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Makkar RR, Chikwe J, Chakravarty T, Chen Q, O’Gara PT, Gillinov M, Mack MJ, Vekstein A, Patel D, Stebbins AL, Gelijns AC, Makar M, Bhatt DL, Kapadia S, Vemulapalli S, Leon MB. Transcatheter Mitral Valve Repair for Degenerative Mitral Regurgitation. JAMA 2023; 329:1778-1788. [PMID: 37219553 PMCID: PMC10208157 DOI: 10.1001/jama.2023.7089] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 04/12/2023] [Indexed: 05/24/2023]
Abstract
Importance There are limited data on the outcomes of transcatheter edge-to-edge mitral valve repair for degenerative mitral regurgitation (MR) in a real-world setting. Objective To evaluate the outcomes of transcatheter mitral valve repair for degenerative MR. Design, Setting, and Participants Cohort study of consecutive patients in the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapies Registry who underwent nonemergent transcatheter mitral valve repair for degenerative MR in the US from 2014 through 2022. Exposure Transcatheter edge-to-edge mitral valve repair with the MitraClip device (Abbott). Main Outcomes and Measures The primary end point was MR success, defined as moderate or less residual MR and a mean mitral gradient of less than 10 mm Hg. Clinical outcomes were evaluated based on the degree of residual MR (mild or less MR or moderate MR) and mitral valve gradients (≤5 mm Hg or >5 to <10 mm Hg). Results A total of 19 088 patients with isolated moderate to severe or severe degenerative MR who underwent transcatheter mitral valve repair were analyzed (median age, 82 years; 48% women; median Society of Thoracic Surgeons predicted risk of mortality with surgical mitral valve repair, 4.6%). MR success was achieved in 88.9% of patients. At 30 days, the incidence of death was 2.7%; stroke, 1.2%; and mitral valve reintervention, 0.97%. MR success compared with an unsuccessful procedure was associated with significantly lower mortality (14.0% vs 26.7%; adjusted hazard ratio, 0.49; 95% CI, 0.42-0.56; P < .001) and heart failure readmission (8.4% vs 16.9%; adjusted hazard ratio, 0.47; 95% CI, 0.41-0.54; P < .001) at 1 year. Among patients with MR success, the lowest mortality was observed in patients who had both mild or less residual MR and mean mitral gradients of 5 mm Hg or less compared with those with an unsuccessful procedure (11.4% vs 26.7%; adjusted hazard ratio, 0.40; 95% CI, 0.34-0.47; P < .001). Conclusions and Relevance In this registry-based study of patients with degenerative MR undergoing transcatheter mitral valve repair, the procedure was safe and resulted in successful repair in 88.9% of patients. The lowest mortality was observed in patients with mild or less residual MR and low mitral gradients.
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Affiliation(s)
- Raj R. Makkar
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Joanna Chikwe
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Tarun Chakravarty
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Qiudong Chen
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | | | | | | | | | - Dhairya Patel
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | | | | | - Moody Makar
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
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Zhou N, Ji Z, Li F, Qiao B, Lin R, Jiang W, Zhu Y, Lin Y, Zhang K, Li S, You B, Gao P, Dong R, Wang Y, Du J. Machine Learning-Based Personalized Risk Prediction Model for Mortality of Patients Undergoing Mitral Valve Surgery: The PRIME Score. Front Cardiovasc Med 2022; 9:866257. [PMID: 35433879 PMCID: PMC9010531 DOI: 10.3389/fcvm.2022.866257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 03/01/2022] [Indexed: 11/24/2022] Open
Abstract
Background Mitral valve surgery (MVS) is an effective treatment for mitral valve diseases. There is a lack of reliable personalized risk prediction models for mortality in patients undergoing mitral valve surgery. Our aim was to develop a risk stratification system to predict all-cause mortality in patients after mitral valve surgery. Methods Different machine learning models for the prediction of all-cause mortality were trained on a derivation cohort of 1,883 patients undergoing mitral valve surgery [split into a training cohort (70%) and internal validation cohort (30%)] to predict all-cause mortality. Forty-five clinical variables routinely evaluated at discharge were used to train the models. The best performance model (PRIME score) was tested in an externally validated cohort of 220 patients undergoing mitral valve surgery. The model performance was evaluated according to the area under the curve (AUC). Net reclassification improvement (NRI) and integrated discrimination improvement (IDI) were compared with existing risk strategies. Results After a median follow-up of 2 years, there were 133 (7.063%) deaths in the derivation cohort and 17 (7.727%) deaths in the validation cohort. The PRIME score showed an AUC of 0.902 (95% confidence interval [CI], 0.849–0.956) in the internal validation cohort and 0.873 (95% CI: 0.769–0.977) in the external validation cohort. In the external validation cohort, the performance of the PRIME score was significantly improved compared with that of the existing EuroSCORE II (NRI = 0.550, [95% CI 0.001–1.099], P = 0.049, IDI = 0.485, [95% CI 0.230–0.741], P < 0.001). Conclusion Machine learning-based model (the PRIME score) that integrate clinical, demographic, imaging, and laboratory features demonstrated superior performance for the prediction of mortality patients after mitral valve surgery compared with the traditional risk model EuroSCORE II. Clinical Trial Registration [http://www.clinicaltrials.gov], identifier [NCT05141292].
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Affiliation(s)
- Ning Zhou
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Zhili Ji
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Fengjuan Li
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Bokang Qiao
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Rui Lin
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Wenxi Jiang
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yuexin Zhu
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yuwei Lin
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
| | - Kui Zhang
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Shuanglei Li
- Department of Cardiac Surgery, Chinese People’s Liberation Army General Hospital, Beijing, China
| | - Bin You
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Pei Gao
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
- Peking University Health Science Center, Peking University, Beijing, China
- Key Laboratory of Molecular Cardiovascular Sciences, Ministry of Education, Peking University, Beijing, China
| | - Ran Dong
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Department of Cardiac Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- *Correspondence: Ran Dong,
| | - Yuan Wang
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Yuan Wang,
| | - Jie Du
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Jie Du,
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Zeitani J, Chiariello GA, Shofti R, Sabbag L, Bruno P, Massetti M, Alfieri O. Evaluation of an Innovative Device for Mitral Valve Regurgitation: Experimental Acute In Vivo Results. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2022; 17:119-126. [PMID: 35343292 DOI: 10.1177/15569845221085223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Currently, mitral prosthetic rings are intended only to reshape the annulus. We present in vivo results of an innovative device characterized by an intraventricular segment designed to enable artificial chordae implantation and simplify leaflets and subvalvular apparatus correction. Methods: Eight sheep were employed. The first 4 underwent solely device implantation. In the last 4, primary chordae of the anterior leaflet (A2) were torn to induce severe mitral regurgitation. The severed chordae were replaced by 2 pairs of 5-0 Gore-Tex artificial chordae previously measured and anchored to the device bridge. Ease of device and chordae implantation were evaluated, and postprocedural valve competence was verified by postoperative echocardiogram. Results: The procedure was completed in all 8 sheep. In the 4 sheep with induced severe mitral regurgitation, repair could be achieved by means of artificial chordae implantation. Length of the 2 chordae implanted was 21.6 ± 2 mm and 22 ± 3 mm, respectively. The time required to suture the artificial chordae was 2.5 ± 1.2 min. Postoperative echocardiograms showed normal left ventricular ejection fraction and free motion of the mitral leaflets. Mitral regurgitation was absent in 5 cases and trivial in 3. The transvalvular peak pressure gradient was 9.5 ± 6 mm Hg, and mean gradient was 3.7 ± 4 mm Hg. Postprocedural evaluation of the heart and mitral valve showed no damage to the left ventricle wall, valve leaflets, chordae, and papillary muscles. Conclusions: In vivo tests confirm safety of the device, ease of chordal length estimation prior to implantation, short operative time, and no negative impact of the device on mitral leaflet motion, function, and structure.
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Affiliation(s)
- Jacob Zeitani
- Neurosciences and Rehabilitation Department, Cardiac Surgery Unit, University of Ferrara, Italy
| | - Giovanni A Chiariello
- Cardiovascular Sciences Department, Agostino Gemelli Foundation Polyclinic IRCCS, Rome, Italy.,Catholic University of The Sacred Heart, Rome, Italy
| | - Rona Shofti
- Department of Biomedical Engineering, 26747Technion-Israel Institute of Technology, Haifa, Israel
| | - Latif Sabbag
- Department of Cardiovascular Medicine, 37255Lady Davis Carmel Medical Center, Haifa, Israel
| | - Piergiorgio Bruno
- Cardiovascular Sciences Department, Agostino Gemelli Foundation Polyclinic IRCCS, Rome, Italy.,Catholic University of The Sacred Heart, Rome, Italy
| | - Massimo Massetti
- Cardiovascular Sciences Department, Agostino Gemelli Foundation Polyclinic IRCCS, Rome, Italy.,Catholic University of The Sacred Heart, Rome, Italy
| | - Ottavio Alfieri
- Department of Cardiac Surgery, 9372San Raffaele University Hospital, Milan, Italy
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Zeitani J, Chiariello GA, Shofti R, Bruno P, Massetti M, Alfieri O. OUP accepted manuscript. Interact Cardiovasc Thorac Surg 2022; 35:6548818. [PMID: 35289855 PMCID: PMC9336580 DOI: 10.1093/icvts/ivac067] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/04/2021] [Accepted: 03/06/2022] [Indexed: 11/27/2022] Open
Affiliation(s)
- Jacob Zeitani
- Neurosciences and Rehabilitation Department, University of Ferrara, Ferrara, Italy
| | - Giovanni Alfonso Chiariello
- Cardiovascular Sciences Department, Agostino Gemelli Foundation Polyclinic IRCCS, Rome, Italy
- Catholic University of The Sacred Heart, Rome, Italy
- Corresponding author. Cardiovascular Sciences Department, Agostino Gemelli Foundation Polyclinic IRCSS, Rome, Italy. Tel: +39 06-30154639; e-mail: (G.A. Chiariello)
| | - Rona Shofti
- Department of Biomedical Engineering, Technion-Israel Institute of Technology, Haifa, Israel
| | - Piergiorgio Bruno
- Cardiovascular Sciences Department, Agostino Gemelli Foundation Polyclinic IRCCS, Rome, Italy
- Catholic University of The Sacred Heart, Rome, Italy
| | - Massimo Massetti
- Cardiovascular Sciences Department, Agostino Gemelli Foundation Polyclinic IRCCS, Rome, Italy
- Catholic University of The Sacred Heart, Rome, Italy
| | - Ottavio Alfieri
- Department of Cardiac Surgery, San Raffaele University Hospital, Milan, Italy
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5
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Chiariello GA, Kuci S, Saitto G, Massetti M, Alfieri O, Zeitani J. A new device to treat mitral valve regurgitation: a proof of concept in bench test study. J Med Eng Technol 2021; 45:197-206. [PMID: 33754927 DOI: 10.1080/03091902.2021.1891312] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Mitral valve repair is typically performed by implanting a ring-like device at the valve annulus to reshape the annulus and to improve leaflet coaptation. In most cases, some additional procedures are needed, including leaflet resection and artificial chordae implantation. However, artificial chordae implantation could be technically challenging and postoperative left ventricular remodeling could increase the risk of recurrent mitral regurgitation. We propose an innovative annular device made of chromo-cobalt, finalized not only to reshape the annulus but also to enable anchoring of leaflets to a fixed intraventricular structure. Durability evaluation of the device was tested by applying eight radial force vectors equally spaced along the ring and related fatigue analysis. To evaluate the efficacy of the mitral valvuloplasty using the tested ring, the device was implanted in five adult swine hearts. Functional analysis of the ring was performed by measuring left ventricular pressure and fluid volume loss, following implantation in normal and dysfunctional mitral valve leaflets. Both fatigue and functional analysis showed satisfactory and promising results in terms of durability and efficacy of mitral valve repair. Because of its favorable durability and functional characteristics this device appears promising and provides good results in terms of valve competence, thus avoiding both manipulations of papillary muscles and interference in left ventricular hemodynamics. However, an in vivo test is mandatory to fully understand the impact of the device on subvalvular apparatus.
