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

Entire Mitral Valve Reconstruction Using Porcine Extracellular Matrix: Adding a Ring Annuloplasty

PURPOSE

This study investigated the implications of inserting a flexible annuloplasty ring after reconstructing the entire mitral valve in a porcine model using a previously investigated tube graft design made of 2-ply small intestinal submucosa extracellular matrix (CorMatrix®).

METHODS

An acute model with eight 80-kg pigs, each acting as its own control, was used. The entire mitral valve was reconstructed with a 2-ply small intestinal submucosa extracellular matrix tube graft (CorMatrix®). Subsequently, a Simulus® flexible ring was inserted. The characterization was based on mitral annular geometry and valvular dynamics with sonomicrometry and echocardiography.

RESULTS

After adding the ring annuloplasty, the in-plane annular dynamics were more constant throughout the cardiac cycle compared to the reconstruction alone. However, the commissure-commissure distance was statistically significantly decreased [35.0 ± 3.4 mm vs. 27.4 ± 1.9 mm, P < 0.001, diff =  - 7.6 mm, 95% CI, - 9.8 to (-5.4) mm] after ring insertion, changing the physiological annular D-shape into a circular shape which created folds at the coaptation zone resulting in a central regurgitant jet on color Doppler.

CONCLUSION

We successfully reconstructed the entire mitral valve using 2-ply small intestinal submucosal extracellular matrix (CorMatrix®) combined with a flexible annuloplasty. The annuloplasty reduced the unphysiological systolic widening previously found with this reconstructive technique. However, the Simulus flex ring changed the physiological annular D-shape into a circular shape and hindered a correct unfolding of the leaflets. Thus, we do not recommend a flexible ring in conjunction with this reconstructive technique; further investigations are needed to discover a more suitable remodelling annuloplasty.

The effect of surgery started at different time point during the day on the clinical outcomes of mitral valve surgery

Background

The clinical prognosis of mitral valve surgery at morning, afternoon, and evening is not yet clear. The aim of the study is to investigate the impact of different time periods of surgery in the morning, afternoon and evening on the short-term and long-term results of mitral valve surgery.

Methods

From January 2018 to December 2020, 947 patients with mitral valve surgery in our department were selected. These patients were divided into 3 groups according to the starting time of surgery. Morning group (operation start time 8:00-10:30, n = 231), afternoon group (operation start time 12:00-14:30, n = 543), and evening group (operation start time 17:30-20:00, n = 173). The short-term and long-term results of the three groups were compared.

Results

There were no significant difference in the long-term mortality, long-term risk of stroke and reoperation. And there were no significant difference in in-hospital outcomes, including mortality, stroke, cardiopulmonary bypass time, aortic cross clamp time, mitral valve repair convert to mitral valve replacement, number of aortic cross clamp ≥2 times, unplanned secondary surgery during hospitalization (including thoracotomy hemostasis, thoracotomy exploration, redo mitral valve surgery, and debridement), intra-aortic balloon pump, extracorporeal membrane oxygenation, continuous renal replacement therapy, mechanical ventilation time, and intensive care unit length of stay.

Conclusion

There is no significant difference in the risk of short-term and long-term survival and adverse events after mitral valve surgery at different time periods in the morning, afternoon, and evening. Mitral valve surgery at night is safe.

Trends in Isolated Mitral Valve Repair or Replacement Surgery in Australia: A Statewide Cohort Linkage Study

BACKGROUND

Global trends in mitral valve surgery (MVSx) suggest increasing repair compared with replacement, especially in the United States and European countries. The relative use, and outcomes of, MV repair and replacement in Australia are unknown.

METHODS

New South Wales residents who underwent isolated MVSx between 2001 and 2017 were identified from the Admitted-Patient-Data-Collection database. Mortality outcomes were tracked to 31 Dec 2018 and adjusted based on age, sex, urgency of operation, and comorbidity status.

RESULTS

The study cohort comprised 5,693 patients: 2020 (35%) underwent repair (MVr), 1,656 (29%) underwent mechanical replacement (mech.MVR), and 2017 (35%) underwent bioprosthetic replacement (bio.MVR). Respective median ages [interquartile range] were 67 yo [59-75 yo], 64 yo [55-71 yo], and 75 yo [68-80 yo] (p<0.001 across groups). Between 2001 and 2017, total MVSx increased steadily with population growth. Whereas the relative use of MVr remained static (34% to 38%), that for bio.MVR (22% to 50%) and mech.MVR (45% to 13%) changed significantly. MVr had the best outcome with 1.2% in-hospital, 2.5% 1-year, and 21.6% total cumulative mortality during a median follow-up of 6.5 years. Compared to MVr, the adjusted hazard ratio (aHR) for mech.MVR and bio.MVR for long-term mortality were 1.41 (95% confidence interval [CI]=1.24-1.61) and 1.73 (95% CI=1.53-1.95), respectively. Heart failure and sepsis were the main cardiovascular and noncardiovascular causes of death in all groups.

CONCLUSION

In this statewide Australian cohort examined over 17 years, MVr is potentially underutilised despite having superior outcomes to MVR. Access to quality dataset which provides the indication for MVSx and quantitative clinical factors is critical to further improve MVr coverage and outcome MVSx.

