Improvement of mitral valve coaptation with supraannular plication of the posterior annulus--a newly designed strip for posterior annular plication--

Non-ischaemic mitral valve suture annuloplasty: late follow-up results

Objective:

To evaluate late outcomes after posterior mitral valve (MV) annulus double-suture annuloplasty for degenerative (non-ischaemic) MV insufficiency.

Design:

Between 2005 and 2011, 138 patients underwent MV repair using posterior MV double-suture annuloplasty and an additional 105 patients underwent tricuspid valve repair. The study protocol included operative mortality, reoperation rate and reasons, as well as echocardiographic parameters at pre- and postoperative and follow-up periods (2-9 years).

Results:

In-hospital mortality was 2/138 (1.45%). Early post operation, no regurgitation was noted in 74/136 (54.4%) patients, Io regurgitation was observed in 55/136 (40.4%), IIo was observed in 6/136 (4.4%) and IIIo was observed in 1/136 (0.7%); during late follow-up (from 2 to 9 years), no regurgitation was observed in 21.6% patients, Io was observed in 58%, IIo was observed in 17% and IIIo was observed in 3.4%. The mean preoperative anterolateral diameter of the MV annulus was 39.02±4.97 mm and, at late follow-up, it was 27.66±3.94 mm (p=0.000); at these same time points, left ventricular end-diastolic diameter (LVEDD) was 55.74±7.29 mm and 49.17±6.01 mm (p=0.000), respectively, and the left ventricular ejection fraction (LVEF) was 53.08±8.93% and 50.92±6.78%, respectively (p=0.007).

Conclusions:

This study demonstrates suture annuloplasty to be an effective treatment up to 9 years for degenerative mitral valve disease. This technique enables preservation of the posterior mitral valve annulus diameter with stable long-term (up to 9 years) reduction, a competent (no regurgitation/⩽IIo regurgitation) MV in 96.6% of cases and positive left ventricular (LV) remodelling.

Posterior mitral annuloplasty for enhancing mitral leaflet coaptation: using a strip designed for placement in the posterior annulus

Background

In patients with mitral valve regurgitation (MR), posterior mitral annuloplasty (PMA) was performed for mitral valve repair using a strip designed for placement in the posterior annulus, sparing the anterior annulus and anterior half of the commissures.

Methods

Between September 2009 and October 2013, we performed PMA using a novel strip in 74 consecutive patients with MR greater than 3+. Procedures associated with mitral valve repairs were performed in 41 patients (56.9 %), including new chord placement for leaflet prolapse (n=30), patch valvuloplasty for posterior chord rupture (n=4), and posterior leaflet augmentation (n=15). All patients were analyzed by serial echocardiographic follow-up, and preoperative and postoperative computed tomography was performed in 10 randomly selected patients.

Results

Hospital death occurred in two patients (2.7 %), and 72 survived patients were completely followed up. At a mean follow-up of 37.2 ± 15.0 months, the MR grade was zero or 1+ in 64 patients (88.9 %), 2+ in 7 patients (9.7 %), and 3+ in one patient (1.4 %). The mean indexed valve area and mean valve gradient were 1.7 ± 0.4 cm²/m² and 3.5 ± 1.2 mmHg, respectively. The mean leaflet coaptation height in early systole was 12.8 ± 3.5 mm. During the cardiac cycle, the repaired valves exhibited dynamic changes of 19.5 ± 9.3 % in the septo-lateral dimensions. No early conversions to valve replacements or late reoperations occurred. None of the patients with remnant or recurrent MR experienced hemolysis.

Conclusions

PMA using a novel strip showed a sufficient coaptation height secondary to reduction of the septo-lateral annular dimensions and dynamic changes in the dimensions. It can be expected to be an alternative mitral annuloplasty technique with satisfactory results.

Midterm results of mitral valve repair with lifting annuloplasty strip for acute phase infective endocarditis

Background

Mitral valve repair is favored over replacement due to superior outcomes. However, extensive infective endocarditis (IE) often has been considered unreconstructable. We retrospectively analyzed the mid-term outcomes of an individualized repair approach using a lifting annuloplasty strip.

