 9.8 h], P = 0.43)
and duration of intensive care unit stay (2 days [1 to 3 days] vs 2 days [1 to 3
days], P = 0.22) were similar. There was no 30-day mortality in
either group. Conclusions: Standardized endoscopic PMR resulted in
favorable periprocedural outcomes in patients with severe LV dysfunction,
suggesting that minimally invasive surgery can safely be extended to this
patient population.
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Affiliation(s)
- Jonas Pausch
- Department of Cardiovascular Surgery, 196169University Heart & Vascular Center Hamburg, Germany
| | - Oliver D Bhadra
- Department of Cardiovascular Surgery, 196169University Heart & Vascular Center Hamburg, Germany
| | | | - Xiaoqin Hua
- Department of Cardiovascular Surgery, 196169University Heart & Vascular Center Hamburg, Germany
| | - Lenard Conradi
- Department of Cardiovascular Surgery, 196169University Heart & Vascular Center Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, 196169University Heart & Vascular Center Hamburg, Germany
| | - Evaldas Girdauskas
- Department of Cardiothoracic Surgery, 39694University Hospital Augsburg, Germany
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Travin N, Dalinin V, Borisov I. Two-year outcome after standardized papillary muscle relocation for type IIIb secondary mitral regurgitation: is it enough to assess the result improvement? Eur J Cardiothorac Surg 2022; 62:6604731. [PMID: 35678572 DOI: 10.1093/ejcts/ezac339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 06/01/2022] [Indexed: 11/13/2022] Open
Affiliation(s)
- Nikolay Travin
- Department of cardiovascular surgery, Central Military Clinical Hospital n.a. P.V. Mandryka, Moscow, Russia
| | - Vadim Dalinin
- Department of cardiovascular surgery, Central Military Clinical Hospital n.a. P.V. Mandryka, Moscow, Russia
| | - Igor Borisov
- Department of cardiovascular surgery, Central Military Clinical Hospital n.a. P.V. Mandryka, Moscow, Russia
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5
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Pausch J, Sequeira Gross TM, Bhadra OD, Hua X, Müller L, Conradi L, Reichenspurner H, Girdauskas E. Standardized papillary muscle relocation for type IIIb secondary mitral regurgitation improves two-year outcome. Eur J Cardiothorac Surg 2022; 62:6576629. [PMID: 35511127 DOI: 10.1093/ejcts/ezac285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Revised: 04/06/2022] [Accepted: 04/27/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES The major drawback of isolated annuloplasty for treatment of secondary mitral regurgitation (SMR) with restricted leaflet motion during systole (type IIIb) is recurrence of SMR, leading to adverse clinical outcome. Additional papillary muscles relocation (PMR) specifically addresses leaflet tethering to restore mitral valve geometry. We aimed to compare the two-year outcome of annuloplasty with additional PMR vs isolated annuloplasty. METHODS A total of 105 consecutive type IIIb SMR patients with preoperative LVEF <45%, LVEDD >55mm and a tenting height >10mm, reached two-year postoperative follow-up after MV repair and were included in the current analysis. 51 patients underwent annuloplasty and additional PMR (study group). 54 patients underwent isolated annuloplasty (control group). Primary composite study end-point comprised death or recurrence of MR ≥2 at two years postoperatively. RESULTS Echocardiographic baseline variables indicating the severity of left ventricular (LV) dysfunction and mitral leaflet tethering were similar. Procedural and periprocedural outcome was comparable in both groups. The primary composite end-point was significantly improved in the study group 19.6% [10/51] in comparison to the control group 44.4% [24/54] (p = 0.009). 2-year all-cause mortality was 7.8% [4/51] in the study group, vs 18.5% [10/54] in the control group (p = 0.098). After two years, significant improvement of NYHA functional class as compared to the baseline values was observed in the study group. CONCLUSIONS Additional PMR to treat SMR type IIIb resulted in an improved 2-year outcome in comparison to isolated annuloplasty. PMR specifically addressing mitral leaflet tethering represents a valid therapeutic option for heart-failure patients with SMR type IIIb.
