Edge-to-edge with partial band mitral valve repair compared to replacement and undersized restrictive annuloplasty for ischemic mitral regurgitation

Objective

Evidence supports replacement over repair for ischemic mitral regurgitation due to improved durability; however, the latter often involves an undersized ring annuloplasty that does not include edge-to-edge approximation. The objective of this study was to evaluate the outcomes of replacement, edge-to-edge leaflet approximation with mild-undersized annuloplasty and undersized ring annuloplasty for ischemic mitral regurgitation.

Methods

This is a single-center retrospective study of patients undergoing mitral surgery for moderate-severe or greater ischemic mitral regurgitation, between 2004 and 2020, with mild-undersized annuloplasty, mitral valve replacement, or undersized restrictive annuloplasty (undersized ring annuloplasty). The primary outcome was all-cause mortality. Secondary outcomes included first recurrence of mitral regurgitation, heart failure hospitalization, and composite of valve-related events (bleeding, thromboembolism, endocarditis, and mitral valve reoperation).

Results

There were 121, 93, and 78 patients in the mitral valve replacement, mild-undersized annuloplasty, and undersized restrictive annuloplasty groups, respectively, with a median follow-up of 3.1, 5.9, and 3.8 years, respectively. Both mitral valve replacement (hazard ratio, 1.87; 95% CI, 1.029-3.415) and undersized restrictive annuloplasty (hazard ratio, 2.73; 95% CI, 1.480-5.061) were associated with worse survival compared with mild-undersized annuloplasty. At 2 years, the rate of mild-moderate mitral regurgitation was greater in the mild-undersized annuloplasty group compared with the mitral valve replacement group (P = .001) but less than in the undersized restrictive annuloplasty group (P = .001). The rate of recurrent moderate or greater mitral regurgitation at 2 years was similar between mild-undersized annuloplasty and mitral valve replacement groups but significantly higher after undersized restrictive annuloplasty (P < .0001). Mitral valve replacement and undersized restrictive annuloplasty were associated with a significant increase in the incidence of first heart failure hospitalization compared with mild-undersized annuloplasty (P < .001 and P = .001, respectively). Mitral valve replacement was associated with an increased incidence of valve-related events compared with mild-undersized annuloplasty (P = .002).

Conclusions

Surgical edge-to-edge approximation in addition to a mild-undersizing annuloplasty offers similar durability compared with replacement, with a lower rate of hospitalization for heart failure, and may confer a survival advantage.

Unmet needs in valvular heart disease

Valvular heart disease (VHD) is the next epidemic in the cardiovascular field, affecting millions of people worldwide and having a major impact on health care systems. With aging of the population, the incidence and prevalence of VHD will continue to increase. However, VHD has not received the attention it deserves from both the public and policymakers. Despite important advances in the pathophysiology, natural history, management, and treatment of VHD including the development of transcatheter therapies, VHD remains underdiagnosed, identified late, and often undertreated with inequality in access to care and treatment options, and there is no medication that can prevent disease progression. The present review article discusses these gaps in the management of VHD and potential actions to undertake to improve the outcome of patients with VHD.

Natural History of Mitral Annulus Calcification and Calcific Mitral Valve Disease

BACKGROUND

The natural history of mitral annular calcification (MAC) and risk for developing calcific mitral valve disease (CMVD) has been poorly defined. We sought to evaluate the progression rate of MAC and of the development of CMVD.

METHODS

Patients with MAC and paired echocardiograms at least one year apart between 2005 and 2019 were included. Progression rates from mild/moderate to severe MAC and to CMVD (defined as severe MAC and significant mitral stenosis and/or regurgitation) were assessed, along with potential association with sex.

RESULTS

A total of 11,605 patients (73±10years, 51%male) with MAC (78% mild, 17% moderate, 5% severe) were included and had a follow up echocardiogram at 4.2±2.7years. In patients with mild/moderate MAC, 33% presented with severe MAC at 10 years. The rate of severe MAC was higher in females than in males (41% vs. 24%, P<0.001, HR=1.3, P<0.001) and in patients with moderate vs. mild MAC (71% vs. 22%, P<0.001, HR=6.1, P<0.001). At 10 years 10% presented with CMVD (4%, 23% and 60% in patients with mild, moderate, and severe MAC respectively) and was predicted by female sex (15% vs. 5%, P<0.0001), even after adjustment for MAC severity (HR=1.9, P<0.001).