Outcomes of Mitral Valve Repair for Degenerative Mitral Disease: A Single-Centre 10-Year Experience

OBJECTIVE

To evaluate the long-term outcomes of degenerative mitral valve (MV) repair.

METHODS

This study analysed 1,069 patients who underwent MV repair due to degenerative MV disease at Beijing Anzhen Hospital from January 2010 to December 2019. All patients were clinically followed until December 2019, with an average follow-up period of 4.7 years. Perioperative complications, 30-day mortality, long-term outcomes, and risk factors of all-cause death and recurrent mitral regurgitation (MR) were summarised.

RESULTS

Ten patients died in the hospital and 33 died during the follow-up period. Recurrent MR occurred in 113 patients. Fourteen patients underwent re-operation. Rates of long-term survival, absence of recurrent MR, and no re-operation were 94.0% (91.6%-96.6%), 81.2% (77.3%-85.3%), and 98.2% (97.2%-99.3%), respectively. The risk factors for long-term all-cause death included age and an ejection fraction (EF) <60%. The risk factors for recurrent MR included age, female sex, E-wave velocity, anterior prolapse, residual 1+MR postoperatively, and lower body mass index.

CONCLUSIONS

Mitral valve repair is an effective treatment for degenerative MV disease that, in an experienced heart centre, can be performed with low mortality, recurrence, and re-operation rates. Advanced age and an EF <60% were risk factors for long-term all-cause death. Age, female sex, residual 1+MR postoperatively, lower body mass index, higher peak E-wave velocity, and anterior prolapse were risk factors for recurrent MR.

Reoperation after failure of mitral valve repair for degenerative disease: A single surgeon experience

Background

With an increasing number of patients undergoing mitral valve repair, more patients are presenting for reoperation. This study aimed to evaluate factors influencing mortality and survival of patients undergoing reoperation for mitral valve surgery after previous mitral valve repair under a single surgeon.

Methods

We retrospectively collected data from 117 patients who underwent reoperation after previous mitral valve repair between 2010 and 2022. We aimed to identify preoperative, operative, and postoperative factors affecting outcomes. The primary outcome was overall survival, and the secondary outcomes included prolonged hospital stay and in-hospital mortality. The mean follow-up was 9.13 ± 10.36 years (median, 6.50 years).

Results

Out of 117 patients, 85 underwent mitral valve replacement (MVR) and 32 underwent mitral valve repair (MVr). The mean age was 64.7 ± 12.7 years (65.5 ± 12.2 years in the MVR group and 62.7 ± 14.0 years in the MVr group), and 66 (56.4%) were men. On a standard multivariate analysis of the overall factors influencing mortality, advanced age was associated with a higher risk of overall mortality (hazard ratio [HR], 1.07; 95% confidence interval [CI], f1.03-1.12; P = .001). The urgency of surgical intervention also played a role, with a higher risk of in-hospital mortality in patients undergoing emergency reoperation (HR, 1.55; 95% CI, 1.60-149.05; P = .02). Furthermore, the presence of mixed lesions, encompassing both mitral regurgitation and stenosis, was strongly linked to increased overall mortality (HR, 17.09; 95% CI, 4.06-71.94; P < .001) and in-hospital mortality (HR, 1.75; 95% CI, 15.83-1925.61; P < .001). Infective endocarditis emerged as a prominent risk factor for overall mortality (HR, 992.08; 95% CI, 85.74-11,479.08; P < .001) and in-hospital mortality (HR, 5.83; 95% CI, 514.81-65,932.99; P < .001). Additionally, chronic obstructive pulmonary disease was associated with a significantly increased risk of overall mortality (HR, 4.3; 95% CI, 1.24-14.97; P = .02).

Conclusions

Our single surgeon experience demonstrates that mitral valve reoperation after a previous repair is associated with good outcomes and survival.

Short-Term Results on Leaflet Mobility in Patients Undergoing Rheumatic Mitral Valve Repair With an Efficient 4-Step Commissuroplasty Technique

BACKGROUND

Mitral valve stenosis (MS) is the primary pathologic feature of rheumatic mitral valve disease, and the complex repair affects its clinical outcome. This study aimed to examine the efficacy of the 4-step commisuroplasty "SCORe" procedure by assessing changes in the mobility of mitral valve leaflets and its clinical effects.

METHODS

From September 1, 2018, to January 13, 2019, patients with MS who underwent mitral valve repair with the SCORe procedure in the study center were analyzed in this prospective study. Mitral valve structure was assessed by transthoracic echocardiography pre- and postoperatively as well as during follow-up.

RESULTS

In total, 60 consecutive patients were examined. In 56 patients (93.3%), mitral valve orifice area (MVOA) was less than 1.5 cm2, and mean (SD) MVOA for the whole cohort was 1.20 (0.34) cm2. The mobility of the anterior leaflet was improved (P < .001) during the cardiac cycle postsurgery, but that of the posterior leaflet was not (P = .591). The mean (SD) coaptation length was increased significantly from 6.69 (1.32) mm to 7.92 (1.24) mm (P < .001) postoperatively. Mean (SD) MVOAs increased to 2.24 (0.38) cm2 postoperatively (P < .001). During the 1-year follow-up, there were no deaths or reoperations. Follow-up echocardiography revealed minor or mild regurgitation in 98.3% of patients.