Methods

Between December 2007 and March 2014, 27 consecutive patients with acute single mitral valve IE (age 43 ± 16 years, 11 men) underwent lifting mitral annuloplasty (LMA) with a strip (Mitracon® strip, 28 mm in 4, 32 mm in 10, and 34 mm in 13). Blood culture was positive in 70 % (Streptococcus 10, Staphylococcus 4, HACEK 3, Enterococcus 1, Gram negative bacilli 1). One case (4 %) had a previously repaired mitral valve—the repair was redone. Via right thoracotomy (74 %) or median sternotomy (26 %), repair was performed by removal of vegetation and resection of infected tissue, the defect typically then being repaired using a bovine pericardial patch (81 %). Artificial chordae were formed in 5 patients. Nine (33 %) of them had posterior leaflet augmentation (PLA) to get sufficient coaptation height. Clinical and echocardiographic follow-up were performed.

Results

Compared with preoperative ones, postoperative echocardiograms revealed decreases of left ventricular (LV) end-diastolic dimensions (57.2 ± 6.3 versus, 45.4 ± 6.2, or 44.8 ± 4.1 mm, all p < 0.01). The LV ejection fraction decreased immediately, but recovered (64.4 ± 9.6 % vs. 54.5 ± 9.8 %, or 65.2 ± 6.1 %, p = 0.002, p = 1.000, respectively). The latest follow-up echocardiograms (median 28 months) universally showed no or minimal regurgitation, with a preserved mitral valve opening area (2.27 ± 0.48 cm²). During the clinical follow-up (median, 54 months), one (3.7 %) death was observed (in-hospital, due to biliary sepsis and pneumonia). There was no reoperation or major cardiovascular event. The 5 year survival rate was 96.3 %.

Conclusions

The repair technique of LMA and/or PLA in patients with IE achieved good structural and functional outcomes as well as an excellent 5 year survival rate. An individualized repair approach should be recommended in patients with acute phase IE.

Lifting posterior mitral annuloplasty for enhancing leaflet coaptation in mitral valve repair: midterm outcomes

BACKGROUND

We evaluated the midterm outcomes of lifting posterior mitral annuloplasty for enhancing leaflet coaptation in mitral valve repair.

METHODS

Between October 2007 and December 2012, 341 consecutive patients with significant mitral regurgitation underwent lifting posterior mitral annuloplasty using a specially designed fabric annuloplasty strip that lifts the middle portion of the posterior annulus. Associated procedures for mitral valve repairs, such as patch valvuloplasty for posterior leaflet prolapse (n=80), new chord placement for anterior leaflet prolapse (n=33), commissurotomy (n=29), and posterior leaflet extension (n=23), were performed in 141 patients (41.3%).

RESULTS

Thirty-day mortality was 0.9%. Nine late deaths (2.6%) occurred. Mean overall survival at 5 years was 96.0%±1.1%. During the mean follow-up period of 38±17 months, six patients (1.8%) underwent valve-related reoperation (5-year freedom from valve-related reoperation, 98.1%±0.8%). At 5 years, mean freedom from recurrence of mitral regurgitation grade 3+ to 4+ (moderate to severe) was 95.1%±1.6%. The mean valve pressure gradient (PG) was 3.2±1.5 mmHg across all strip sizes at the time of follow-up.

CONCLUSIONS

Lifting posterior mitral annuloplasty using an innovative annuloplasty strip in mitral valve repair has a low rate of recurrent regurgitation or valve-related reoperation with rare relevant complications.

Right atrial reduction plasty associated with the cox-maze procedure

We performed a right atrial reduction plasty combined with the Cox‐maze procedure in a patient with a giant right atrium and permanent atrial fibrillation. The reduction plasty involved excisions of the redundant atrial wall along two ablation lines of the maze procedure, and excision of the redundant thin septum primum. This procedure achieved a 60% dimension reduction and an 80% volume reduction. The reduced atrial size and sinus rhythm were maintained after 3.5 years. doi: 10.1111/jocs.12542 (J Card Surg 2015;30:544–546)

Preoperative risk factor analysis of postoperative stroke after Cox-maze procedure with mitral valve repair

Background

Atrial fibrillation (AF) is a life-threatening arrhythmia that carries the high risk of thromboembolic complication. Stroke often develops in patients who undergo successful Cox Maze procedure, despite the fact that the procedure has shown a high rate of success in sinus conversion from AF. This study examined the preoperative risk factors predictive of stroke following Cox Maze procedure in patients with mitral valve disease.