CONCLUSION

In this large cohort of patients with MAC, progression to severe MAC was common and frequently results in CMVD. Female sex was associated with higher progression rates. MAC and CMVD are expected to dramatically increase as the population ages highlighting the importance of a better understanding of the pathophysiology of MAC in order to develop effective preventive medical therapies.

Systematic Approach to the Calcified Mitral Valve Apparatus at Time of Mitral Valve Replacement

Mitral annular calcification (MAC) represents a surgical challenge to mitral valve replacement. The presence of MAC at the time of mitral valve replacement is associated with perivalvular leak and atrial-ventricular groove injury. Although percutaneous and hybrid approaches may offer alternatives to surgical mitral valve replacement, the early and late results from these techniques remain unknown. As such, the surgical management of MAC remains relevant in the contemporary treatment of patients with MAC. Herein, we present a systematic approach to the management of MAC at the time of mitral valve replacement.

Impact of sex on outcomes after percutaneous repair of functional mitral valve regurgitation

BACKGROUND

The role of percutaneous repair of functional mitral regurgitation (MR) is evolving. Left ventricle remodeling is known to be different between men and women; however, outcomes following percutaneous repair of functional MR have not considered the impact of sex.

METHODS

Between 2012 and 2018, 175 patients underwent percutaneous repair of functional MR with the Mitra Clip NT/NTR (Abbott) at our institution. Patients were assessed in a dedicated clinic with a follow-up that averaged 0.7 ± 1.2 years and extended to 5.7 years.

RESULTS

Men had a larger body surface area than women (p < .001), and were more likely than women to have diabetes preoperatively (p = .02). There were no deaths or instances of single leaflet detachment. Immediate postprocedure MR was ≤2+ in 158 (90%) with a mean trans-mitral valve repair gradient of 3.4 ± 1.0 and 3.5 ± 2.1 mmHg, respectively for women and men (p = .8). One- and 2-year freedom from MR ≥3+ was 86.0 ± 3.5% and 77.6 ± 5.1%, respectively. After adjusting for differences between male and female patients, women were more likely to have recurrent MR ≥3+ (hazard ratio, 4.7; 95% confidence interval, 1.2-18.4; p = .03). Upon adjusted analysis, there was also no association between gender and survival (p = .2). One- and 2-year survival was 69.8 ± 4.3% and 54.3 ± 5.5%, respectively.

CONCLUSION

Women are more likely to have recurrent severe MR after percutaneous repair of functional MR. The mechanism for this remains undetermined.

Management and Outcome of Patients Admitted With Tricuspid Regurgitation in France

BACKGROUND

Growing evidence shows a major outcome impact and undertreatment of tricuspid regurgitation (TR), but large and comprehensive contemporary reports of management and outcome at the nationwide level are lacking.

METHODS

We gathered all consecutive patients admitted with a diagnosis of likely functional TR in 2014-2015 in France from the Programme de Médicalisation des Systèmes d'Information national database and collected rate of surgery, in-hospital mortality, 1-year mortality, or heart failure (HF) readmission rates.

RESULTS

In 2014-2015, 17,676 consecutive patients (75 ± 14 years of age, 51% female) were admitted with a TR diagnosis. Charlson index was ≥ 2 in 56% of the population and 46% presented with HF. TR was associated with prior cardiac surgery, ischemic/dilated cardiomyopathy, or mitral regurgitation in 73% of patients. Only 10% of TR patients overall and 67% of those undergoing mitral valve surgery received a tricuspid valve intervention. Among the 13,654 (77%) conservatively managed patients, in-hospital mortality, 1-year mortality, and 1-year mortality or HF readmission rates were 5.1%, 17.8%, and 41%, respectively, overall, and 5.3%,17.2%, and 37%, respectively, among those with no underlying medical conditions (8-fold higher than predicted for age and gender).

CONCLUSIONS

This nationwide cohort of patients admitted with TR included elderly patients with frequent comorbidities/underlying cardiac diseases. In patients conservatively managed, mortality and morbidity were considerably high over a short time span. Despite this poor prognosis, only 10% of patients underwent a tricuspid valve intervention. These nationwide data showing a considerable risk and potential underuse of treatment highlight the critical need to develop strategies to improve the management and outcomes of TR patients.