CONCLUSION

These findings demonstrated that the SCORe procedure can effectively improve the mobility of mitral leaflets and enlarge the valve orifice area in patients with rheumatic MS in China, with minimal complications and promising results.

Role of Vector Flow Mapping in Evaluating Left Ventricular Diastolic Flow Dynamics in Patients Who Underwent Mitral Valve Repair for Degenerative Mitral Regurgitation

Background

Mitral valve (MV) morphology after MV repair affects postoperative left ventricular (LV) blood flow pattern and long-term cardiac function. Pilot data suggest that LV diastolic vortex flow pattern changes after operation, but specific quantifiers remain unknown. We aimed to explore the role of vector flow mapping (VFM) in LV diastolic vortex flow pattern in patients who underwent MV repair.

Methods

A total of 70 patients with degenerative mitral regurgitation were consecutively enrolled and 30 age- and gender-matched controls were recruited. 50 Patients who underwent MV repair were eventually included in our study. LV average energy loss (EL-AVE) during diastole was measured in the MV repair group by VFM one week before and one month after the operation, and compared with that of controls using one-way analysis of variance. The effect of surgical techniques and the extension of leaflet degeneration on postoperative EL-AVE were analyzed using muti-way analysis of variance, and patients were categorized into a resection subgroup (n = 29) and a non-resection subgroup (n = 21).

Results

The EL-AVE one month after operation in the MV repair group was decreased (p < 0.001) compared to that one week before the operation, and was increased (p < 0.001) compared to that in controls. Mitral leaflet resection had a statistically significant effect on postoperative EL-AVE. The EL-AVE of the resection subgroup was higher than that of non-resection subgroup (p < 0.001).

Conclusions

VFM can be used to evaluate the diastolic blood flow pattern of LV after MV repair, and to observe the changes of LV blood flow pattern caused by different surgical techniques. VFM may be a potential new hemodynamic evaluation method after MV repair.

Mitral valve repair for anterior/bi-leaflet versus posterior leaflet degenerative mitral valve disease: a systematic review and meta-analysis

Mitral valve repair (MVr) secondary to degenerative anterior/bi-leaflet mitral valve disease is more challenging than posterior leaflet repair. However, conclusive evidence is needed to make decisions based on the outcomes rather than technical difficulties. This meta-analysis compares anterior/bi-leaflet MVr with isolated posterior leaflet repair in patients with mitral regurgitation (MR) due to degenerative mitral valve disease. The outcomes of interest were long-term (≥ 5 years) survival and freedom from re-operation and moderate-to-severe MR. Meta-analysis of 10 studies showed that there was no significant difference in long-term survival (RR: 1.00; 95% CI 0.96-1.04), freedom from moderate-to-severe MR (RR: 0.95; 95% CI 0.87-1.03), and freedom from re-operation (RR: 0.96; 95% CI 0.90-1.02) between anterior/bi-leaflet MVr and posterior leaflet repair. As outcomes of anterior/bilateral repair were comparable with those of isolated posterior leaflet repair, our findings do not support the inclination towards replacement over repair for MR caused by anterior/bilateral degenerative mitral disease.

Evaluation of an Innovative Device for Mitral Valve Regurgitation: Experimental Acute In Vivo Results

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.

Long-term cardiac remodeling associated with heart failure following left-ventricular valve replacement surgery: A retrospective study

To investigate long-term cardiac remodeling and prognosis of patients post-left-ventricular valve replacement, and explored related risk factors of heart failure and management strategies. Retrospective cohort of patients with left-ventricular valve replacement between 2005 and 2007. Major adverse cardiac events were recorded, including death, hospitalization, stroke, and New York Heart Association (NYHA) functional classifications. Cardiac remodeling was assessed by comparing pre-operative, post-operative, and follow-up echocardiographic images. (1).. Two hundred fifty-seven patients who received left-ventricular mitral, aortic, or double-valve replacement surgery were followed up for 10.4 ± 1.5 years with an all-cause mortality rate 18.7% and an incidence of heart failure that significantly restricted daily life (NYHA III or IV) 21.3%. (2).. There were no significant differences in classic cardiac-remodeling variables between baseline and long-term follow-up, such as left-ventricular diameter (47.9 ± 8.3 vs 49.9 ± 8.0 mm, P = .14) and left-ventricular ejection fraction (58.6 ± 9.6% vs 57.0 ± 10.3%, P = .34), whereas there were significant differences in terms of left-atrial anteroposterior diameter (LA) (39.7 ± 9.5 vs 49.0 ± 14.3 mm, P < .001) and tricuspid regurgitation (TR) (1.4 ± 1.0 vs 2.2 ± 1.2, P < .001). Multivariable logistic regression analysis showed that LA ≥ 50 mm (P = .011) and more than moderate tricuspid regurgitation (TR > 2) (P = .012) were associated with poor prognoses for long-term consequences of heart failure. Both LA and TR progressed with the length of time after surgery. LA enlargement and TR after left-ventricular valve replacement surgery were time-dependent events, which represented cardiac remodeling and were closely related to post-operative long-term consequences of heart failure. It is important to be cognizant of and to explore long-term preventive and treatment strategies for adverse cardiac events in patients following left-ventricular valve replacement.