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Affiliation(s)
- Jonas Pausch
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Germany
| | | | - Oliver D Bhadra
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Germany
| | - Xiaoqin Hua
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Germany
| | - Lisa Müller
- Department of Cardiothoracic Surgery, University Hospital Augsburg, Germany
| | - Lenard Conradi
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Germany
| | - Evaldas Girdauskas
- Department of Cardiothoracic Surgery, University Hospital Augsburg, Germany
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Sinn M, Pausch J, Ragab H, Sequeira-Gross T, von Stumm M, Spink C, Adam G, Reichenspurner H, Bannas P, Lund G, Girdauskas E. Changes in left ventricular geometry after subannular repair in type IIIb functional mitral regurgitation. Eur J Cardiothorac Surg 2022; 62:6561280. [DOI: 10.1093/ejcts/ezac226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 03/09/2022] [Accepted: 03/25/2022] [Indexed: 11/12/2022] Open
Abstract
Abstract
OBJECTIVES
Papillary muscle repositioning in functional mitral regurgitation (FMR) alleviates mitral valve (MV) tenting by reducing the distance between papillary muscle tips and MV annular plane, i.e. apical left ventricular (LV) displacement. We aimed to quantify the effect of papillary muscle repositioning on papillary muscle geometry and to evaluate whether improved papillary muscle geometry after papillary muscle repositioning translates into the global LV reverse remodelling in FMR type IIIb.
METHODS
Patients with severe FMR type IIIb were prospectively enrolled and underwent pre- and postoperative 1.5-T cardiac magnetic resonance imaging. A new variable was defined, the papillary muscle to mitral annulus distance, which quantifies the distance between papillary muscle tips and MV annular plane. All parameters were measured by 2 independent investigators.
RESULTS
A total of 63 patients were enrolled. In all patients, papillary muscle to mitral annulus distance correlated significantly with established markers of LV remodelling and MV tenting severity. In patients who underwent subannular papillary muscle repositioning procedure (surgical cohort, n = 23), preoperative median papillary muscle to mitral annulus distance was 30 mm [interquartile range (IQR): 27–34 mm] and was significantly reduced postoperatively to 25 mm (IQR: 21–27 mm) (P = 0.001). LV end-diastolic diameter was reduced from 66 mm (IQR: 60–71) preoperatively to 58 mm (IQR: 53–67) after the surgery (P = 0.001).
CONCLUSIONS
MV repair with papillary muscle repositioning results in a papillary muscle to mitral annulus distance reduction and significantly improved MV tenting parameters. Improved papillary muscle geometry after papillary muscle repositioning is associated with a global LV reverse remodelling and may, thereby, improve the prognosis of FMR patients.
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Affiliation(s)
- Martin Sinn
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Hospital Eppendorf, Hamburg, Germany
| | - Jonas Pausch
- Department of Cardiovascular Surgery, University Hospital Eppendorf, Hamburg, Germany
| | - Haissam Ragab
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Hospital Eppendorf, Hamburg, Germany
| | | | - Maria von Stumm
- Department of Cardiovascular Surgery, University Hospital Eppendorf, Hamburg, Germany
| | - Clemens Spink
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Hospital Eppendorf, Hamburg, Germany
| | - Gerhard Adam
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Hospital Eppendorf, Hamburg, Germany
| | | | - Peter Bannas
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Hospital Eppendorf, Hamburg, Germany
| | - Gunnar Lund
- Department of Diagnostic and Interventional Radiology and Nuclear Medicine, University Hospital Eppendorf, Hamburg, Germany
| | - Evaldas Girdauskas
- Department of Cardiovascular Surgery, University Hospital Eppendorf, Hamburg, Germany
- Department of Cardiothoracic Surgery, Augsburg University Hospital, Augsburg, Germany
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7
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Pausch J, Bhadra O, Mersmann J, Conradi L, Sill B, Barten MJ, Reichenspurner H, Bernhardt AM. Prognostic impact of functional mitral regurgitation prior to left ventricular assist device implantation. J Cardiothorac Surg 2022; 17:24. [PMID: 35216595 PMCID: PMC8876108 DOI: 10.1186/s13019-021-01748-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Accepted: 12/27/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Functional mitral regurgitation (FMR) is a common finding of advanced heart failure with detrimental effects. The prognostic impact of uncorrected FMR prior to left ventricular assist device (LVAD) implantation remains controversial. METHODS Between 2016 and 2019 77 patients underwent continuous-flow LVAD implantation at our institution. 34 patients showed FMR ≥ 2 (MR-group), whereas 43 patients showed FMR < 2 (Control-group). Data was retrospectively analyzed. Primary composite endpoint comprised freedom from death, stroke, pump-thrombosis, major bleeding and right heart failure (RHF) after 1 year. RESULTS Baseline characteristics, including the severity of left and right ventricular dysfunction, and periprocedural results were comparable. The overall survival during a mean follow up of 24.9 months was 55.9% in the MR-group versus 58.1% in the Control-group (p = 0.963), whereas 1-year event-free survival was 35.3% in the MR-group compared to 44.2% in the Control-group (p = 0.404). RHF within the first postoperative year occurred more frequently in the MR-group (35.3% vs. 11.6%; p = 0.017). Furthermore, RV function was significantly reduced in comparison to baseline values in the MR-group. 12 months after surgery, 74% of patients in the MR-group were classified as NYHA III in comparison to 24% of patients in the Control-group (p < 0.001). CONCLUSIONS Preoperative uncorrected FMR prior to LVAD implantation did not affect overall survival, nevertheless it was associated with an impaired RV function and increased incidence of right heart failure during follow-up. Furthermore, preoperative FMR ≥ 2 was associated with persistent symptoms of heart failure.
