Early and late results of mitral valve repair with anterior leaflet patch augmentation

Surgery for Active Infective Endocarditis on Mitral Valve: Anatomical, Surgical, and Disease Factors as Long-Term Outcome Modifiers

Background and Objectives: Determinants of long-term outcomes after surgery for native mitral valve endocarditis have not been thoroughly investigated. The aim of this study was to assess anatomical, disease, and surgical risk factors for long-term mortality and need of reintervention, in patients undergoing mitral valve surgery for active endocarditis. Materials and Methods: Patients who underwent surgery for active native mitral valve endocarditis at three academic centres, between 2000 and 2022, were analysed. The primary outcome was long-term survival. The secondary outcome was the freedom from mitral reoperation. Survival curves were constructed with Kaplan-Meier methodology. Multivariable Cox regression was used to identify demographic, anatomical, disease, and surgical factors associated with late mortality and reoperation. Results: 335 consecutive patients with active mitral endocarditis were analysed. Two hundred and one patients (70.5%) had infection confined to the valve cusp whereas 89 (25.6%) had invasive disease extended to the annulus and surrounding tissues. Preoperative neurological events occurred at the diagnosis in 52 cases. Streptococci were the most common causative organisms followed by Staphylococcus aureus, Coagulase-negative Staphylococcus, and Enterococcus. Valve repair was performed in 108 patients (32.2%). Survival at 5 and 10 years was 70.1% and 59.2%, respectively. Staphylococcus emerged as an independent predictor of late mortality, along with age, chronic obstructive pulmonary disease, and previous cardiac surgery. Survival was considerably reduced in patients with S. aureus compared with those without (log rank p < 0.001). The type of surgery (repair vs. replacement) did not emerge as a risk factor for late mortality and reoperation. Seventeen patients underwent mitral reoperation during the follow-up. The 5- and 10-year freedom from reoperation was 94.7% and 91.8%, respectively. Conclusions: Active mitral valve endocarditis remains a life-threatening disease with impaired survival. While lesion characteristics influenced surgical decision-making and intraoperative management, their impact on long-term survival and freedom from reintervention appears to be moderated by other factors such as infecting pathogens and patient comorbidities.

Surgical repair and replacement for native mitral valve infective endocarditis

AIMS

The clinical benefits of mitral valve repair over replacement in the setting of mitral infective endocarditis are not clearly established.

METHODS

Data of patients who underwent cardiac surgery for infective endocarditis over a 20-year period (2001-2021) at two cardiac centres were reviewed. Among them, 282 patients underwent native mitral valve surgery and were included in the study. Nearest-neighbour propensity-score matching was performed to account for differences in patients' profile between the repair and replacement subgroups.

RESULTS

Mitral valve replacement was performed in 186 patients, while in 96 cases patients underwent mitral valve repair. Propensity match analysis provided 89 well matched pairs. Mean age was 60 ± 15 years; 75% of the patients were male. Mitral valve replacement was more commonly performed in patients with involvement of both mitral leaflets, commissure(s) and mitral annulus. Patients with lesion(s) limited to P2 segment formed the majority of the cases undergoing mitral valve repair. There was no difference in terms of microbiological findings. In-hospital mortality was 7% with no difference between the repair and the replacement cohorts. Survival probabilities at 1, 5 and 10 years were 88%, 72% and 68%, respectively after mitral repair, and 88%, 78% and 63%, respectively after mitral replacement (log-rank P  = 0.94).

CONCLUSIONS

Mitral valve repair was more commonly performed in patients with isolated single leaflet involvement and provided good early and 10-year outcomes. Patients with annular disruption, lesion(s) on both leaflets and commissure(s) were successfully served on early and mid-term course by mitral valve replacement.

Mitral valve repair using leaflet expansion and subpartial annuloplasty in children

Objective

Mitral valve reconstruction in the pediatric population is a challenge due to the frequent combination of annular dilatation and leaflet restriction and the need for growth. We present a novel strategy using leaflet expansion and subpartial annuloplasty with polytetrafluoroethylene reinforcement.

Methods

From January 2014 through May 2021, 11 children aged 5 months to 14 years (median, 24 months) underwent elective mitral valve repair due to severe mitral valve regurgitation. The mitral valve abnormalities included congenital malformations (n = 7), postoperative leakage following commissurotomy (n = 1), and functional mitral valve regurgitation due to dilated cardiomyopathy (n = 3). Surgery consisted of leaflet expansions with autologous, untreated pericardium and subpartial annuloplasty with polytetrafluoroethylene reinforcement.

Results

All children survived their surgeries with uneventful postoperative courses, except for 1 patient who needed an early reoperation to resolve a functional stenosis due to a spinnaker phenomenon. At discharge, mean gradient was 3.5 ± 3.9 mm Hg, with trivial mitral regurgitation in 9 patients (82%). All patients were alive and asymptomatic during the median follow-up of 3 years (range, 1-7 years). Their echocardiographic data showed a mean transmitral gradient of 4.4 ± 1.7 mm Hg and remained unchanged. Residual mitral valve regurgitation was trivial or mild in 9 patients (82%) and moderate in 2 patients (18%).

Conclusions

Leaflet expansion with autologous pericardium and subpartial annuloplasty with polytetrafluoroethylene reinforcement for mitral regurgitation in the pediatric population gives stable and satisfactory results both early and at intermediate follow-up, permitting growth of the mitral valve.