Minimally invasive versus conventional sternotomy for Mitral valve repair: protocol for a multicentre randomised controlled trial (UK Mini Mitral)

INTRODUCTION

Numbers of patients undergoing mitral valve repair (MVr) surgery for severe mitral regurgitation have grown and will continue to rise. MVr is routinely performed via median sternotomy; however, there is a move towards less invasive surgical approaches.There is debate within the clinical and National Health Service (NHS) commissioning community about widespread adoption of minimally invasive MVr surgery in the absence of robust research evidence; implementation requires investment in staff and infrastructure.The UK Mini Mitral trial will provide definitive evidence comparing patient, NHS and clinical outcomes in adult patients undergoing MVr surgery. It will establish the best surgical approach for MVr, setting a standard against which emerging percutaneous techniques can be measured. Findings will inform optimisation of cost-effective practice.

METHODS AND ANALYSIS

UK Mini Mitral is a multicentre, expertise based randomised controlled trial of minimally invasive thoracoscopically guided right minithoracotomy versus conventional sternotomy for MVr. The trial is taking place in NHS cardiothoracic centres in the UK with established minimally invasive mitral valve surgery programmes. In each centre, consenting and eligible patients are randomised to receive surgery performed by consultant surgeons who meet protocol-defined surgical expertise criteria. Patients are followed for 1 year, and consent to longer term follow-up.Primary outcome is physical functioning 12 weeks following surgery, measured by change in Short Form Health Survey (SF-36v2) physical functioning scale. Early and 1 year echo data will be reported by a core laboratory. Estimates of key clinical and health economic outcomes will be reported up to 5 years.The primary economic outcome is cost effectiveness, measured as incremental cost per quality-adjusted life year gained over 52 weeks following index surgery.

ETHICS AND DISSEMINATION

A favourable opinion was given by Wales REC 6 (16/WA/0156). Trial findings will be disseminated to patients, clinicians, commissioning groups and through peer reviewed publication.

TRIAL REGISTRATION NUMBER

ISRCTN13930454.

Benefits of mitral valve repair over replacement in the elderly: a systematic review and meta-analysis

OBJECTIVES

Mitral valve (MV) repair has demonstrated excellent short- and long-term outcomes, however, its merit in the elderly population is still debated. We conducted a meta-analysis of studies that have compared the MV repair to replacement in the elderly population.

METHODS

A systematic literature search was conducted for any study published on MV surgery on elderly patients (≥75 years old). A pooled risk-ratio meta-analysis was done to evaluate short-term mortality, postoperative complications, surgical timings, and long-term survival rates.

RESULTS

A total of nine retrospective observational studies were included in the quantitative meta-analysis. Pooled meta-analysis showed a reduced risk of short-term mortality for the MV repair group (risk ratio [RR] = 0.41 [0.24-0.71], p-value = .005). Postoperative neurological complications were in favor of repair, although not significantly (RR = 0.49 [0.21-1.11], p-value = .07). Operative timings (cardiopulmonary bypass and crossclamp time) were not different between the groups although no data were available on the complexity of the repairs. Long-term survival rates were in favor of the repairs (pooled treatment effect of -0.47 [-0.64; -0.29], p = .005).

CONCLUSIONS

MV surgery is a safe and effective procedure for the elderly. MV repair demonstrated better short-term outcomes compared to replacement. Long-term survival rates are significantly better after repair.

A new device to treat mitral valve regurgitation: a proof of concept in bench test study

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.

Asian Pacific Society of Cardiology Consensus Recommendations on the Use of MitraClip for Mitral Regurgitation

Transcatheter mitral valve repair with the MitraClip, a catheter-based percutaneous edge-to-edge repair technique to correct mitral regurgitation (MR), has been demonstrated in Western studies to be an effective and safe MR treatment strategy. However, randomised clinical trial data on its use in Asian-Pacific patients is limited. Hence, the Asian Pacific Society of Cardiology convened an expert panel to review the available literature on MitraClip and to develop consensus recommendations to guide clinicians in the region. The panel developed statements on the use of MitraClip for the management of degenerative MR, functional MR, and other less common indications, such as acute MR, dynamic MR, hypertrophic obstructive cardiomyopathy, and MR after failed surgical repair. Each statement was voted on by each panel member and consensus was reached when 80% of experts voted 'agree' or 'neutral'. This consensus-building process resulted in 10 consensus recommendations to guide general cardiologists in the evaluation and management of patients in whom MitraClip treatment is being contemplated.