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Affiliation(s)
- Giovanni Alfonso Chiariello
- Cardiovascular Sciences Department, Agostino Gemelli Foundation Polyclinic IRCSS, Rome, Italy.,Catholic University of The Sacred Heart, Rome, Italy
| | - Saimir Kuci
- Department of Anesthesiology and Reanimation, Mother Teresa University, Tirana, Albania
| | - Guglielmo Saitto
- Department of Cardiac Surgery, IRCCS, San Donato Polyclinic, Milan, Italy
| | - Massimo Massetti
- Cardiovascular Sciences Department, Agostino Gemelli Foundation Polyclinic IRCSS, Rome, Italy.,Catholic University of The Sacred Heart, Rome, Italy
| | - Ottavio Alfieri
- Department of Cardiac Surgery, San Raffaele University Hospital, Milan, Italy
| | - Jacob Zeitani
- Neurosciences and Rehabilitation Department, University of Ferrara, Ferrara, Italy
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Tarasoutchi F, Montera MW, Ramos AIDO, Sampaio RO, Rosa VEE, Accorsi TAD, Santis AD, Fernandes JRC, Pires LJT, Spina GS, Vieira MLC, Lavitola PDL, Ávila WS, Paixão MR, Bignoto T, Togna DJD, Mesquita ET, Esteves WADM, Atik F, Colafranceschi AS, Moises VA, Kiyose AT, Pomerantzeff PMA, Lemos PA, Brito Junior FSD, Weksler C, Brandão CMDA, Poffo R, Simões R, Rassi S, Leães PE, Mourilhe-Rocha R, Pena JLB, Jatene FB, Barbosa MDM, Abizaid A, Ribeiro HB, Bacal F, Rochitte CE, Fonseca JHDAPD, Ghorayeb SKN, Lopes MACQ, Spina SV, Pignatelli RH, Saraiva JFK. Update of the Brazilian Guidelines for Valvular Heart Disease - 2020. Arq Bras Cardiol 2020; 115:720-775. [PMID: 33111877 PMCID: PMC8386977 DOI: 10.36660/abc.20201047] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Affiliation(s)
- Flavio Tarasoutchi
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | - Roney Orismar Sampaio
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Vitor Emer Egypto Rosa
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Tarso Augusto Duenhas Accorsi
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Antonio de Santis
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - João Ricardo Cordeiro Fernandes
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Lucas José Tachotti Pires
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Guilherme S Spina
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Marcelo Luiz Campos Vieira
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Paulo de Lara Lavitola
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Walkiria Samuel Ávila
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Milena Ribeiro Paixão
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Tiago Bignoto
- Instituto Dante Pazzanese de Cardiologia, São Paulo, SP - Brasil
| | | | | | | | - Fernando Atik
- Fundação Universitária de Cardiologia (FUC), São Paulo, SP - Brasil
| | | | | | | | | | - Pedro A Lemos
- Hospital Israelita Albert Einstein, São Paulo, SP - Brasil
| | | | - Clara Weksler
- Instituto Nacional de Cardiologia, Rio de Janeiro, RJ - Brasil
| | - Carlos Manuel de Almeida Brandão
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Robinson Poffo
- Hospital Israelita Albert Einstein, São Paulo, SP - Brasil
| | - Ricardo Simões
- Faculdade Ciências Médicas de Minas Gerais, Belo Horizonte, MG - Brasil
| | | | | | - Ricardo Mourilhe-Rocha
- Hospital Pró-Cardíaco, Rio de Janeiro, RJ - Brasil
- Hospital Universitário Pedro Ernesto, Rio de Janeiro, RJ - Brasil
| | - José Luiz Barros Pena
- Faculdade Ciências Médicas de Minas Gerais, Belo Horizonte, MG - Brasil
- Hospital Felício Rocho, Belo Horizonte, MG - Brasil
| | - Fabio Biscegli Jatene
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | - Alexandre Abizaid
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Henrique Barbosa Ribeiro
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Fernando Bacal
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | - Carlos Eduardo Rochitte
- Instituto do Coração (Incor) do Hospital de Clínica da Faculdade de Medicina da Universidade de São Paulo (HCFMUSP), São Paulo, SP - Brasil
| | | | | | | | | | | | - José Francisco Kerr Saraiva
- Sociedade Campineira de Educação e Instrução Mantenedora da Pontifícia Universidade Católica de Campinas, Campinas, SP - Brasil
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7
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Savic V, Pozzoli A, Gülmez G, Demir H, Batinkov N, Kuwata S, Weber A, Vogel R, Tanner F, Zuber M, Maisano F, Taramasso M. Transcatheter mitral valve chord repair. Ann Cardiothorac Surg 2018; 7:731-740. [PMID: 30598886 DOI: 10.21037/acs.2018.09.09] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
The field of mitral valve disease diagnosis and management is rapidly evolving. New understanding of pathophysiology and improvements in the adoption of sophisticated multimodality imaging modalities have led to early diagnosis and to more complex treatment. The most common cause of mitral regurgitation (MR) in the western world is in the primary alteration of the valve, which leads to degenerative leaflet prolapse due to chordal elongation or rupture and annular dilatation. Untreated, significant MR has a negative impact prognosis, leading to reduction of survival. In the setting of degenerative MR, surgical repair currently represents the standard of care. Treatment of asymptomatic patients with severe MR in the Valve Center of Excellence, in which successful repair reaches more than 95% and surgical mortality less than 1%, symbolizes the direction for the next years. Transcatheter mitral valve repair with different devices, more recently the chordal replacement ones, is providing good outcomes and became a therapeutic option in high-risk patients with degenerative MR. In the future, more advances are expected from further development of interventional techniques, careful evaluation and better patient selection. This review will focus on long-term surgical outcomes of mitral valve repair with artificial chordae and on the emerging transcatheter chordal repair devices as therapeutic options for degenerative MR patients.
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Affiliation(s)
- Vedran Savic
- Heart Valve Clinic, University Hospital of Zürich, University of Zürich, Zürich, Switzerland
| | - Alberto Pozzoli
- Heart Valve Clinic, University Hospital of Zürich, University of Zürich, Zürich, Switzerland
| | - Gökhan Gülmez
- Heart Valve Clinic, University Hospital of Zürich, University of Zürich, Zürich, Switzerland
| | - Halil Demir
- Heart Valve Clinic, University Hospital of Zürich, University of Zürich, Zürich, Switzerland
| | - Nikola Batinkov
- Heart Valve Clinic, University Hospital of Zürich, University of Zürich, Zürich, Switzerland
| | - Shingo Kuwata
- Heart Valve Clinic, University Hospital of Zürich, University of Zürich, Zürich, Switzerland
| | - Alberto Weber
- Heart Surgery, HerzZentrum Hirslanden Zürich, Zürich, Switzerland
| | - Rolf Vogel
- Department of Cardiology, Bürgerspital Solothurn, Solothurn, Switzerland
| | - Felix Tanner
- Heart Valve Clinic, University Hospital of Zürich, University of Zürich, Zürich, Switzerland
| | - Michel Zuber
- Heart Valve Clinic, University Hospital of Zürich, University of Zürich, Zürich, Switzerland
| | - Francesco Maisano
- Heart Valve Clinic, University Hospital of Zürich, University of Zürich, Zürich, Switzerland
| | - Maurizio Taramasso
- Heart Valve Clinic, University Hospital of Zürich, University of Zürich, Zürich, Switzerland
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8
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Hendrix RJ, Bello RA, Flahive JM, Kakouros N, Aurigemma GP, Keaney JF, Hoffman W, Vassileva CM. Mitral Valve Repair Versus Replacement in Elderly With Degenerative Disease: Analysis of the STS Adult Cardiac Surgery Database. Ann Thorac Surg 2018; 107:747-753. [PMID: 30612990 DOI: 10.1016/j.athoracsur.2018.09.018] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 09/05/2018] [Accepted: 09/06/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND It has been postulated that mitral valve repair in the elderly does not confer short-term benefits over mitral valve replacement with complete preservation of the chordal apparatus. Our purpose was to test this hypothesis using data from The Society of Thoracic Surgeons Adult Cardiac Surgery Database (STS ACSD). METHODS Patients aged 70 years or more undergoing primary isolated elective mitral valve repair or mitral valve replacement for degenerative disease were obtained from the STS ACSD versions 2.73 and 2.81. Patients with a concomitant tricuspid procedure, atrial fibrillation surgery, or atrial septal defect/patent foramen ovale repair were included. The two treatment groups were further stratified by age in years (70 to 74, 75 to 79, and 80 or more). Adjusted 30-day mortality rates were analyzed by mitral procedure and chordal preservation strategy. RESULTS The study included 12,043 patients, of whom 71% underwent mitral valve repair. Observed 30-day mortality after repair was lower than after replacement (2.2% versus 4.8%, respectively; p < 0.0001). Using repair as reference, adjusted operative mortality was higher for replacement in the overall cohort (odds ratio 1.83, 95% confidence interval: 1.45 to 2.31). There was no significant difference in mortality between complete versus partial chordal preservation in repair (odds ratio 1.24, 95% confidence interval: 0.80 to 1.93). Mitral valve replacement with chordal preservation remained inferior to repair (odds ratio 1.66, 95% confidence interval: 1.28 to 2.14). The failed repair rate was 7.9%, with a 30-day mortality of 6%. CONCLUSIONS In patients aged 70 years or more, degenerative mitral repair was associated with lower operative mortality compared with replacement, irrespective of chordal preservation strategy. Failed repairs reduced this short-term benefit compared with chordal-sparing replacement as evidenced by the similar operative mortality on an intention to treat analysis.