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Affiliation(s)
- Jonas Pausch
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Martinistraße 52, 20251, Hamburg, Germany.
| | - Oliver Bhadra
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Martinistraße 52, 20251, Hamburg, Germany
| | - Julian Mersmann
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Martinistraße 52, 20251, Hamburg, Germany
| | - Lenard Conradi
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Martinistraße 52, 20251, Hamburg, Germany
| | - Bjoern Sill
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Martinistraße 52, 20251, Hamburg, Germany
| | - Markus J Barten
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Martinistraße 52, 20251, Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Martinistraße 52, 20251, Hamburg, Germany
| | - Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Martinistraße 52, 20251, Hamburg, Germany
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Pausch J, Girdauskas E, Conradi L, Reichenspurner H. Secondary mitral regurgitation repair techniques and outcomes: Subannular repair techniques in secondary mitral regurgitation type IIIb. JTCVS Tech 2022; 10:92-97. [PMID: 34977710 PMCID: PMC8691802 DOI: 10.1016/j.xjtc.2021.09.019] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 09/02/2021] [Indexed: 11/30/2022] Open
Affiliation(s)
- Jonas Pausch
- Department of Cardiovascular Surgery University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Evaldas Girdauskas
- Department of Cardiothoracic Surgery, University Hospital Augsburg, Augsburg, Germany
| | - Lenard Conradi
- Department of Cardiovascular Surgery University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery University Heart & Vascular Center Hamburg, Hamburg, Germany
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Pausch J, Sequeira Gross T, Müller L, von Stumm M, Kloth B, Reichenspurner H, Girdauskas E. Subannular repair for functional mitral regurgitation type IIIb in patients with ischaemic versus dilated cardiomyopathy. Eur J Cardiothorac Surg 2021; 60:122-130. [PMID: 33693797 DOI: 10.1093/ejcts/ezab048] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 12/08/2020] [Accepted: 01/08/2021] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVES Functional mitral regurgitation (FMR) is a sequel of left ventricular (LV) remodelling in heart failure patients. Relocation of both papillary muscles aims to specifically address mitral leaflet tethering to improve long-term durability of modern FMR repair. Nevertheless, the prognostic impact of the underlying cardiomyopathy on the outcome after FMR repair is unknown. METHODS We analysed 84 consecutive heart failure patients with severe FMR, LV ejection fraction <40%, LV end-diastolic diameter ≥55 mm and tenting height >10 mm, who underwent ring annuloplasty and simultaneous bilateral papillary muscles relocation between June 2016 and March 2019. One-year outcome of 54 patients with ischaemic cardiomyopathy ('ICM group') was prospectively compared to the remaining 30 patients with dilated cardiomyopathy ('DCM group'). RESULTS One-year survival was similar in both groups (96% in the 'ICM group' vs 97% in the 'DCM group'; P = 0.93). Furthermore, primary composite outcome (i.e. freedom from death or mitral regurgitation ≥ 2) at 1-year postoperatively was comparable between the study groups (94%in the 'ICM group' vs 87% in the 'DCM group'; P = 0.10). LV end-diastolic diameter 1-year after surgery was significantly reduced, as compared to preoperative values, in the 'DCM group' (P = 0.018), but not in the 'ICM group' (P = 0.058). Improvement of New York Heart Association functional class and reduction of serum levels of N-terminal pro-B natriuretic peptide at 1 year was comparable in both study groups. CONCLUSIONS Standardized relocation of both papillary muscles to correct FMR resulted in very satisfactory in-hospital and 1-year outcomes, in both ICM and DCM. DCM patients showed similar improvement in heart failure symptoms and LV re-remodelling compared to ICM patients. Subannular repair is developing towards a valid therapeutic option in heart failure patients presenting with severe FMR.