Transapical off-pump mitral valve repair with NeoChord implantation: A systematic review

INTRODUCTION

Mitral valve repair (MVr) is the gold standard for the treatment of degenerative mitral valve regurgitation (MR). The recently introduced NeoChord DS1000 has gained increasing recognition as a feasible, potentially safe, and effective procedure with minor complications and promising outcomes. This study aims to conduct a systematic review of the published literature that discusses the technical feasibility and outcome of transapical off-pump MVr with NeoChord DS1000 device implantation in the treatment of degenerative MR.

METHODS

This review was performed according to the PRISMA statement. Databases searched in this review included Pubmed, Web of Science, Scopus, and Cochrane databases for systematic reviews. All English articles on humans reporting isolated MVr using NeoChord DS1000 device were included provided that basic preoperative data, operative specifications, and postoperative mortality and morbidity were reported.

RESULTS

This review included six studies comprised 249 patients who had NeoChord mitral procedure. Almost all patients included had severe MR (243/249, 97.6%). Operative success was achieved in 241 out of the 249 patients (96.8%). No intraoperative mortality was reported. Intraoperative arrhythmia was reported in six patients (2.4%) and significant bleeding was reported in eight patients (3.2%).

CONCLUSION

Awaiting more evidence, NeoChord mitral procedure appears to be a promising procedure that can be considered in selected cases.

Surgical rheumatic mitral valve repair compared with percutaneous balloon mitral valvuloplasty in mitral stenosis in current era: a propensity score matching study

Background

Many comparative studies of percutaneous balloon mitral valvuloplasty (PBMV) and surgical mitral commissurotomy (SMC) in rheumatic mitral stenosis (MS) were done in the last few decades. With the development of valve repair techniques, various surgical rheumatic valve repair techniques have been applied in clinic, but there is a lack of comparison with PBMV. Our study was designed to compare the perioperative and mid-term outcomes of PBMV and mitral valve repair with “four-step” procedure in the treatment of rheumatic MS.

Methods

Patients with MS were treated with PBMV or rheumatic mitral valve repair (rMVP) at Beijing Anzhen Hospital between January 1, 2013 and September 30, 2018 were selected. By using propensity score matching (PSM) method, we compared the changes in post-operation clinical outcomes between the two matched groups. Kaplan-Meier analyses was used for survival analysis and drawing the curve, and log-rank test were used to compare intergroup differences.

Results

A total of 252 cases were enrolled after selection, 74 cases in PBMV and 178 cases in rMVP. Seventy-four pairs were matched successfully after PSM. There were 53 females in PBMV and 54 in rMVP. The mean age of two groups was 46.95±12.50 and 47.55±11.91 years respectively. There was no significantly differences in mitral valve orifice area (MVOA) (1.05±0.32 vs. 0.97±0.24 cm², P=0.12) and left ventricular ejection fraction (EF) (62.36%±5.17% vs. 62.52%±4.94%, P=0.76) between two groups preoperatively. Baseline characteristics were basically balanced after PSM. In each group, there was one case transferred to surgical mitral valve replacement due to the failure of valvuloplasty before discharge. All patients survived the interventions and no severe complications were found. MVOA were significantly increased in rMVP compared with PBMV postoperatively, as well as grading of MS and tricuspid regurgitation (TR) were significantly improved in rMVP. Three cases in PBMV were lost during the follow-up. Mitral replacement was performed in 11 patients and one of them died in PBMV, while none of patients underwent re-intervention in rMVP, but one patient died of pneumonia.

Conclusions

For selected patients with rheumatic MS in China, our study shows that there are comparable clinical outcomes in terms of operative, mid-term mortality and complications between PBMV and surgical rMVP with “four-step” procedure. Surgical rMVP shows more advantageous in the correction of valve stenosis and the management of concomitant tricuspid valve lesions and atrial fibrillation (AF).

Mitral valve re-repair vs replacement following failed initial repair: a systematic review and meta-analysis

Background

The optimal treatment strategy following a failed mitral valve repair remains unclear. This study aims to compare and analyse available studies which report the clinical outcomes post mitral valve re-repair (MVr) or replacement (MVR) after a prior mitral valve repair.

Methods

Based on PRISMA guidelines, a literature search was performed utilising PubMed, Cochrane and Scopus databases to identify retrospective cohort studies that reported outcomes of MVr and MVR after a prior mitral valve repair. Data regarding operative mortality, clinical outcomes and complications were extracted, synthesized and meta-analysed where appropriate.

Results

Eight studies with a total cohort of 1632 patients were used. After analysis, no significant differences in the short term and long-term operative mortality, incidence of stroke, congestive heart failure, Grade 1 and Grade 2 mitral regurgitation, requirement of 3rd mitral valve operation and reoperation due bleeding were found between the two groups. However, a slightly higher incidence of postoperative atrial fibrillation (OR: 0.11, CI: 0.02 to 0.17, I² = 0%, p = 0.02) was observed in the MVR group, as compared to the MVr group.

Conclusion

MVr appears to be a viable alternative to MVR for mitral valve reoperation, given that they are associated with similar post-operative outcomes.