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Affiliation(s)
- Ryan J Hendrix
- Division of Cardiac Surgery, Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Ricardo A Bello
- Division of Cardiac Surgery, Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Julie M Flahive
- Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Nikolaos Kakouros
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Gerard P Aurigemma
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - John F Keaney
- Division of Cardiovascular Medicine, Department of Medicine, University of Massachusetts Medical School, Worcester, Massachusetts
| | - William Hoffman
- Department of Anesthesiology, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Christina M Vassileva
- Division of Cardiac Surgery, Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts; Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, Massachusetts.
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9
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van der Wall SJ, Olsthoorn JR, Heuts S, Klautz RJM, Tomsic A, Jansen EK, Vonk ABA, Sardari Nia P, Klok FA, Huisman MV. Antithrombotic therapy after mitral valve repair: VKA or aspirin? J Thromb Thrombolysis 2018; 46:473-481. [PMID: 30132244 PMCID: PMC6182386 DOI: 10.1007/s11239-018-1724-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
The optimal antithrombotic therapy following mitral valve repair (MVr) is still a matter of debate. Therefore, we evaluated the rate of thromboembolic and bleeding complications of two antithrombotic prevention strategies: vitamin K antagonists (VKA) versus aspirin. Consecutive patients who underwent MVr between 2004 and 2016 at three Dutch hospitals were evaluated for thromboembolic and bleeding complications during three postoperative months. The primary endpoint was the combined incidence of thromboembolic and bleeding complications to determine the net clinical benefit of VKA strategy as compared with aspirin. Secondary objectives were to evaluate both thromboembolic and bleeding rates separately and to identify predictors for both complications. A total of 469 patients were analyzed, of whom 325 patients (69%) in the VKA group and 144 patients (31%) in the aspirin group. Three months postoperatively, the cumulative incidence of the combined end point of the study was 9.2% (95%CI 6.1-12) in the VKA group and 11% (95%CI 6.0-17) in the aspirin group [adjusted hazard ratio (HR) 1.6, 95%CI 0.83-3.1]. Moreover, no significant differences were observed in thromboembolic rates (adjusted HR 0.82, 95%CI 0.16-4.2) as well as in major bleeding rates (adjusted HR 1.89, 95%CI 0.90-3.9). VKA and aspirin therapy showed a similar event rate of 10% during 3 months after MVr in patients without prior history of AF. In both treatment groups thromboembolic event rate was low and major bleeding rates were comparable. Future prospective, randomized trials are warranted to corroborate our findings.
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Affiliation(s)
- Sake J van der Wall
- Department of Thrombosis and Hemostasis, Leiden University Medical Centre, Albinusdreef 2, 2300 RC, Leiden, The Netherlands.
| | - Jules R Olsthoorn
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Samuel Heuts
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Robert J M Klautz
- Department of Cardio-Thoracic Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Anton Tomsic
- Department of Cardio-Thoracic Surgery, Leiden University Medical Centre, Leiden, The Netherlands
| | - Evert K Jansen
- Department of Cardio-Thoracic Surgery, VU University Medical Centre, Amsterdam, The Netherlands
| | - Alexander B A Vonk
- Department of Cardio-Thoracic Surgery, VU University Medical Centre, Amsterdam, The Netherlands
| | - Peyman Sardari Nia
- Department of Cardio-Thoracic Surgery, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Frederikus A Klok
- Department of Thrombosis and Hemostasis, Leiden University Medical Centre, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
| | - Menno V Huisman
- Department of Thrombosis and Hemostasis, Leiden University Medical Centre, Albinusdreef 2, 2300 RC, Leiden, The Netherlands
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10
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Ginty OK, Moore JM, Xu Y, Xia W, Fujii S, Bainbridge D, Peters TM, Kiaii BB, Chu MWA. Dynamic Patient-Specific Three-Dimensional Simulation of Mitral Repair. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2018. [DOI: 10.1177/155698451801300103] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
| | | | - Yuanwei Xu
- Robarts Research Institute, London, ON Canada
| | - Wenyao Xia
- Robarts Research Institute, London, ON Canada
| | - Satoru Fujii
- Western University and London Health Sciences Centre, London, ON Canada
| | - Daniel Bainbridge
- Western University and London Health Sciences Centre, London, ON Canada
| | | | - Bob B. Kiaii
- Robarts Research Institute, London, ON Canada
- Western University and London Health Sciences Centre, London, ON Canada
| | - Michael W. A. Chu
- Robarts Research Institute, London, ON Canada
- Western University and London Health Sciences Centre, London, ON Canada
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11
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Dynamic Patient-Specific Three-Dimensional Simulation of Mitral Repair. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2018; 13:11-22. [DOI: 10.1097/imi.0000000000000463] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Objective Planned mitral repair strategies are generally established from preoperative echocardiography; however, specific details of the repair are often determined intraoperatively. We propose that three-dimensional printed, patient-specific, dynamic mitral valve models may help surgeons plan and trial all the details of a specific patient's mitral repair preoperatively. Methods Using preoperative echocardiography, segmentation, modeling software, and three-dimensional printing, we created dynamic, high-fidelity, patient-specific mitral valve models including the subvalvular apparatus. We assessed the accuracy of 10 patient mitral valve models anatomically and functionally in a heart phantom simulator, both objectively by blinded echocardiographic assessment, and subjectively by two mitral repair experts. After this, we attempted model mitral repair and compared the outcomes with postoperative echocardiography. Results Model measurements were accurate when compared with patients on anterior-posterior diameter, circumference, and anterior leaflet length; however, less accurate on posterior leaflet length. On subjective assessment, Likert scores were high at 3.8 ± 0.4 and 3.4 ± 0.7, suggesting good fidelity of the dynamic model echocardiogram and functional model in the phantom to the preoperative three-dimensional echocardiogram, respectively. Mitral repair was successful in all 10 models with significant reduction in mitral insufficiency. In two models, mitral repair was performed twice, using two different surgical techniques to assess which provided a better outcome. When compared with the actual patient mitral repair outcome, the repaired models compared favorably. Conclusions Complex mitral valve modeling seems to predict an individual patient's mitral anatomy well, before surgery. Further investigation is required to determine whether deliberate preoperative practice can improve mitral repair outcomes.
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12
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Russell EA, Walsh WF, Reid CM, Tran L, Brown A, Bennetts JS, Baker RA, Tam R, Maguire GP. Outcomes after mitral valve surgery for rheumatic heart disease. HEART ASIA 2017; 9:e010916. [PMID: 29467839 DOI: 10.1136/heartasia-2017-010916] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Revised: 05/03/2017] [Accepted: 05/04/2017] [Indexed: 11/03/2022]
Abstract
Objective To further the understanding of the factors influencing outcome following rheumatic heart disease (RHD) related mitral valve surgery, which globally remains an important cause of heart disease and a particular problem in Indigenous Australians. Methods The Australian Cardiac Surgery Database was utilised to assess outcomes following mitral valve repair and replacement for RHD and non-RHD valve disease. The association with aetiology, demographics, comorbidities, preoperative status and operative procedure was evaluated. Results Mitral valve repairs and replacements undertaken in Australia were analysed from 119 and 1078 RHD surgical procedures and 3279 and 2400 non-RHD procedures, respectively. RHD mitral valve repair, compared with replacement, resulted in a slightly shorter hospital stay and more reoperation for valve dysfunction, but no difference in 30-day survival. In unadjusted survival analysis to 5 years, RHD mitral valve repair and replacement were no different (HR 0.86, 95% CI 0.4 to 1.7), non-RHD repair was superior to replacement (HR 1.7, 95% CI 1.4 to 2.0), RHD and non-RHD repair were no different (HR 0.9, 95% CI 0.5 to 1.7), and RHD replacement was superior to non-RHD (HR 1.5, 95% CI 1.2 to 1.9). None of these differences persisted in adjusted analyses and there was no difference in long-term survival for Indigenous Australians. Conclusion In this large prospective cohort study we have demonstrated that adjusted long-term survival following RHD mitral valve repair surgery in Australia is no different to replacement and no different to non-RHD. Interpretation of valve surgery outcome requires careful consideration of patient factors that may also influence survival.
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Affiliation(s)
- E Anne Russell
- Clinical Research Domain, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia.,School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Warren F Walsh
- Department of Cardiology, Prince of Wales Hospital, Randwick, NSW, Australia
| | - Christopher M Reid
- School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,School of Public Health, Curtin University, Perth, WA, Australia
| | - Lavinia Tran
- School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Alex Brown
- Wardliparingga Aboriginal Research Unit, South Australia Health and Medical Research Institute, Adelaide, Australia.,School of Population Health, University of South Australia, Adelaide, South Australia
| | - Jayme S Bennetts
- Department of Cardiac and Thoracic Surgery, Flinders Medical Centre, Adelaide, Australia.,Department of Surgery, School of Medicine, Flinders University, Adelaide, South Australia, Australia
| | - Robert A Baker
- Department of Cardiac and Thoracic Surgery, Flinders Medical Centre, Adelaide, Australia
| | - Robert Tam
- Department of Cardiothoracic Surgery, The Townsville Hospital, Townsville, Queensland, Australia
| | - Graeme P Maguire
- Clinical Research Domain, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia.,School of Epidemiology and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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13
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Apostolidou E, Maslow AD, Poppas A. Primary mitral valve regurgitation: Update and review. Glob Cardiol Sci Pract 2017; 2017:e201703. [PMID: 31139637 PMCID: PMC6516795 DOI: 10.21542/gcsp.2017.3] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Mitral regurgitation is the second most common valvular disorder requiring surgical intervention worldwide. This review summarizes the current understanding of primary, degenerative mitral regurgitation with respect to etiology, comprehensive assessment, natural history and management. The new concept of staging of the valvular disorders, newer predictors of adverse and controversy of “watchful waiting” versus “early surgical intervention” for severe, asymptomatic, primary mitral regurgitation are addressed.