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Affiliation(s)
- Jonas Pausch
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Tatiana Sequeira Gross
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Lisa Müller
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Maria von Stumm
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Benjamin Kloth
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Hamburg, Germany
| | - Evaldas Girdauskas
- Department of Cardiovascular Surgery, University Heart & Vascular Center Hamburg, Hamburg, Germany
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Vinciguerra M, Grigioni F, Romiti S, Benfari G, Rose D, Spadaccio C, Cimino S, De Bellis A, Greco E. Ischemic Mitral Regurgitation: A Multifaceted Syndrome with Evolving Therapies. Biomedicines 2021; 9:biomedicines9050447. [PMID: 33919263 PMCID: PMC8143318 DOI: 10.3390/biomedicines9050447] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 04/14/2021] [Accepted: 04/19/2021] [Indexed: 12/24/2022] Open
Abstract
Dysfunction of the left ventricle (LV) with impaired contractility following chronic ischemia or acute myocardial infarction (AMI) is the main cause of ischemic mitral regurgitation (IMR), leading to moderate and moderate-to-severe mitral regurgitation (MR). The site of AMI exerts a specific influence determining different patterns of adverse LV remodeling. In general, inferior-posterior AMI is more frequently associated with regional structural changes than the anterolateral one, which is associated with global adverse LV remodeling, ultimately leading to different phenotypes of IMR. In this narrative review, starting from the aforementioned categorization, we proceed to describe current knowledge regarding surgical approaches in the management of IMR.
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Affiliation(s)
- Mattia Vinciguerra
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (S.R.); (S.C.); (E.G.)
- Correspondence:
| | - Francesco Grigioni
- Unit of Cardiovascular Sciences, Department of Medicine Campus Bio-Medico, University of Rome, 00128 Rome, Italy;
| | - Silvia Romiti
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (S.R.); (S.C.); (E.G.)
| | - Giovanni Benfari
- Division of Cardiology, Department of Medicine, University of Verona, 37219 Verona, Italy;
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN 55905, USA
| | - David Rose
- Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool FY3 8NP, UK; (D.R.); (C.S.)
| | - Cristiano Spadaccio
- Lancashire Cardiac Centre, Blackpool Victoria Hospital, Blackpool FY3 8NP, UK; (D.R.); (C.S.)
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8QQ, UK
| | - Sara Cimino
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (S.R.); (S.C.); (E.G.)
| | - Antonio De Bellis
- Department of Cardiology and Cardiac Surgery, Casa di Cura “S. Michele”, 81024 Maddaloni, Caserta, Italy;
| | - Ernesto Greco
- Department of Clinical, Internal Medicine, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy; (S.R.); (S.C.); (E.G.)