Expert Consensus Systems of Care Proposal to Optimize Care for Patients With Valvular Heart Disease Review of the 2019 Document for the Cardiac Anesthesiologist

Valvular heart disease requiring intervention is increasing in prevalence in the adult population. With advancement in transcatheter and surgical procedures for valvular heart disease, optimization of patient selection, availability of resources and personnel, appropriate training and certification, and optimal periprocedural management rely on clinical evaluation, accurate echocardiographic interpretation, and understanding of valvular pathophysiology by the cardiac anesthesiologist. To optimize care and improve access for patients with valvular heart disease the Expert Consensus Systems of Care Document by Nishimura et al.¹ was recently published. The authors propose a protocol with guidelines and performance metrics to create tiered-level valve centers. This review focuses and expands on aspects discussed in Nishimura et al.'s Expert Consensus Systems of Care Document that are relevant to the cardiac anesthesiologist in the periprocedural setting.

Contemporary Status of Percutaneous Transcatheter Edge-to-Edge Repair: Is It a Complement or Replacement to Mitral Surgery?

Transcatheter mitral valve repair devices borrow from the concept of surgical edge-to-edge approximation and are becoming increasingly used in patients with both primary and functional mitral regurgitation. The application of these new devices is expanding globally; however, debates between which patients are amenable to surgery vs. percutaneous approaches are ongoing. As new trials and regulatory approvals have evolved, the indications for transcatheter approaches have expanded, in a way that is complementaty to existing indications for surgical repair. In general, the treatment of mitral regurgitation should be stratified based on underlying pathophysiology and anatomy by a multidisciplinary team including cardiac surgeons and interventional cardiologists. This review aims to provide practical approaches to patient selection and treatment strategies for mitral regurgitation based on historical data and recently published trials, with a focus on the distinction between surgical and transcatheter mitral therapies.

Utility of Cardiac CT for Preoperative Evaluation of Mitral Regurgitation: Morphological Evaluation of Mitral Valve and Prediction of Valve Replacement

OBJECTIVE

We aimed to investigate the diagnostic accuracy of cardiac computed tomography (CT) for the detection of mitral valve (MV) prolapse in mitral regurgitation (MR) with surgical findings as the standard reference, and to assess the predictability of MV replacement based on morphologic CT findings.

MATERIALS AND METHODS

A total of 156 patients who had undergone preoperative cardiac CT and subsequently received MV surgery due to severe MR were retrospectively enrolled. Non-repairable MV was defined when at least one of the following conditions was met: 1) anterior leaflet prolapse, 2) bi-leaflet prolapse, or 3) valve morphology (leaflet thickening, calcification, or mitral annular calcification [MAC]). Diagnostic performance of CT for the detection of the prolapsed segment was assessed with surgical findings as the standard reference. Logistic regression analysis was performed to evaluate the value of CT findings to predict actual valve replacement.

RESULTS

During surgery, MV prolapse was identified in 72.1%. The sensitivity, specificity, and diagnostic accuracy for the detection of MV prolapse were 99.1%, 81.4%, and 94.2%, respectively, per patient. One-hundred eighteen patients (75.6%) underwent MV repair and the remaining 38 patients received MV replacement. Bi-leaflet prolapse and valve morphology were independent predictors of valve replacement after adjusting for clinical variables (adjusted odds ratio, [OR] 8.63 for bi-leaflet prolapse; OR, 4.14 for leaflet thickening; and OR, 5.37 for leaflet calcium score > 5.6; p < 0.05).

CONCLUSION

Cardiac CT can have high diagnostic performance for detecting the prolapsed segment of the MV and predictability of valve replacement before surgery. Bi-leaflet prolapse and valve morphology, such as leaflet thickening, or calcification or MAC, are the most important predictors of valve replacement.

A Novel Multiparametric Score for the Detection and Grading of Prosthetic Mitral Valve Obstruction in Cases With Different Disc Motion Abnormalities

Prosthetic mechanical valves are the elective choice in mitral valve (MV) replacement, because of their reliability and easiness of implantation. However, these prostheses can suffer from complications, the major one being prosthetic mitral valve thrombosis (PMVT). In these cases, transthoracic doppler echocardiogram (TDE) is the standard diagnostic workup for diagnosis of valve malfunction. The American Society of Echocardiography (ASE) indicates the possible TDE-derived indexes, which can help in identifying insurgence of MV replacement complications. Unfortunately, in some cases, it is not possible to detect PMVT based on these criteria. In these cases, we speak of Doppler silent thrombosis and only more accurate and invasive analyses, such as fluoroscopy, allow for a correct diagnosis. In this work, computational fluid dynamic models were implemented to simulate valve fluid dynamics in different clinical scenarios in order to improve the reliability of PMVT diagnosis based on TDE. In detail, seven mechanical valve configurations, associated to different potential thrombotic conditions (symmetric and asymmetric stenosis), were designed and tested using five pathologic transmitral velocity profile, extracted from real TDE images; to obtain the flow rate profiles, each TDE velocity profile was scaled to yield a mean flow rate (MFR) of 4, 5 and 6 L/min, respectively. As a result, 105 (7 × 5 × 3) synthetic cases, accounting for different velocity profiles, MFRs and valve configurations, were simulated. TDE-derived indexes were calculated according to the ASE guidelines that were extracted. Advanced statistical methods were applied to propose a new diagnostic algorithm for detecting PMVT. Our results showed that there isn't any significant difference between symmetric and asymmetric stenosis, probe location and flow rate waveform and confirmed that the single modality diagnostic is not able to predict thrombosis in a relevant number of cases, referable to mild and mild-severe stenosis cases. To overcome the problem, a novel multi-parametric discrete score based on the designed diagnostic algorithm was attained and tested; the percentage of stenosis (POS) was predicted with an accuracy rate of 90.5%. Even more interestingly, the error rate of 9.5% is related to four false positive cases corresponding to mild stenosis (POS = 15%) which were erroneously classified as mild-severe stenosis. No false negatives were obtained. Our results suggest that a reliable estimation must take into account the mean flow rate as well as the transmitral velocity profile in order to provide a correct diagnosis.