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Affiliation(s)
| | - Andrew D Maslow
- Section of Cardiac Anesthesia, Rhode Island and Miriam Hospital, Providence, RI, USA
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14
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Mvondo CM, Pugliese M, Giamberti A, Chelo D, Kuate LM, Boombhi J, Dailor EM. Surgery for rheumatic mitral valve disease in sub-saharan African countries: why valve repair is still the best surgical option. Pan Afr Med J 2016; 24:307. [PMID: 28154662 PMCID: PMC5267788 DOI: 10.11604/pamj.2016.24.307.7504] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2015] [Accepted: 05/12/2016] [Indexed: 11/11/2022] Open
Abstract
Rheumatic valve disease, a consequence of acute rheumatic fever, remains endemic in developing countries in the sub-Saharan region where it is the leading cause of heart failure and cardiovascular death, involving predominantly a young population. The involvement of the mitral valve is pathognomonic and mitral surgery has become the lone therapeutic option for the majority of these patients. However, controversies exist on the choice between valve repair or prosthetic valve replacement. Although the advantages of mitral valve repair over prosthetic valve replacement in degenerative mitral disease are well established, this has not been the case for rheumatic lesions, where the use of prosthetic valves, specifically mechanical devices, even in poorly compliant populations remains very common. These patients deserve more accurate evaluation in the choice of the surgical strategy which strongly impacts the post-operative outcomes. This report discusses the factors supporting mitral repair surgery in rheumatic disease, according to the patients' characteristics and the effectiveness of the current repair techniques compared to prosthetic valve replacement in developing countries.
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Affiliation(s)
| | - Marta Pugliese
- Divison of Cardiac Surgery, University of Rome Tor Vergata, Rome, Italy
| | | | - David Chelo
- Department of Pediatrics, Chantal Biya Foundation, Yaoundé, Cameroon
| | | | - Jerome Boombhi
- Department of Cardiology, Yaoundé General Hospital, Yaoundé Cameroon
| | - Ellen Marie Dailor
- Department of Anesthesiology, University of Rochester School of Medicine and Dentistry, Rochester, New York, USA
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15
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Morgan AE, Pantoja JL, Grossi EA, Ge L, Weinsaft JW, Ratcliffe MB. Neochord placement versus triangular resection in mitral valve repair: A finite element model. J Surg Res 2016; 206:98-105. [PMID: 27916382 DOI: 10.1016/j.jss.2016.07.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Revised: 05/23/2016] [Accepted: 07/07/2016] [Indexed: 01/27/2023]
Abstract
BACKGROUND Recurrent mitral regurgitation after mitral valve repair is common, occurring in nearly 50% of patients within 10 years of surgery. Durability of repair is partly related to stress distribution over the mitral leaflets. We hypothesized that repair with neochords (NCs) results in lower stress than leaflet resection (LR). MATERIALS AND METHODS Magnetic resonance imaging and 3D echocardiography were performed before surgical repair of P2 prolapse in a single patient. A finite element model of the left ventricle and mitral valve was created previously, and the modeling program LS-DYNA was used to calculate leaflet stress for the following repairs: Triangular LR; LR with ring annuloplasty (LR + RA); One NC; Two NCs; and 2NC + RA. RESULTS (1) NC placement resulted in stable posterior leaflet stress: Baseline versus 2 NC at end diastole (ED), 12.1 versus 12.0 kPa, at end systole (ES) 20.3 versus 21.7 kPa. (2) In contrast, LR increased posterior leaflet stress: Baseline versus LR at ED 12.1 versus 40.8 kPa, at ES 20.3 versus 46.1 kPa. (3) All repair types reduced anterior leaflet stress: Baseline versus 2 NC versus LR 34.2 versus 25.8 versus 20.6 kPa at ED and 80.8 versus 76.8 versus 67.8 kPa at ES. (4) The addition of RA reduced leaflet stress relative to repair without RA. CONCLUSIONS Neochord repair restored normal leaflet coaptation without creating excessive leaflet stress, whereas leaflet resection more than doubled stress across the posterior leaflet. The excess stress created by leaflet resection was partially, but not completely, mitigated by ring annuloplasty.
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Affiliation(s)
- Ashley E Morgan
- East Bay Surgical Residency, University of California, San Francisco, California
| | - Joe L Pantoja
- College of Medicine, University of California, San Francisco, California
| | - Eugene A Grossi
- Department of Cardiothoracic Surgery, New York University, New York, New York; Department of Cardiothoracic Surgery, New York Harbor Veterans Affairs Medical Center, New York, New York
| | - Liang Ge
- Department of Surgery, University of California, San Francisco, California; Department of Bioengineering, University of California, San Francisco, California; Department of Surgery, Veterans Affairs Medical Center, San Francisco, California
| | - Jonathan W Weinsaft
- Department of Medicine (Cardiology), Weill Cornell Medical College, New York, New York; Department of Radiology, Weill Cornell Medical College, New York, New York
| | - Mark B Ratcliffe
- Department of Surgery, University of California, San Francisco, California; Department of Bioengineering, University of California, San Francisco, California; Department of Surgery, Veterans Affairs Medical Center, San Francisco, California.
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16
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Magruder JT, Crawford TC, Grimm JC, Fredi JL, Shah AS. Managing mitral regurgitation: focus on the MitraClip device. MEDICAL DEVICES-EVIDENCE AND RESEARCH 2016; 9:53-60. [PMID: 27110142 PMCID: PMC4835144 DOI: 10.2147/mder.s86645] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Based on the principle of surgical edge-to-edge mitral valve repair (MVR), the MitraClip percutaneous MVR technique has emerged as a minimally invasive option for MVR. This catheter-based system has been widely demonstrated to be safe, although inferior to surgical MVR. Studies examining patients with ≥3+ mitral regurgitation (MR) show that, for all patients treated, freedom from death, surgery, or MR ≥3+ is in the 75%–80% range 1 year following MitraClip implantation. Despite its inferiority to surgical therapy, in high-risk surgical patients, data suggest that the MitraClip system can be employed safely and that it can result in symptomatic improvement in the majority of patients, while not precluding future surgical options. MitraClip therapy also appears to reduce heart failure readmissions in the high-risk cohort, which may lead to an economic benefit. Ongoing study is needed to clarify the impact of percutaneous mitral valve clipping on long-term survival in high-risk populations, as well as its role in other patient populations, such as those with functional MR.
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Affiliation(s)
- J Trent Magruder
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, Nashville, TN, USA
| | - Todd C Crawford
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, Nashville, TN, USA
| | - Joshua C Grimm
- Division of Cardiac Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, Nashville, TN, USA
| | - Joseph L Fredi
- Department of Medicine, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Ashish S Shah
- Department of Cardiac Surgery, Vanderbilt University School of Medicine, Nashville, TN, USA
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17
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Hemkens LG, Contopoulos-Ioannidis DG, Ioannidis JPA. Agreement of treatment effects for mortality from routinely collected data and subsequent randomized trials: meta-epidemiological survey. BMJ 2016; 352:i493. [PMID: 26858277 PMCID: PMC4772787 DOI: 10.1136/bmj.i493] [Citation(s) in RCA: 122] [Impact Index Per Article: 15.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/08/2016] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To assess differences in estimated treatment effects for mortality between observational studies with routinely collected health data (RCD; that are published before trials are available) and subsequent evidence from randomized controlled trials on the same clinical question. DESIGN Meta-epidemiological survey. DATA SOURCES PubMed searched up to November 2014. METHODS Eligible RCD studies were published up to 2010 that used propensity scores to address confounding bias and reported comparative effects of interventions for mortality. The analysis included only RCD studies conducted before any trial was published on the same topic. The direction of treatment effects, confidence intervals, and effect sizes (odds ratios) were compared between RCD studies and randomized controlled trials. The relative odds ratio (that is, the summary odds ratio of trial(s) divided by the RCD study estimate) and the summary relative odds ratio were calculated across all pairs of RCD studies and trials. A summary relative odds ratio greater than one indicates that RCD studies gave more favorable mortality results. RESULTS The evaluation included 16 eligible RCD studies, and 36 subsequent published randomized controlled trials investigating the same clinical questions (with 17,275 patients and 835 deaths). Trials were published a median of three years after the corresponding RCD study. For five (31%) of the 16 clinical questions, the direction of treatment effects differed between RCD studies and trials. Confidence intervals in nine (56%) RCD studies did not include the RCT effect estimate. Overall, RCD studies showed significantly more favorable mortality estimates by 31% than subsequent trials (summary relative odds ratio 1.31 (95% confidence interval 1.03 to 1.65; I(2)=0%)). CONCLUSIONS Studies of routinely collected health data could give different answers from subsequent randomized controlled trials on the same clinical questions, and may substantially overestimate treatment effects. Caution is needed to prevent misguided clinical decision making.