Methods

240 patients with the mean age of 57 years underwent Cox-Maze IV procedure with mitral valve repair from November 2007 through December 2010. All patients were available during the follow-up period with the mean duration of 23.6 months. This study excluded those patients who had undergone mitral valve replacement because of maintenance of warfarin medication

Results

Sixteen patients had an ischemic stroke. Of these sixteen patients, six had a transitional ischemic accident while the remaining ten had cerebral infarction. Twelve of sixteen showed sustained sinus rhythm, three showed AF and one had pacing rhythm. Univariate analysis showed that only preoperative stroke history was associated with postoperative stroke (p = 0.03). High CHA₂DS₂-VASc score, rheumatic etiology, large left atrium (LA), preoperative or postoperative LA thrombus, age, sex, hypertension, and concomitant surgery were not associated with predictive risks for stroke.

Conclusions

In the group of patients who underwent the Cox-Maze procedure with mitral valve repair, having a stroke history was the only preoperative risk factor that could lead to a stroke event after surgery. Accordingly, patients with affliction of ischemic stroke, albeit sustained sinus rhythm, may require prophylactic anticoagulation.

Determination of mitral valve area with echocardiography, using intra-operative 3-dimensional versus intra- & post-operative pressure half-time technique in mitral valve repair surgery

Background

We hypothesized that mitral valve areas (MVAs) with echocardiography, using 3D planimetry technique (measured at one point at maximal opening of mitral valve) versus pressure half-time technique (PHT, measured during entire diastolic phase) in mitral valve repair surgery (MVR) would be different.

Methods

Patients who had undergone MVR were retrospectively reviewed, and two different observers measured the MVAs using PHT and 3D planimetry technique. The MVAs derived from recorded medical data, using PHT and 3D planimetry technique were abbreviated to MVA-PHT1 and MVA-3D1, and data from the PHT and 3D planimetry techniques by observer A and observer B were determined as MVA-PHT2 and MVA-3D2, and MVA-PHT3 and MVA-3D3, respectively. The MVA derived by post-operative transthoracic echocardiography using the PHT technique was determined as MVA-TTE.

Results

Intraclass correlation coefficients were 0.90 for the intra-operative PHT technique and 0.78 for the intra-operative 3D planimetry technique. MVA-3D1 (2.91 ± 0.65 cm²), MVA-3D2 (3.00 ± 0.63 cm2) and MVA-3D3 (2.97 ± 0.88 cm²) were significantly larger than MVA-TTE (2.40 ± 0.59 cm²), but intra-operative MVAs-PHT were not. The biases and precisions were larger, and the correlation coefficients were lower in 3D planimetry technique compared with PHT technique.

Conclusions

MVA measured by 3D planimetry technique with TEE at the intra-operative post-MVR period was seemed to be larger than that measured by the PHT technique with TTE at the post-operative period. However, it did not mean that the 3D planimetry technique was inaccurate but needs cautions at determination of MVA using different techniques.

Mitral valve re-repair in an adolescent patient with prosthetic ring endocarditis: posterior leaflet augmentation and posterior strip annuloplasty

Endocarditis after mitral valve (MV) annuloplasty is uncommon. The ring used in MV annuloplasty is often inadequate because it opposes the growth of the MV leaflets and annulus. We report a 15-year-old male that required redo surgery for prosthetic ring endocarditis 40 months after a previous MV annuloplasty. After the previous ring was removed, the undergrown posterior leaflet was repaired with pericardial augmentation and the posterior annulus was stabilized with a Mitra-Lift® supra-annular strip to preserve a flexible valve orifice and allow the anterior MV annulus and the commissures to grow in relation to body size.