The role of transcatheter mitral valve therapy in heart failure

Mitral valve regurgitation is detected in up to 75% of patients with heart failure. Interventional mitral valve therapies can be used to treat mitral regurgitation with very low morbidity and mortality rates and minimal invasiveness. Devices intended for the replacement of the mitral valve still require significant development and refinement before entering clinical practice on a large scale. The derived benefit of these therapies, the priority (repair over replacement) and the therapeutic role in patients with secondary mitral regurgitation due to heart failure remain to be investigated.

Follow-up and management of valvular heart disease patients with prosthetic valve: a clinical practice guideline for Indian scenario

PURPOSE

Valvular heart disease (VHD) patients after prosthetic valve implantation are at risk of thromboembolic events. Follow-up care of patients with prosthetic valve has a paramount role in reducing the morbidity and mortality. Currently, in India, there is quintessential need to stream line the follow-up care of prosthetic valve patients. This mandates the development of a consensus guideline for the antithrombotic therapy in VHD patients post prosthetic valve implantation.

METHODS

A national level panel was constituted comprising 13 leading cardio care experts in India who thoroughly reviewed the up to date literature, formulated the recommendations, and developed the consensus document. Later on, extensive discussions were held on this draft and the recommendations in 8 regional meetings involving 79 additional experts from the cardio care in India, to arrive at a consensus. The final consensus document is developed relying on the available evidence and/or majority consensus from all the meetings.

RESULTS

The panel recommended vitamin K antagonist (VKA) therapy with individualized target international normalized ratio (INR) in VHD patients after prosthetic valve implantation. The panel opined that management of prosthetic valve complications should be personalized on the basis of type of complications. In addition, the panel recommends to distinguish individuals with various co-morbidities and attend them appropriately.

CONCLUSIONS

Anticoagulant therapy with VKA seems to be an effective option post prosthetic valve implantation in VHD patients. However, the role for non-VKA oral therapy in prosthetic valve patients and the safety and efficacy of novel oral anticoagulants in patients with bioprosthetic valve need to be studied extensively.

Aortic and mitral valve repair for anterior mitral leaflet perforation caused by severe aortic regurgitation

A 23-year-old man presented with acute onset of dyspnea on exert. Preoperative echocardiography showed a severe regurgitation of the bicuspid aortic valve (due to prolapse of the fused cusp) creating a jet directed through the defect in the anterior leaflet of the mitral valve. Both valves were repaired. Endocarditis was excluded with cultures and polymerase chain reaction (PCR). Postoperative course was uneventful.

Mycobacterium chimaera infection following cardiac surgery in the United Kingdom: clinical features and outcome of the first 30 cases

OBJECTIVES

Mycobacterium chimaera infection following cardiac surgery, due to contaminated cardiopulmonary bypass heater-cooler units, has been reported worldwide. However, the spectrum of clinical disease remains poorly understood. To address this, we report the clinical and laboratory features, treatment and outcome of the first 30 UK cases.

METHODS

Case note review was performed for cases identified retrospectively through outbreak investigations and prospectively through ongoing surveillance. Case definition was Mycobacterium chimaera detected in any clinical specimen, history of cardiothoracic surgery with cardiopulmonary bypass, and compatible clinical presentation.

RESULTS

Thirty patients were identified (28 with prosthetic material) exhibiting a spectrum of disease including prosthetic valve endocarditis (14/30), sternal wound infection (2/30), aortic graft infection (4/30) and disseminated (non-cardiac) disease (10/30). Patients presented a median of 14 months post surgery (maximum 5 years) most commonly complaining of fever and weight loss. Investigations frequently revealed lymphopenia, thrombocytopenia, liver cholestasis and non-necrotizing granulomatous inflammation. Diagnostic sensitivity for a single mycobacterial blood culture was 68% but increased if multiple samples were sent. In all, 27 patients started macrolide-based combination treatment and 14 had further surgery. To date, 18 patients have died (60%) a median of 30 months (interquartile range 20-39 months) after initial surgery. Survival analysis identified younger age, mitral valve surgery, mechanical valve replacement, higher serum sodium concentration and lower C-reactive protein as factors associated with better survival.

CONCLUSIONS

Mycobacterium chimaera infection following cardiac surgery is associated with a wide spectrum of disease. The diagnosis should be considered in all patients who develop an unexplained illness following cardiac surgery.