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Affiliation(s)
- Lars G Hemkens
- Stanford Prevention Research Center, Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA Basel Institute for Clinical Epidemiology and Biostatistics, University Hospital Basel, Basel, Switzerland
| | - Despina G Contopoulos-Ioannidis
- Department of Pediatrics, Division of Infectious Diseases, Stanford University School of Medicine, Stanford, California, USA Meta-Research Innovation Center at Stanford (METRICS)
| | - John P A Ioannidis
- Stanford Prevention Research Center, Department of Medicine, Stanford University School of Medicine, Stanford, CA 94305, USA Meta-Research Innovation Center at Stanford (METRICS) Department of Health Research and Policy, Stanford University School of Medicine, Stanford, California, USA Department of Statistics, Stanford University School of Humanities and Sciences, Stanford, California, USA
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18
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LaPar DJ, Acker MA, Gelijns AC, Kron IL. Repair or replace for severe ischemic mitral regurgitation: prospective randomized multicenter data. Ann Cardiothorac Surg 2015; 4:411-6. [PMID: 26539344 DOI: 10.3978/j.issn.2225-319x.2015.04.11] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Ischemic mitral regurgitation (IMR) is a subset of functional mitral regurgitation (MR) that has the potential to impact an increasing number of patients in the future. This is in the context of a worldwide population, which continues to live longer with improved survival after myocardial infarction. Substantial data have accumulated over the past few decades demonstrating the negative effects of IMR. Further, significant research has been done to define the optimal surgical approach and several studies have compared mitral repair versus replacement for patients with severe mitral regurgitation (SMR). Studies supporting performance of mitral repair cite superior operative morbidity and mortality rates, while proponents of mitral replacement cite improved long-term durability and correction of MR. Lack of clinically robust Level I randomized controlled trial data have curtailed attempts to better define appropriate surgical treatment allocation over the past few decades. Recently, however, the Cardiothoracic Surgical Trials Network (CTSN) conducted the first randomized controlled trial, funded by the National Heart, Lung, and Blood Institute, the National Institute for Neurological Diseases and Stroke and the Canadian Institute for Health Research, to compare the performance of mitral repair versus replacement for SMR. Herein, the present review describes the design, results and implications of the CTSN SMR trial and its efforts to identify the most efficacious surgical approach to SMR. This review also describes CTSN investigation to predict the recurrence of MR after mitral repair.
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Affiliation(s)
- Damien J LaPar
- 1 Investigators for the Cardiothoracic Surgical Trials Network (CTSN): University of Virginia School of Medicine, Charlottesville, VA, USA ; 2 University of Pennsylvania School of Medicine, Philadelphia, PA, USA ; 3 Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Michael A Acker
- 1 Investigators for the Cardiothoracic Surgical Trials Network (CTSN): University of Virginia School of Medicine, Charlottesville, VA, USA ; 2 University of Pennsylvania School of Medicine, Philadelphia, PA, USA ; 3 Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Annetine C Gelijns
- 1 Investigators for the Cardiothoracic Surgical Trials Network (CTSN): University of Virginia School of Medicine, Charlottesville, VA, USA ; 2 University of Pennsylvania School of Medicine, Philadelphia, PA, USA ; 3 Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Irving L Kron
- 1 Investigators for the Cardiothoracic Surgical Trials Network (CTSN): University of Virginia School of Medicine, Charlottesville, VA, USA ; 2 University of Pennsylvania School of Medicine, Philadelphia, PA, USA ; 3 Icahn School of Medicine at Mount Sinai, New York, NY, USA
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19
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Li FP, Rajchl M, Moore J, Peters TM. A mitral annulus tracking approach for navigation of off-pump beating heart mitral valve repair. Med Phys 2015; 42:456-68. [PMID: 25563285 DOI: 10.1118/1.4904022] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
PURPOSE To develop and validate a real-time mitral valve annulus (MVA) tracking approach based on biplane transesophageal echocardiogram (TEE) data and magnetic tracking systems (MTS) to be used in minimally invasive off-pump beating heart mitral valve repair (MVR). METHODS The authors' guidance system consists of three major components: TEE, magnetic tracking system, and an image guidance software platform. TEE provides real-time intraoperative images to show the cardiac motion and intracardiac surgical tools. The magnetic tracking system tracks the TEE probe and the surgical tools. The software platform integrates the TEE image planes and the virtual model of the tools and the MVA model on the screen. The authors' MVA tracking approach, which aims to update the MVA model in near real-time, comprises of three steps: image based gating, predictive reinitialization, and registration based MVA tracking. The image based gating step uses a small patch centered at each MVA point in the TEE images to identify images at optimal cardiac phases for updating the position of the MVA. The predictive reinitialization step uses the position and orientation of the TEE probe provided by the magnetic tracking system to predict the position of the MVA points in the TEE images and uses them for the initialization of the registration component. The registration based MVA tracking step aims to locate the MVA points in the images selected by the image based gating component by performing image based registration. RESULTS The validation of the MVA tracking approach was performed in a phantom study and a retrospective study on porcine data. In the phantom study, controlled translations were applied to the phantom and the tracked MVA was compared to its "true" position estimated based on a magnetic sensor attached to the phantom. The MVA tracking accuracy was 1.29 ± 0.58 mm when the translation distance is about 1 cm, and increased to 2.85 ± 1.19 mm when the translation distance is about 3 cm. In the study on porcine data, the authors compared the tracked MVA to a manually segmented MVA. The overall accuracy is 2.37 ± 1.67 mm for single plane images and 2.35 ± 1.55 mm for biplane images. The interoperator variation in manual segmentation was 2.32 ± 1.24 mm for single plane images and 1.73 ± 1.18 mm for biplane images. The computational efficiency of the algorithm on a desktop computer with an Intel(®) Xeon(®) CPU @3.47 GHz and an NVIDIA GeForce 690 graphic card is such that the time required for registering four MVA points was about 60 ms. CONCLUSIONS The authors developed a rapid MVA tracking algorithm for use in the guidance of off-pump beating heart transapical mitral valve repair. This approach uses 2D biplane TEE images and was tested on a dynamic heart phantom and interventional porcine image data. Results regarding the accuracy and efficiency of the authors' MVA tracking algorithm are promising, and fulfill the requirements for surgical navigation.
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Affiliation(s)
- Feng P Li
- Imaging Laboratory, Robarts Research Institute, Western University, London, Ontario N6A 5B7, Canada
| | - Martin Rajchl
- Imaging Laboratory, Robarts Research Institute, Western University, London, Ontario N6A 5B7, Canada
| | - John Moore
- Imaging Laboratory, Robarts Research Institute, Western University, London, Ontario N6A 5B7, Canada
| | - Terry M Peters
- Imaging Laboratory, Robarts Research Institute, Western University, London, Ontario N6A 5B7, Canada
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20
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Madesis A, Tsakiridis K, Zarogoulidis P, Katsikogiannis N, Machairiotis N, Kougioumtzi I, Kesisis G, Tsiouda T, Beleveslis T, Koletas A, Zarogoulidis K. Review of mitral valve insufficiency: repair or replacement. J Thorac Dis 2014; 6 Suppl 1:S39-51. [PMID: 24672698 DOI: 10.3978/j.issn.2072-1439.2013.10.20] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2013] [Accepted: 10/29/2013] [Indexed: 01/29/2023]
Abstract
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.
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Affiliation(s)
- Athanasios Madesis
- 1 Cardiothoracic Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiothoracic Surgery Department, "Saint Luke" Private Hospital, Thessaloniki, Panorama, Greece ; 3 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 5 Medical Oncology, "Saint Luke" Private Hospital, Thessaloniki, Panorama, Greece ; 6 Internal Medicine Department, "Theageneio" Anticancer Hospital, Thessaloniki, Greece ; 7 Cardiology Department, "Saint Luke" Private Hospital, Thessaloniki, Panorama, Greece ; 8 Anesthesiology Department, "Saint Luke" Private Hospital, Thessaloniki, Panorama, Greece
| | - Kosmas Tsakiridis
- 1 Cardiothoracic Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiothoracic Surgery Department, "Saint Luke" Private Hospital, Thessaloniki, Panorama, Greece ; 3 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 5 Medical Oncology, "Saint Luke" Private Hospital, Thessaloniki, Panorama, Greece ; 6 Internal Medicine Department, "Theageneio" Anticancer Hospital, Thessaloniki, Greece ; 7 Cardiology Department, "Saint Luke" Private Hospital, Thessaloniki, Panorama, Greece ; 8 Anesthesiology Department, "Saint Luke" Private Hospital, Thessaloniki, Panorama, Greece
| | - Paul Zarogoulidis
- 1 Cardiothoracic Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiothoracic Surgery Department, "Saint Luke" Private Hospital, Thessaloniki, Panorama, Greece ; 3 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 5 Medical Oncology, "Saint Luke" Private Hospital, Thessaloniki, Panorama, Greece ; 6 Internal Medicine Department, "Theageneio" Anticancer Hospital, Thessaloniki, Greece ; 7 Cardiology Department, "Saint Luke" Private Hospital, Thessaloniki, Panorama, Greece ; 8 Anesthesiology Department, "Saint Luke" Private Hospital, Thessaloniki, Panorama, Greece
| | - Nikolaos Katsikogiannis
- 1 Cardiothoracic Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiothoracic Surgery Department, "Saint Luke" Private Hospital, Thessaloniki, Panorama, Greece ; 3 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 5 Medical Oncology, "Saint Luke" Private Hospital, Thessaloniki, Panorama, Greece ; 6 Internal Medicine Department, "Theageneio" Anticancer Hospital, Thessaloniki, Greece ; 7 Cardiology Department, "Saint Luke" Private Hospital, Thessaloniki, Panorama, Greece ; 8 Anesthesiology Department, "Saint Luke" Private Hospital, Thessaloniki, Panorama, Greece
| | - Nikolaos Machairiotis