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von Stumm M, Dudde F, Gasser S, Sequeira-Gross T, Pausch J, Sinning C, Reichenspurner H, Girdauskas E. Prognostic value of mitral valve tenting area in patients with functional mitral regurgitation. Interact Cardiovasc Thorac Surg 2020; 30:431-438. [PMID: 31808513 DOI: 10.1093/icvts/ivz291] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Revised: 10/25/2019] [Accepted: 11/01/2019] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES Mitral valve (MV) repair in functional mitral regurgitation is still associated with suboptimal outcomes. Our goal was to determine whether the clinical outcome following MV repair correlates with preoperative tenting parameters. METHODS We retrospectively identified consecutive patients with functional mitral regurgitation who underwent an isolated MV annuloplasty during a 7-year period (2010-2016) from our institutional database. Preoperative tenting parameters (i.e. tenting height, coaptation length, tenting area, posterior mitral leaflet and anterior mitral leaflet angles and interpapillary muscle distance) were systematically measured. The primary end point was the composite of survival and freedom from adverse cardiac events. The follow-up protocol consisted of a structured clinical questionnaire and an analysis of the echocardiographic data. RESULTS A total of 240 patients (mean age 67.8 ± 9.8 years, 57% of men) were analysed. The overall 5-year survival rate for the whole study cohort was 74.7 ± 4.2%, and freedom from adverse cardiac events was 84.8 ± 3.4%. A tenting area ≥2.4 cm2 was identified as a cut-off value, independently predicting the composite primary study end point (hazard ratio 2.0; P = 0.03). Furthermore, a Kaplan-Meier analysis revealed a strong tendency towards worse 5-year outcomes in patients with a tenting area ≥2.4 cm2 (n = 153) versus patients with a tenting area <2.4 cm2 (n = 87) (65.3 ± 5.5% vs 77.1 ± 6.3%; P = 0.06). CONCLUSIONS MV annuloplasty is associated with acceptable clinical and echocardiographic outcomes in patients with functional mitral regurgitation 5 years postoperatively. A preoperative tenting area ≥2.4 cm2 showed a strong trend towards a worse 5-year survival rate and an increased risk of adverse cardiac events after an isolated MV annuloplasty.
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Affiliation(s)
- Maria von Stumm
- Department of Cardiovascular Surgery, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Florian Dudde
- Department of Cardiovascular Surgery, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Simone Gasser
- Department of Cardiovascular Surgery, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tatiana Sequeira-Gross
- Department of Cardiovascular Surgery, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jonas Pausch
- Department of Cardiovascular Surgery, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christoph Sinning
- Department of Cardiology, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Evaldas Girdauskas
- Department of Cardiovascular Surgery, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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12
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Drake DH, Zimmerman KG, Sidebotham DA. Past, current and future management of secondary mitral valve disease: the importance of anatomic staging. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:968. [PMID: 32953768 PMCID: PMC7475447 DOI: 10.21037/atm.2020.03.82] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Daniel H Drake
- Department of Surgery, Munson Medical Center, Traverse City, MI, USA
| | - Karen G Zimmerman
- Department of Cardiology, Henry Ford Health System, Detroit, MI, USA
| | - David A Sidebotham
- Department of Cardiothoracic Anesthesia and Cardiothoracic Intensive Care Unit, Auckland City Hospital, Grafton, Auckland, New Zealand
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13
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Pausch J, Sequeira Gross T, Reichenspurner H, Girdauskas E. Left ventricular reverse remodeling after successful subannular mitral valve repair in end-stage heart failure: a case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2020; 4:1-5. [PMID: 32617510 PMCID: PMC7319855 DOI: 10.1093/ehjcr/ytaa087] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 10/02/2019] [Accepted: 03/24/2020] [Indexed: 01/15/2023]
Abstract
Background Due to ongoing left ventricular (LV) remodeling and consecutive geometric displacement of both papillary muscles, end-stage heart failure is frequently associated with relevant functional mitral regurgitation (FMR) Type IIIb. Treatment strategies of FMR and their prognostic impact are still controversial. Case summary We present a case of an 80-year-old patient who suffered from recurrent symptoms of congestive heart failure due to dilated cardiomyopathy and concomitant severe FMR. To specifically address severe tethering of both mitral leaflets heart team decision was to perform minimally invasive mitral valve repair (MVR) including a subannular LV remodeling procedure, instead of an interventional edge-to-edge repair (MitraClip® procedure). In addition to mitral valve ring annuloplasty, standardized relocation of both papillary muscles was performed successfully, leading to a complete resolution of mitral leaflet tethering. There were no procedural complications and the patient was discharged with an excellent functional result without residual mitral regurgitation. Furthermore, after 12 and 24 months, he reported an increase of his functional exercise capacity and a remarkable reverse LV remodeling could be demonstrated. Discussion Novel subannular repair techniques, especially the relocation of both papillary muscles, specifically address severe leaflet tethering in FMR and have an obvious potential to improve long-term competence of MVR. Therefore, they could be considered as a viable therapeutic option even in elderly patients presenting with end-stage cardiomyopathy and severe leaflet tenting.
