Midterm outcomes of chordal cutting in combination with downsized ring annuloplasty for ischemic mitral regurgitation

Long-term outcomes of left ventricular posterior wall plication for ischemic mitral regurgitation

Purpose

To evaluate the early and long-term outcomes of left ventricular posterior wall plication for ischemic mitral regurgitation.

Methods

Patients with ischemic mitral regurgitation who underwent left ventricular posterior wall plication via right-sided left atriotomy at our institution between 2010 and 2020 were retrospectively reviewed. Cases with normal cardiac function, left ventricular end-systolic diameter < 50 mm, and left ventriculotomy approach were excluded.

Results

The mean follow-up period was 5.3 years [standard deviation (SD) = 3.5], with a maximum of 10 years. Among the 21 patients enrolled, 9 had New York Heart Association (NYHA) class ≥ III. Three patients required preoperative inotrope support, while two preoperative ventilator support. The mean left ventricular ejection fraction was 31.4% (SD: 8.6), and 16 patients had mitral regurgitation grade ≥ III. All patients underwent coronary artery bypass grafting and mitral annuloplasty. Concomitant surgeries included 11 chordae cutting and 3 tricuspid annuloplasties. One in-hospital death occurred due to sepsis. At the follow-up, echocardiographic data showed significant improvement in cardiac dilation and function and good control of mitral regurgitation. The serum brain natriuretic peptide level was significantly reduced, and 85% of patients improved to NYHA class I. Four deaths occurred later due to sudden, unknown causes. The 5- and 8-year survival rates were 60.2% and 46.8%, respectively, and the 5- and 8-year hospitalization rates due to heart failure were 14.9% and 21.3%, respectively.

Conclusion

The long-term outcomes of left ventricular posterior wall plication were satisfactory for controlling heart failure and improving survival rate and patient prognosis.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12055-023-01527-2.

Ciddi restriksiyonu olan mitral anterior liflet için kordal ayırma

Functional mitral regurgitation (MR) is usually caused by cardiomyopathy. Herein, we present chordal cutting and ring annuloplasty due to severely restricted anterior leaflet. Seventy-seven years old, male patient suffering shortness of breath had the diagnosis of severe mitral regurgitation and coronary artery disease. Preoperative echocardiography showed reduced ejection fraction and severe central jet due to tethering of secondary chordae. Restricted chordae were resected by transverse aortotomy, saphenous graft bypass was done, and semi-rigid ring was implanted. Postoperative echocardiography showed no residual regurgitation, excellent mobility of anterior leaflet. Chordal cutting seems to be an effective technique to treat functional MR caused by the restriction of anterior leaflet

Surgical mitral valve repair technique considerations based on the available evidence

Mitral valve regurgitation is the second most common valve disease in the western world. Surgery is currently the best tool for generating a long-lasting elimination of mitral valve regurgitation. However, the mitral valve apparatus is a complex anatomical and functional structure, and repair results and durability show substantial heterogeneity. This is not only due to differences in the underlying mitral valve regurgitation pathophysiology but also due to differences in repair techniques. Repair philosophies differ substantially from one surgeon to the other, and consensus for the technically best repair strategy has not been reached yet. We had previously addressed this topic by suggesting that ring sizing is "voodoo". We now review the available evidence regarding the various repair techniques described for structural and functional mitral valve regurgitation. Herein, we illustrate that for structural mitral valve regurgitation, resuspension of prolapsing valve segments or torn chordae with polytetrafluoroethylene sutures and annuloplasty can generate the most durable results paired with the best achievable hemodynamics. For functional mitral valve regurgitation, the evidence suggests that annuloplasty alone is insufficient in most cases to generate durable results, and additional subvalvular strategies are associated with improved durability and possibly improved clinical outcomes. This review addresses current strategies but also implausibilities in mitral valve repair and informs the mitral valve surgeon about the current evidence. We believe that this information may help improve outcomes in mitral valve repair as the heterogeneity of mitral valve regurgitation pathophysiology does not allow a one-size-fits-all concept.

Surgical Treatment of Ischemic Mitral Regurgitation: Valve Repair Versus Replacement

PURPOSE OF REVIEW

Ischemic mitral regurgitation (MR), which occurs in about 20-30% patients with a prior myocardial infarction, is associated with worsening heart failure and an increase in cardiovascular mortality. It should be treated surgically if certain hemodynamic severity criteria are met and in patients who continue to experience symptoms of heart failure despite optimal medical therapy. However, current guidelines do not suggest which of the available approaches to mitral valve surgery-mitral valve (MV) repair or replacement (MVR) is superior for this indication. While MV repair is reported to confer improved survival, MVR may provide higher rates of freedom from recurrent MR. This article attempts to provide the reader with a comprehensive review and comparison of current techniques of mitral valve surgery in patients with severe ischemic MR.