- 1 Cardiothoracic Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiothoracic Surgery Department, "Saint Luke" Private Hospital, Thessaloniki, Panorama, Greece ; 3 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 5 Medical Oncology, "Saint Luke" Private Hospital, Thessaloniki, Panorama, Greece ; 6 Internal Medicine Department, "Theageneio" Anticancer Hospital, Thessaloniki, Greece ; 7 Cardiology Department, "Saint Luke" Private Hospital, Thessaloniki, Panorama, Greece ; 8 Anesthesiology Department, "Saint Luke" Private Hospital, Thessaloniki, Panorama, Greece
| | - Ioanna Kougioumtzi
- 1 Cardiothoracic Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiothoracic Surgery Department, "Saint Luke" Private Hospital, Thessaloniki, Panorama, Greece ; 3 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 5 Medical Oncology, "Saint Luke" Private Hospital, Thessaloniki, Panorama, Greece ; 6 Internal Medicine Department, "Theageneio" Anticancer Hospital, Thessaloniki, Greece ; 7 Cardiology Department, "Saint Luke" Private Hospital, Thessaloniki, Panorama, Greece ; 8 Anesthesiology Department, "Saint Luke" Private Hospital, Thessaloniki, Panorama, Greece
| | - George Kesisis
- 1 Cardiothoracic Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiothoracic Surgery Department, "Saint Luke" Private Hospital, Thessaloniki, Panorama, Greece ; 3 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 5 Medical Oncology, "Saint Luke" Private Hospital, Thessaloniki, Panorama, Greece ; 6 Internal Medicine Department, "Theageneio" Anticancer Hospital, Thessaloniki, Greece ; 7 Cardiology Department, "Saint Luke" Private Hospital, Thessaloniki, Panorama, Greece ; 8 Anesthesiology Department, "Saint Luke" Private Hospital, Thessaloniki, Panorama, Greece
| | - Theodora Tsiouda
- 1 Cardiothoracic Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiothoracic Surgery Department, "Saint Luke" Private Hospital, Thessaloniki, Panorama, Greece ; 3 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 5 Medical Oncology, "Saint Luke" Private Hospital, Thessaloniki, Panorama, Greece ; 6 Internal Medicine Department, "Theageneio" Anticancer Hospital, Thessaloniki, Greece ; 7 Cardiology Department, "Saint Luke" Private Hospital, Thessaloniki, Panorama, Greece ; 8 Anesthesiology Department, "Saint Luke" Private Hospital, Thessaloniki, Panorama, Greece
| | - Thomas Beleveslis
- 1 Cardiothoracic Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiothoracic Surgery Department, "Saint Luke" Private Hospital, Thessaloniki, Panorama, Greece ; 3 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 5 Medical Oncology, "Saint Luke" Private Hospital, Thessaloniki, Panorama, Greece ; 6 Internal Medicine Department, "Theageneio" Anticancer Hospital, Thessaloniki, Greece ; 7 Cardiology Department, "Saint Luke" Private Hospital, Thessaloniki, Panorama, Greece ; 8 Anesthesiology Department, "Saint Luke" Private Hospital, Thessaloniki, Panorama, Greece
| | - Alexander Koletas
- 1 Cardiothoracic Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiothoracic Surgery Department, "Saint Luke" Private Hospital, Thessaloniki, Panorama, Greece ; 3 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 5 Medical Oncology, "Saint Luke" Private Hospital, Thessaloniki, Panorama, Greece ; 6 Internal Medicine Department, "Theageneio" Anticancer Hospital, Thessaloniki, Greece ; 7 Cardiology Department, "Saint Luke" Private Hospital, Thessaloniki, Panorama, Greece ; 8 Anesthesiology Department, "Saint Luke" Private Hospital, Thessaloniki, Panorama, Greece
| | - Konstantinos Zarogoulidis
- 1 Cardiothoracic Department, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 2 Cardiothoracic Surgery Department, "Saint Luke" Private Hospital, Thessaloniki, Panorama, Greece ; 3 Pulmonary Department-Oncology Unit, "G. Papanikolaou" General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece ; 4 Surgery Department (NHS), University General Hospital of Alexandroupolis, Alexandroupolis, Greece ; 5 Medical Oncology, "Saint Luke" Private Hospital, Thessaloniki, Panorama, Greece ; 6 Internal Medicine Department, "Theageneio" Anticancer Hospital, Thessaloniki, Greece ; 7 Cardiology Department, "Saint Luke" Private Hospital, Thessaloniki, Panorama, Greece ; 8 Anesthesiology Department, "Saint Luke" Private Hospital, Thessaloniki, Panorama, Greece
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Chatterjee S, Rankin JS, Gammie JS, Sheng S, O'Brien SM, Brennan JM, Alexander JC, Thourani VH, Pearson PJ, Suri RM. Isolated Mitral Valve Surgery Risk in 77,836 Patients From The Society of Thoracic Surgeons Database. Ann Thorac Surg 2013; 96:1587-94; discussion 1594-5. [DOI: 10.1016/j.athoracsur.2013.06.051] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2013] [Revised: 05/29/2013] [Accepted: 06/06/2013] [Indexed: 11/28/2022]
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Graser B, Wald D, Al-Maisary S, Grossgasteiger M, de Simone R, Meinzer HP, Wolf I. Using a shape prior for robust modeling of the mitral annulus on 4D ultrasound data. Int J Comput Assist Radiol Surg 2013; 9:635-44. [PMID: 24122458 DOI: 10.1007/s11548-013-0942-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2013] [Accepted: 09/03/2013] [Indexed: 11/28/2022]
Abstract
PURPOSE Over 40,000 annuloplasty rings are implanted each year in the USA to treat mitral regurgitation. However, the used measuring techniques to select a suitable annuloplasty ring are imprecise and highly depending on the expert's experience. This can cause a re-occurrence of the mitral regurgitation or an annuloplasty ring dehiscence, and thus the necessity of a re-operation. We propose a method to create a 4D model of the mitral annulus from ultrasound data to enable precise measurement and patient-specific implant planning. METHODS An initial mitral annulus model is placed interactively in the 4D image data by defining commissure points and the annulus plane for one time step in diastole and systole. The model is automatically optimized using distinct image features. A shape and pose prior of the mitral annulus is used to compensate for artifacts and to enforce a plausible anatomical morphology, while a temporal alignment ensures a natural motion of the 4D model. RESULTS Ground truth data were created for 4D images of 42 patients with varying image quality. A parameter and shape prior training was performed on a third of the ground truth data, while the rest was used to validate the method. The average error of the resulting mitral annulus models was computed as 2.25 ( +/-0.38 ) mm. The average expert standard deviation was determined as 1.86 (+/-0.32 ) mm. CONCLUSION The proposed method enables the 4D modeling of mitral annuli based on ultrasound data in less than 2 min. The resulting models are comparable to manually delineated models and can be used for measurements of annular geometries and patient-specific annuloplasty treatment planning.
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Intraoperative evaluation of transmitral pressure gradients after edge-to-edge mitral valve repair. PLoS One 2013; 8:e73617. [PMID: 24023891 PMCID: PMC3759443 DOI: 10.1371/journal.pone.0073617] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 07/23/2013] [Indexed: 12/11/2022] Open
Abstract
Objective Edge-to-edge repair of the mitral valve (MV) has been described as a viable option used for the surgical management of mitral regurgitation (MR). Based on the significant changes in MV geometry associated with this technique, we hypothesized that edge-to-edge MV repairs are associated with higher intraoperative transmitral pressure gradients (TMPG) compared to conventional methods. Methods Patient records and intraoperative transesophageal echocardiography (TEE) examinations of 552 consecutive patients undergoing MV repair at a single institution over a three year period were assessed. After separation from cardiopulmonary bypass (CPB), peak and mean TMPG were recorded for each patient and subsequently analyzed. Results 84 patients (15%) underwent edge-to-edge MV repair. Peak and mean TMPG were significantly higher compared to gradients in patients undergoing conventional repairs: 10.7±0.5 mmHg vs 7.1±0.2 mmHg; P<0.0001 and 4.3±0.2 mmHg vs 2.8±0.1 mmHg; P<0.0001. Only patients with mean TMPG ≥7 mmHg (n = 9) required prompt reoperation for iatrogenic mitral stenosis (MS). No differences in peak and mean TMPG were observed among edge-to-edge repairs performed in isolation, compared to those performed in combination with annuloplasty: 11.0±0.7 mmHg vs 10.3±0.6 mmHg and 4.4±0.3 mmHg vs 4.3±0.3 mmHg. There were no differences in TMPG between various types of annuloplasty techniques used in combination with the edge-to-edge repairs. Conclusions Edge-to-edge MV repairs are associated with higher intraoperative peak and mean TMPG after separation from CPB compared to conventional repair techniques. Unless gradients are severely elevated, these findings are not necessarily suggestive of iatrogenic MS. Thus, in the immediate postoperative period mildly elevated TMPG can be expected and tolerated after edge-to-edge mitral repairs.
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Kilic A, Shah AS, Conte JV, Baumgartner WA, Yuh DD. Operative outcomes in mitral valve surgery: Combined effect of surgeon and hospital volume in a population-based analysis. J Thorac Cardiovasc Surg 2013; 146:638-46. [DOI: 10.1016/j.jtcvs.2012.07.070] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2012] [Revised: 06/08/2012] [Accepted: 07/26/2012] [Indexed: 11/29/2022]
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Vengen ØA, Abdelnoor M, Westheim AS, Smith G, Fjeld NB. Outcome of mitral valve plasty or replacement: atrial fibrillation an effect modifier. J Cardiothorac Surg 2013; 8:142. [PMID: 23724788 PMCID: PMC3673869 DOI: 10.1186/1749-8090-8-142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2013] [Accepted: 05/27/2013] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Advances in the understanding of mitral valve pathology have laid to mitral valve plasty (MPL) as the procedure of choice of all the mitral intervention as compared to mitral valve replacement (MVR). MATERIAL AND METHODS A cohort of 355 patients with mitral valve disease operated between January 1993 to January 2007 with closing date first of mars 2011. There were 214 MPL and 141 MVR at the Hospital discharge. This retrospective cohort had the design of exposed (MPL) versus non-exposed (MVR) with outcome total mortality and reoperation during follow up. Also echocardiography follow-up was undertaken to estimate the true long-term failure rate of repair. RESULTS The mean follow up was 5.3 years SE (3.82) maximum follow up was 14.1 years. Considering the patient time model the association between repair/replacement and total mortality RR = 0.43 95% (0.28-074) p = 0.002 controlling for the confounding effect of 3-vessels disease. Those results were confirmed by propensity score analysis. CONCLUSION In a cohort of patient with mitral valve disease undergoing MPL/MVR was examined. MPL was associated with better survival, and lower reoperation rate for patients without AF but same rate for patients with AF. We advocate more attention in controlling risk factors of AF in the clinical management of mitral disease. Long-term failure rate of MPL was low during follow up time. A replication of our results by a randomized clinical trial is mandatory.