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Affiliation(s)
- Jonas Pausch
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Martinistraße 52, D-20246 Hamburg, Germany
| | - Tatiana Sequeira Gross
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Martinistraße 52, D-20246 Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Martinistraße 52, D-20246 Hamburg, Germany
| | - Evaldas Girdauskas
- Department of Cardiovascular Surgery, University Heart and Vascular Center Hamburg, Martinistraße 52, D-20246 Hamburg, Germany
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14
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Li B, Sun H. Subannular repair for moderate to severe ischemic mitral regurgitation: Still a long way to go. Authors' reply. Cardiol J 2020; 27:223-224. [PMID: 32463102 DOI: 10.5603/cj.2020.0052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 03/25/2020] [Indexed: 11/25/2022] Open
Affiliation(s)
- Baotong Li
- SunState Key Laboratory of Cardiovascular Disease, Department of Adult Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science, Peking Union Medical College, Beijing, China.
| | - Hansong Sun
- SunState Key Laboratory of Cardiovascular Disease, Department of Adult Cardiac Surgery, Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Science, Peking Union Medical College, Beijing, China
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15
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Micali LR, Qadrouh MN, Parise O, Parise G, Matteucci F, de Jong M, Tetta C, Moula AI, Johnson DM, Gelsomino S. Papillary muscle intervention vs mitral ring annuloplasty in ischemic mitral regurgitation. J Card Surg 2020; 35:645-653. [PMID: 31951676 PMCID: PMC7078820 DOI: 10.1111/jocs.14407] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Background and Aims The main pathophysiological factor of chronic ischemic mitral regurgitation (MR) is the outward displacement of the papillary muscles (PMs) leading to leaflet tethering. For this reason, papillary muscle intervention (PMI) in combination with mitral ring annuloplasty (MRA) has recently been introduced into clinical practice to correct this displacement, and to reduce the recurrence of regurgitation. Methods A meta‐analysis was conducted comparing the outcomes of PMI and MRA performed in combination vs MRA performed alone, in terms of MR recurrence and left ventricular reverse remodeling (LVRR). A meta‐regression was carried out to investigate the impact of the type of PMI procedure on the outcomes. Results MR recurrence in patients undergoing both PMI and MRA was lower than in those who only had MRA (log incidence rate ratio, −0.66; lower‐upper limits, −1.13 to 0.20; I2 = 0.0%; p = .44; Egger's test: intercept 0.35 [−0.78 to 1.51]; p = .42). The group with both PMI and MRA and that with only MRA showed a slightly higher reduction in left ventricular diameters (−5.94%; −8.75% to 3.13%,). However, in both groups, LVRR was <10%. No difference was detected between PM relocation/repositioning and papillary muscle approximation in terms of LVRR (p = .33). Conclusions Using PMI and MRA together has a lower MR recurrence than using MRA alone. No significant LVRR was observed between the two groups nor between the PMI techniques employed.
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Affiliation(s)
- Linda R Micali
- Department of Cardiothoracic Surgery, Maastricht University Hospital, Maastricht, The Netherlands
| | - Mohammad N Qadrouh
- Department of Cardiothoracic Surgery, Maastricht University Hospital, Maastricht, The Netherlands
| | - Orlando Parise
- Department of Cardiothoracic Surgery, Maastricht University Hospital, Maastricht, The Netherlands
| | - Gianmarco Parise
- Department of Cardiothoracic Surgery, Maastricht University Hospital, Maastricht, The Netherlands
| | - Francesco Matteucci
- Department of Cardiothoracic Surgery, Maastricht University Hospital, Maastricht, The Netherlands
| | - Monique de Jong
- Department of Cardiothoracic Surgery, Maastricht University Hospital, Maastricht, The Netherlands
| | - Cecilia Tetta
- Department of Cardiothoracic Surgery, Maastricht University Hospital, Maastricht, The Netherlands
| | - Amalia I Moula
- Department of Cardiothoracic Surgery, Maastricht University Hospital, Maastricht, The Netherlands
| | - Daniel M Johnson
- Department of Cardiothoracic Surgery, Maastricht University Hospital, Maastricht, The Netherlands
| | - Sandro Gelsomino
- Department of Cardiothoracic Surgery, Maastricht University Hospital, Maastricht, The Netherlands
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