RECENT FINDINGS

The first randomized trial to compare MV repair versus MVR in patients with severe ischemic MR, the Cardiothoracic Surgical Trials Network (CTSN) trial, was recently concluded and reported no significant difference in the primary outcome of left ventricular end systolic volume index between the two approaches at either 1- or 2-year follow-ups. Data comparing approaches of MV repair and MVR for ischemic MR is largely limited to small, non-randomized retrospective trials. The only randomized trial data to examine this issue suggested no difference in mortality with either MVR or MV repair; however, MVR was shown to be consistently associated with higher rates of MR recurrence. Certain echocardiographic features have been reported to predict poor outcomes with MVR and may help refine the selection of the surgical approach in the individual patient.

Comparison of mitral competence after mitral repair with papillary muscle approximation versus papillary muscle relocation for functional mitral regurgitation

The purpose of this study was to evaluate the surgical results of papillary muscle approximation (PMA) and papillary muscle relocation (PMR) for functional mitral regurgitation (FMR) and to compare the effects of both procedures on the change in mitral regurgitation (MR) and echocardiogram parameters associated with tethering. Eighteen patients with moderate-to-severe FMR (MR grade ≥2) who underwent PMA or PMR were retrospectively analyzed. Underlying diseases were ischemic cardiomyopathy, idiopathic dilated cardiomyopathy, and aortic valve disease for seven, six, and five patients, respectively. Eleven patients underwent PMA and seven patients underwent PMR. Mitral annuloplasty and surgical ventricular restoration were performed concomitantly for 18 and 6 patients, respectively. None of these patients died in the hospital. Three patients died during the late period; two of these deaths were cardiac related. The rate of 3 years of freedom from cardiac-related death was 89%. After a mean follow-up of 33 months, MR grade was significantly improved compared with preoperative values (3.0 ± 0.8 to 0.7 ± 1.2; p < 0.01). Recurrence of MR grade ≥2 occurred in three patients and the rate of 3 years of freedom from recurrence of MR grade ≥2 was 87%. During follow-up, tenting height (1.1 ± 0.2 to 0.7 ± 0.2 cm; p < 0.01), tenting area (2.2 ± 0.7 to 0.9 ± 0.5 cm²; p < 0.01), and anterior leaflet tethering angle (39° ± 11° to 26° ± 8°; p < 0.01) were significantly improved compared with preoperative values. Posterior leaflet tethering angle significantly deteriorated from 40° ± 7° to 53° ± 15° (p < 0.01); however, it did not further deteriorate compared with the early postoperative value of 55° ± 16° (p = 0.7). There was no difference in echocardiogram parameters associated with tethering between PMA and PMR throughout the observation period. Both methods were associated with lasting relief of MR and reverse left ventricular remodeling. There was no difference between PMA and PMR regarding the effect on mitral valve competence. Both methods allowed durable mitral repair and good clinical outcomes.

A Meta-Analysis of Ring Annuloplasty Versus Combined Ring Annuloplasty and Subvalvular Repair for Moderate-to-Severe Functional Mitral Regurgitation

BACKGROUND

A ring annuloplasty (Ring) for moderate-to-severe functional mitral regurgitation (MR) is associated with suboptimal outcomes, and adjunctive subvalvular repair techniques (Ring + Subvalvular) have been advocated to improve repair durability. However, the outcomes of this strategy are not clearly defined.

METHODS

A systematic review was performed to identify studies that compared a Ring versus Ring + Subvalvular repair for the treatment of moderate-to-severe functional MR. A meta-analysis was conducted on clinical outcomes and echocardiographic measures of follow-up MR and left ventricular reverse remodeling. Risk ratio (RR) and mean difference (MD) were calculated by the Mantel-Haenszel and Inverse Variance methods under a fixed or random effects model, as appropriate.

RESULTS

Seven non-randomized studies were identified, with a total of 531 patients (Ring = 301, Ring + Subvalvular = 230). At follow-up (range 30-47 months), a Ring + Subvalvular repair was associated with a lower mortality (RR = 0.59, 95%confidence interval [CI] 0.37-0.94, p = 0.03), greater freedom from moderate or greater MR (RR = 0.44, 95%CI 0.27-0.72, p = 0.001), and improved left ventricular end-diastolic diameter (MD = -3.49 mm, 95%CI -5.45 to -1.53, p = 0.0005) and New York Heart Association functional class (MD = -0.25, 95%CI -0.42 to -0.08, p = 0.004). A trend toward a reduced risk of reoperation for recurrent MR was noted with a combined Ring + Subvalvular repair (RR = 0.28, 95%CI 0.06-1.22, p = 0.09). Finally, a Ring + Subvalvular repair did not impact operative mortality or follow-up left ventricular ejection fraction.

CONCLUSION

A combined Ring + Subvalvular repair for moderate-to-severe functional MR can be safely performed, and may improve mid-term outcomes, as compared with Ring alone.