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Affiliation(s)
- Øystein A Vengen
- Dept of Cardiothoracic Surgery, Oslo University Hospital, Ullevaal, Norway
| | - Michael Abdelnoor
- Centre of Clinical Research: Unit of Epidemiology and Biostatistics, Oslo University Hospital, Ullevaal, Norway
- Centre for Clinical Heart Research, Oslo University Hospital, Ullevaal, Norway
| | - Arne S Westheim
- Dept of Cardiology, Oslo University Hospital, Ullevaal, Norway
| | - Gunnar Smith
- Dept of Cardiology, Oslo University Hospital, Ullevaal, Norway
| | - Nils Bj Fjeld
- Dept of Cardiothoracic Surgery, Oslo University Hospital, Ullevaal, Norway
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Tenenholtz NA, Hammer PE, Fabozzo A, Feins EN, Del Nido PJ, Howe RD. Fast Simulation of Mitral Annuloplasty for Surgical Planning. FUNCTIONAL IMAGING AND MODELING OF THE HEART : ... INTERNATIONAL WORKSHOP, FIMH ..., PROCEEDINGS. FIMH 2013; 7945:106-113. [PMID: 29399667 PMCID: PMC5794342 DOI: 10.1007/978-3-642-38899-6_13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Mitral valve repair is a complex procedure that requires the ability to predict closed valve shape through the examination of an unpressurized, accid valve. These procedures typically include the remodeling of the mitral annulus through the insertion of an annuloplasty ring. While simulations could facilitate the planning of the procedure, traditional finite-element models of mitral annuloplasty are too slow to be clinically feasible and have never been validated in tissue. This work presents a fast method for simulating valve closure post-annuloplasty using a mass-spring tissue model and subject-specific valve geometry. Closed valve shape is predicted in less than one second. The results are validated by implanting an annuloplasty ring in an excised porcine heart and comparing simulated to imaged results. Results indicate that not only can mitral annuloplasty be simulated quickly, but also with submillimeter accuracy.
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Affiliation(s)
- Neil A Tenenholtz
- Harvard School of Engineering and Applied Sciences, Cambridge, MA, USA
| | - Peter E Hammer
- Harvard School of Engineering and Applied Sciences, Cambridge, MA, USA
- Department of Cardiac Surgery, Children's Hospital, Boston, MA, USA
| | - Assunta Fabozzo
- Department of Cardiac Surgery, Children's Hospital, Boston, MA, USA
- Division of Cardiac Surgery, University of Padova, Padova, Italy
| | - Eric N Feins
- Department of Cardiac Surgery, Children's Hospital, Boston, MA, USA
| | - Pedro J Del Nido
- Department of Cardiac Surgery, Children's Hospital, Boston, MA, USA
| | - Robert D Howe
- Harvard School of Engineering and Applied Sciences, Cambridge, MA, USA
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Rankin JS, He X, O'Brien SM, Jacobs JP, Welke KF, Filardo G, Shahian DM. The Society of Thoracic Surgeons Risk Model for Operative Mortality After Multiple Valve Surgery. Ann Thorac Surg 2013; 95:1484-90. [DOI: 10.1016/j.athoracsur.2012.11.077] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2012] [Revised: 11/08/2012] [Accepted: 11/12/2012] [Indexed: 12/14/2022]
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Shafii AE, Gillinov AM, Mihaljevic T, Stewart W, Batizy LH, Blackstone EH. Changes in left ventricular morphology and function after mitral valve surgery. Am J Cardiol 2012; 110:403-408.e3. [PMID: 22534055 DOI: 10.1016/j.amjcard.2012.03.041] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2011] [Revised: 03/09/2012] [Accepted: 03/09/2012] [Indexed: 01/20/2023]
Abstract
Degenerative mitral valve disease is the leading cause of mitral regurgitation in North America. Surgical intervention has hinged on the symptoms and ventricular changes that develop as compensatory ventricular remodeling occurs. In the present study, we sought to characterize the temporal response of left ventricular (LV) morphology and function to mitral valve surgery for degenerative disease and to identify the preoperative factors that influence reverse remodeling. From 1986 to 2007, 2,778 patients with isolated degenerative mitral valve disease underwent valve repair (n = 2,607 [94%]) or replacement (n = 171 [6%]) and had ≥1 postoperative transthoracic echocardiogram; 5,336 transthoracic echocardiograms were available for analysis. Multivariate longitudinal repeated-measures analysis was performed to identify the factors associated with reverse remodeling. The LV dimensions decreased in the first year after surgery (end-diastolic from 5.7 ± 0.80 to 4.9 ± 1.4 cm; end-systolic from 3.4 ± 0.71 to 3.1 ± 1.4 cm). The LV mass index decreased from 139 ± 44 to 112 ± 73 g/m(2). The reduction in LV hypertrophy was less pronounced in patients with greater preoperative left heart enlargement (p <0.0001) and a greater preoperative LV mass (p <0.0001). The postoperative LV ejection fraction initially decreased from 58 ± 7.0% to 53 ± 20%, increased slightly during the first postoperative year, and was negatively influenced by preoperative heart failure symptoms (p <0.0001) and a lower preoperative LV ejection fraction (p <0.0001). The risk-adjusted response of LV morphology and function to valve repair and replacement was similar (p >0.2). In conclusion, a positive response toward normalization of LV morphology and function after mitral valve surgery is greatest in the first year. The best response occurs when surgery is performed before left heart dilation, LV hypertrophy, or LV dysfunction develop.
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Mascherbauer J, Fuchs C, Pernicka E, Wollenek G, Rosenhek R, Bonderman D, Maurer G, Baumgartner H. Predictors of outcome of non-ischemic mitral valve surgery. Int J Cardiol 2011; 165:87-92. [PMID: 21862149 DOI: 10.1016/j.ijcard.2011.07.088] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2011] [Revised: 07/08/2011] [Accepted: 07/26/2011] [Indexed: 11/25/2022]
Abstract
BACKGROUND Data on the risk stratification of patients undergoing mitral valve (MV) surgery for non-ischemic mitral disease are sparse. The present study seeks to define them in a contemporary cohort. METHODS 193 consecutive patients referred to non-ischemic MV surgery were prospectively studied. Baseline characteristics and the type of surgery were analyzed with regard to operative and late mortality as well as functional outcome. RESULTS 129 patients underwent MV replacement and 64 MV repair. MV replacement patients presented with more symptoms (p = 0.010), higher EuroSCORE (6.1 versus 5.6; p=0.009), more frequently underwent additional valve surgery (7.8 versus 0%; p = 0.003) and were more frequently female (p=0.048). Operative mortality was 3.1%, two thirds of operative deaths had additional surgery of the tricuspid valve (p = 0.019). Patients were followed for 5.2 ± 2.7 years. 1-, 3-, 5- and 7-year survival rates were 93-, 91-, 82-, and 79% in MV replacement patients versus 100-, 98-, 96-, and 89% in patients with MV repair (p = 0.015). However, by multivariate logistic regression, overall mortality was determined by additional surgery of the tricuspid valve (p = 0.0103), multivessel coronary disease (p = 0.026), and age (p<0.0001), but not by the type of surgery (p=0.066). Furthermore, the type of surgery did not influence functional outcome (p = 0.515). CONCLUSIONS Apart from age and coronary artery disease the need for additional tricuspid valve surgery significantly determines the outcome of non-ischemic MV surgery. The type of operation appears less important when the need for additional valve surgery and co-morbidities like coronary artery disease are taken into consideration.
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Affiliation(s)
- Julia Mascherbauer
- Department of Cardiology, Medical University of Vienna, Vienna, Austria.
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Postoperative Functional Outcome After Off-Pump Versus On-Pump Coronary Artery Bypass Grafting Using Gated Myocardial SPECT: A Comparison by Propensity Score Analysis. Nucl Med Mol Imaging 2010; 44:110-5. [PMID: 25013522 DOI: 10.1007/s13139-010-0025-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2009] [Revised: 01/29/2010] [Accepted: 02/01/2010] [Indexed: 10/19/2022] Open
Abstract
PURPOSE We evaluated the short-term and mid-term differences in perfusion and function after off-pump and on-pump coronary artery bypass grafting (CABG) using gated myocardial single photon emission computed tomography. MATERIALS AND METHODS A total of 70 patients with coronary artery disease who underwent CABG were included based on the propensity score matching results from 165 patients. Thirty-five patients underwent off-pump and 35 patients on-pump CABG. Rest (201)Tl/dipyridamole stress (99 m)Tc-methoxyisobutylisonitrile gated single photon emission computed tomographies were performed preoperatively and postoperatively at short-term (103 ± 23 days after surgery) and mid-term follow-up (502 ± 111 days after surgery). Changes in left ventricular ejection fraction, end systolic volume, stress and rest segmental perfusion, and segmental wall thickening were compared between the two groups. The segments with preoperative rest (201)Tl uptake under 60% of maximum uptake were included in the segmental analysis. RESULTS Left ventricular ejection fraction (P = 0.001) and end systolic volume (P = 0.008) showed significant improvement in both groups. There were no significant short-term and mid-term differences between the two groups in terms of left ventricular ejection fraction (P = 0.309) and end systolic volume (P = 0.938). Likewise, segmental rest (P = 0.178) and stress perfusion (P = 0.071), and systolic wall thickening (P = 0.241) showed significant improvement in both groups with similar time courses. CONCLUSION Off-pump CABG resulted in significant improvements in left ventricular ejection fraction, end systolic volume, and regional myocardial perfusion and function that are comparable to on-pump CABG at short-term and mid-term. Gated myocardial SPECT successfully revealed that off-pump CABG is as good as on-pump CABG from the viewpoint of myocardial perfusion and function.
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Mutevedzi PC, Lessells RJ, Heller T, Bärnighausen T, Cooke GS, Newell ML. Scale-up of a decentralized HIV treatment programme in rural KwaZulu-Natal, South Africa: does rapid expansion affect patient outcomes? Bull World Health Organ 2010; 88:593-600. [PMID: 20680124 DOI: 10.2471/blt.09.069419] [Citation(s) in RCA: 94] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2009] [Revised: 12/09/2009] [Accepted: 12/11/2009] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To describe the scale-up of a decentralized HIV treatment programme delivered through the primary health care system in rural KwaZulu-Natal, South Africa, and to assess trends in baseline characteristics and outcomes in the study population. METHODS The programme started delivery of antiretroviral therapy (ART) in October 2004. Information on all patients initiated on ART was captured in the programme database and follow-up status was updated monthly. All adult patients (> or = 16 years) who initiated ART between October 2004 and September 2008 were included and stratified into 6-month groups. Clinical and sociodemographic characteristics were compared between the groups. Retention in care, mortality, loss to follow-up and virological outcomes were assessed at 12 months post-ART initiation. FINDINGS A total of 5719 adults initiated on ART were included (67.9% female). Median baseline CD4+ lymphocyte count was 116 cells/microl (interquartile range, IQR: 53-173). There was an increase in the proportion of women who initiated ART while pregnant but no change in other baseline characteristics over time. Overall retention in care at 12 months was 84.0% (95% confidence interval, CI: 82.6-85.3); 10.9% died (95% CI: 9.8-12.0); 3.7% were lost to follow-up (95% CI: 3.0-4.4). Mortality was highest in the first 3 months after ART initiation: 30.1 deaths per 100 person-years (95% CI: 26.3-34.5). At 12 months 23.0% had a detectable viral load (> 25 copies/ml) (95% CI: 19.5-25.5). CONCLUSION Outcomes were not affected by rapid expansion of this decentralized HIV treatment programme. The relatively high rates of detectable viral load highlight the need for further efforts to improve the quality of services.