Dynamic Patient-Specific Three-Dimensional Simulation of Mitral Repair

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.

Features of rheumatic mitral valves and a grading system to identify suitable repair cases in China

Background

We aimed to assess the pathological characteristics of rheumatic mitral valve disease in Chinese patients and formulate a pathological grading system to identify cases suitable for rheumatic mitral valve repair (rMVP).

Methods

Nearly 5 years of follow-up data on patients who underwent rMVP were analysed. A Kaplan-Meier survival curve for freedom from reoperation and valve failure was constructed. A pathological grading system of rheumatic mitral valve lesions (PGSRMVL) was developed based on the pathological characteristics of rheumatic mitral valve disease and tested by receiver operating characteristics (ROCs) curve analysis. Predictors of endpoints for rheumatic repair were analysed.

Results

From January 2012 to June 2016, 179 patients underwent rMVP in our centre. The mean follow-up duration was 24±14 months. A left atrial anterior and posterior diameter >60 mm was an independent predictor for the 16 endpoints [hazard ratio (HR) =3.884, P=0.029]. Between 2015 and 2016, 126 consecutive pathological characteristics of rheumatic mitral valve were evaluated (61 and 65 repair and replacement cases, respectively). The ROCs area under the curve was 0.891 for the correlation between the pathological score and successful repair (cut-off point, 17.5; sensitivity, 78%; specificity, 85.2%). Seven lesions had higher ratios in the replacement group than the repair group. Commissural fusion/calcification and main chordae tendineae fusion/calcification were the most common severe pathological lesions.

Conclusions

The main pathological characteristics of rheumatic mitral valve disease in Chinese patients are commissure and sub-valvular apparatus lesions. Most patients can be appropriately treated via commissurotomy and leaflet thinning. Severe calcification of the commissure and sub-valvular apparatus can considerably decrease the odds of a successful repair. The median follow-up results of rheumatic mitral repair are considered satisfactory for the pathological characteristics in Chinese patients.

Prevalence of optimal valve morphology for MitraClip in patients with mitral regurgitation

AIMS

To evaluate how often patients with moderate-to-severe or severe mitral regurgitation (MR) meet the anatomical criteria for MitraClip implant and to examine the role of transthoracic echocardiography (TTE) for this task.

METHODS AND RESULTS

From February to June 2015, all patients undergoing a TTE in nine Spanish hospitals were prospectively included. Patients with moderate-to-severe and severe mitral regurgitation were selected for analysis. Anatomical eligibility criteria for MitraClip were defined according to the EVEREST trial. A total of 39 855 consecutive TTE were reviewed, and 1403 patients with moderate-to-severe and severe MR were finally included. Primary MR was found in 779 patients (56%). Only in 74 patients (16%), all anatomical criteria for MitraClip could be assessed by TTE. Of these, 56% of patients had optimal valve morphology. Secondary MR was described in 361 patients (26%), and at least 249 of these (69%) had a high surgical risk. All five criteria for MitraClip were adequately assessed by TTE in 299 patients (83%). Of them, 118 patients (39%) had optimal valve morphology.

CONCLUSIONS

A considerable proportion of patients have optimal mitral valve morphology for MitraClip. Moreover, TTE was particularly useful in determining whether or not the anatomical criteria for MitraClip implant were met in the majority of patients with secondary MR but in only a minority of those with primary MR.

Tissue-engineered mitral valve chordae tendineae: Biomechanical and biological characterization of decellularized porcine chordae

Chordae tendineae are essential for maintaining mitral valve function. Chordae replacement is one of the valve repair procedures commonly used to treat mitral valve regurgitation. But current chordae alternatives (polytetrafluoroethylene, ePTFE) do not have the elastic and self-regenerative properties. Moreover, the ePTFE sutures sometimes fail due to degeneration, calcification and rupture. Tissue-engineered chordae tendineae may overcome these problems. The utility of xenogeneic chordae for tissue-engineered chordae tendineae has not yet been adequately explored. In this study, polyelectrolyte multilayers (PEM) film modified decellularized porcine mitral valve chordae (PEM-DPC) were developed to explore tissue-engineered chordae tendineae as neochordae substitutes. Fresh porcine mitral chordae were decellularized and reserved the major elastic fiber and collagen components. Decellularized chordae with a PEM film were produced with chitosan-heparin by a lay-by-lay technique. Mesenchymal stem cells and vascular endothelial cells could grow well on the surface of the PEM-DPC. The superior biomechanical properties of PEM-DPC were proved with good flexibility and strength both in vitro and in vivo. PEM-DPC can be developed for potential alternative mitral valve chordae graft.

Mitral valve repair versus replacement

Degenerative, ischemic, rheumatic and infectious (endocarditis) processes are responsible for mitral valve disease in adults. Mitral valve repair has been widely regarded as the optimal surgical procedure to treat mitral valve dysfunction of all etiologies. The supporting evidence for repair over replacement is strongest in degenerative mitral regurgitation. The aim of the present review is to summarize the data in each category of mitral insufficiency and to provide recommendations based upon this data.