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Affiliation(s)
- Portia C Mutevedzi
- Africa Centre for Health and Population Studies, Mtubatuba, South Africa.
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Abstract
From Walton Lillehei, who performed the first successful open mitral valve surgery in 1956, until the advent of robotic surgery in the 21st Century, only 50 years have passed. The introduction of the first heart valve prosthesis, in 1960, was the next major step forward. However, correction of mitral disease by valvuloplasty results in better survival and ventricular performance than mitral valve replacement. However, the European Heart Survey demonstrated that only 40% of the valves are repaired. The standard procedures (Carpentier's techniques and Alfieri's edge-to-edge suture) are the surgical basis for the new technical approaches. Minimally invasive surgery led to the development of video-assisted and robotic surgery and interventional cardiology is already making the first steps on endovascular procedures, using the classical concepts in highly differentiated approaches. Correction of mitral regurgitation is a complex field that is still growing, whereas classic surgery is still under debate as the new era arises.
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Affiliation(s)
- Paulo Calvinho
- Department of Cardiothoracic Surgery, University Hospital, Coimbra, Portugal
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Stürmer T, Joshi M, Glynn RJ, Avorn J, Rothman KJ, Schneeweiss S. A review of the application of propensity score methods yielded increasing use, advantages in specific settings, but not substantially different estimates compared with conventional multivariable methods. J Clin Epidemiol 2006; 59:437-47. [PMID: 16632131 PMCID: PMC1448214 DOI: 10.1016/j.jclinepi.2005.07.004] [Citation(s) in RCA: 466] [Impact Index Per Article: 25.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2005] [Accepted: 06/15/2005] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Propensity score (PS) analyses attempt to control for confounding in nonexperimental studies by adjusting for the likelihood that a given patient is exposed. Such analyses have been proposed to address confounding by indication, but there is little empirical evidence that they achieve better control than conventional multivariate outcome modeling. STUDY DESIGN AND METHODS Using PubMed and Science Citation Index, we assessed the use of propensity scores over time and critically evaluated studies published through 2003. RESULTS Use of propensity scores increased from a total of 8 reports before 1998 to 71 in 2003. Most of the 177 published studies abstracted assessed medications (N=60) or surgical interventions (N=51), mainly in cardiology and cardiac surgery (N=90). Whether PS methods or conventional outcome models were used to control for confounding had little effect on results in those studies in which such comparison was possible. Only 9 of 69 studies (13%) had an effect estimate that differed by more than 20% from that obtained with a conventional outcome model in all PS analyses presented. CONCLUSIONS Publication of results based on propensity score methods has increased dramatically, but there is little evidence that these methods yield substantially different estimates compared with conventional multivariable methods.
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Affiliation(s)
- Til Stürmer
- Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital, Harvard Medical School, 1620 Tremont Street, Suite 3030, Boston, MA 02120, USA.
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Chirillo F, Salvador L, Cavallini C. Medical and surgical treatment of chronic mitral regurgitation. J Cardiovasc Med (Hagerstown) 2006; 7:96-107. [PMID: 16645368 DOI: 10.2459/01.jcm.0000199793.09608.14] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Chronic severe mitral regurgitation is a progressive disease that can lead to left ventricular dysfunction. New information on the natural history of the disease, along with advances in surgical techniques, has changed the roles of medical and surgical therapies. There is no well-defined role for medical therapy in chronic mitral regurgitation. The goal of the treating physician is therefore to identify the optimal timing for surgical intervention. The timing of surgical intervention depends primarily on two factors: (i) clinical symptoms and (ii) the left ventricular response to volume overload. However, the aetiology of mitral regurgitation, the likelihood of surgical repair, the occurrence of atrial fibrillation and the presence of pulmonary hypertension, together with the haemodynamic response to exercise, are important factors in the optimal surgical timing. New concepts in the understanding of the natural history of the disease coupled with success of mitral repair have recently resulted in a widespread evolution towards earlier surgery.
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Affiliation(s)
- Fabio Chirillo
- Cardiology Unit, Cardiovascular Department, Ca' Foncello Hospital, Treviso, Italy.
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Abstract
Valvular heart disease is a significant cause of morbidity and mortality. Rates increase with age and the prevalence will increase as the population ages. Several factors have led to an interest in expanding percutaneous valve repair and replacement techniques to more lesions in more patients. This review explores current percutaneous valve repair and replacement techniques in mitral stenosis, mitral regurgitation, aortic stenosis and aortic regurgitation in adults, outlines the future directions, and discusses some technique-related issues.
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Affiliation(s)
- B Munt
- St Paul's Hospital, 2350-1081 Burrard Street, Vancouver, British Columbia, Canada V6Z 1Y6.
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Mantovani V, Sala A. Mitral regurgitation: overview of current surgical techniques and future developments. Expert Rev Cardiovasc Ther 2005; 3:271-84. [PMID: 15853601 DOI: 10.1586/14779072.3.2.271] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Mitral regurgitation is a complex disease with many different etiologies, underlying dysfunctions and histologic alterations. Surgical correction of this condition dramatically improves the life expectancy and life quality of affected patients. The structure of the mitral valve lends itself to many surgical techniques. The purpose of this review is to offer readers an overview on this subject.
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Affiliation(s)
- Vittorio Mantovani
- University of Insubria, Department of Cardiac Surgery, Ospedale di Circolo-Fondazione Macchi, Viale Borri 57, 21100 Varese, Italy.
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Kruse RL, Mehr DR, Boles KE, Lave JR, Binder EF, Madsen R, D'Agostino RB. Does hospitalization impact survival after lower respiratory infection in nursing home residents? Med Care 2004; 42:860-70. [PMID: 15319611 DOI: 10.1097/01.mlr.0000135828.95415.b1] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Lower respiratory infection (LRI) is the leading cause of hospitalization for nursing home residents, but hospitalization is costly and may cause complications. OBJECTIVE We sought to compare mortality and cost between episodes of LRI initially treated in the hospital versus the nursing home after controlling for illness severity and the probability of hospitalization. DESIGN This was a prospective cohort study of nursing home residents with LRIs. SUBJECTS We identified 1406 episodes of LRI in 36 nursing homes in central Missouri and the St. Louis area between August 15, 1995, and September 30, 1998. Economic analysis was restricted to 1033 episodes identified after March 31, 1997. MEASURES We adjusted for the higher probability of initial hospitalization in sicker residents using measures of illness severity and a hospitalization propensity score. The propensity score was derived from a logistic regression model that included patient, physician, and facility variables. Estimated costs were attributed to initial treatment setting. RESULTS After controlling for the probability of hospitalization and illness severity, hospitalization was not a significant mortality predictor (odds ratio 0.89, 95% confidence interval 0.52-1.52). Mean daily cost was $138.24 for initial nursing home treatment and $419.75 for the hospital. CONCLUSIONS After controlling for illness severity and propensity for hospitalization, hospital treatment is not associated with either increased or decreased risk for mortality for nursing home residents with LRIs. For residents with low and medium mortality risk, nursing home treatment is likely to be safe and less costly.
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Affiliation(s)
- Robin L Kruse
- Department of Family and Community Medicine, School of Medicine, University of Missouri-Columbia, Columbia, Missouri 65212, USA.
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Timek TA, Lai DT, Liang D, Tibayan F, Langer F, Rodriguez F, Daughters GT, Ingels NB, Miller DC. Effects of Paracommissural Septal-Lateral Annular Cinching on Acute Ischemic Mitral Regurgitation. Circulation 2004; 110:II79-84. [PMID: 15364843 DOI: 10.1161/01.cir.0000138975.05902.a5] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Previous experimental studies demonstrated that central septal-lateral (SL) annular cinching (SLAC) abolishes acute ischemic mitral regurgitation (IMR), but whether localized cinching near the anterior (ACOM) or posterior (PCOM) commissure is equally effective is unknown. METHODS Six adult sheep underwent implantation of 9 radiopaque markers on the left ventricle, 8 around the mitral annulus (MA) and 1 on each papillary muscle (PM) tip. Transannular SL sutures were placed at the valve center (CENT) and near ACOM and PCOM and externalized. Acute IMR was induced by proximal circumflex coronary snare occlusion. Biplane videofluoroscopy and transesophageal echocardiography were performed before and continuously during 3 episodes of myocardial ischemia including 20 seconds of SLAC at each different location. End-systolic MA SL dimension at each suture location and distances between the anterior and posterior PM tips and mid-septal annulus ("saddle horn") were calculated from the 3-dimensional (3D) marker coordinates. RESULTS SLAC interventions in all 3 locations reduced the degree of IMR, but cinching at the center, SLAC(CENT), had a significantly greater effect on reducing the magnitude of IMR than SLAC(PCOM) or SLAC(ACOM) (mean grade of IMR reduction=1.0+/-0.5, 1.8+/-0.5, and 0.9+/-0.2 for SLAC(ACOM), SLAC(CENT), and SLAC(PCOM), respectively; P=0.044). Although ACOM and PCOM cinching reduced SL(CENT) somewhat, only SLAC(CENT) simultaneously reduced both SL(ACOM) and SL(PCOM) and also repositioned both PM tips closer to the annular saddle horn. CONCLUSIONS SLAC in all 3 positions reduced acute IMR, but central SLAC cinching was most effective, reduced all mitral annular SL dimensions, and relocated both PM tips closer to the mid-septal annulus. Central SLAC is most capable of correcting the annular and subvalvular perturbations accompanying acute left ventricular ischemia that lead to IMR.
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Affiliation(s)
- Tomasz A Timek
- Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif 94305-5247, USA
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