Presentation and outcomes of mitral valve surgery in France in the recent era: a nationwide perspective

Objectives

Unbiased information regarding the surgical management of patients with mitral regurgitation (MR) at the nationwide level are scarce and mainly US-based. The Programme de Médicalisation des Systèmes d’Information, a mandatory national database, offers the unique opportunity to assess the presentation and outcomes of all consecutive mitral valve (MV) surgeries performed in France in the contemporary era.

Methods

We collected all MV surgeries performed for MR in France in 2014–2016. MR aetiology was classified as degenerative (DMR), secondary (SMR) or Other (rheumatic or congenital disease and infective endocarditis).

Results

During the 3-year period, 18 167 MV surgeries were performed in France (55% repair and 45% replacement; 52% isolated). Age was 66±12 years and 59% were male. Aetiology was DMR in 42%, SMR in 16% and other in 42% including 19% with uncertain aetiologies. Overall, in-hospital mortality was 6.5% and increased with age, female gender, Charlson Comorbidity Index, type of surgery (replacement vs repair), associated surgery (combined vs isolated) and MR aetiology (all p<0.01). In-hospital mortality and rate of death/readmission for heart failure (HF) at 1 year were 3.4% and 13%, respectively for DMR (2.4% and 11% for isolated DMR) and 7.8% and 27%, respectively for SMR (5.5% and 23% for isolated SMR). Repair rate was 55% overall, 68% in DMR and 72% for isolated DMR surgery (70% of all DMR). Repair rates decreased with age, Charlson Comorbidity Index and female sex (all p<0.0001).

Conclusion

In this cross-sectional contemporary prospective nationwide database, in-hospital mortality and 1 year rate of death and HF readmission were considerable overall and in all subsets. Repair rates were suboptimal overall especially in the elderly and women subsets. These results underline the need to develop strategies to improve management and outcomes of patients with both DMR and SMR.

A randomized surgical trial of mitral valve repair with leaflet resection versus leaflet preservation on functional mitral stenosis – primary results of the CAMRA CardioLink-2 trial

Background

The gold standard treatment for mitral valve regurgitation due to prolapse involves surgery with annuloplasty and either leaflet resection or leaflet preservation, with placement of artificial neochordae. It has been suggested that leaflet resection may be prone to functional mitral stenosis, whereby a patient may have a higher mitral gradient at peak exercise compared to a leaflet preservation strategy. Although both techniques are widely used, there has been no prospective randomized study conducted to compare these two techniques, particularly in regard to functional mitral stenosis.

Methods

A total of 104 patients with posterior leaflet prolapse were randomized to undergo mitral repair with either leaflet resection (N=54) or leaflet preservation (N=50) at 7 specialized Canadian cardiac centers. Patient age, proportion of female patients, and mean Society of Thoracic Surgeons risk score was 63.9±10.4 years, 19%, and 1.4% for those who underwent leaflet resection, and 66.3±10.8 years, 16%, and 1.9% for those who underwent leaflet preservation, respectively. The primary endpoint was the mean trans-mitral repair gradient at peak exercise 12-months after repair.

Results

Baseline characteristics were similar between the groups. At 12-months, the mean trans-mitral repair gradient at peak exercise in patients who underwent leaflet resection and preservation was 9.1±5.2 and 8.3±3.3 mmHg (P=0.4), respectively. The two groups had similar mean mitral valve gradient at rest (3.2±1.9 mmHg following resection and 3.1±1.1 mmHg following leaflet preservation, P=0.7). There was no between-group difference for the 6-minute walk distance (451±147 m and 481±95 m for the resection and preservation groups, respectively, P=0.3).

Conclusion

We report the first prospective surgical randomized trial to evaluate commonly used mitral valve repair strategies for posterior leaflet prolapse. Leaflet resection and leaflet preservation both yield acceptable results with no difference in postoperative valve gradient and functional status 12-months after surgical mitral valve repair.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Heart and Stroke Foundation of Canada

Transcatheter Mitral Valve Repair in Cardiogenic Shock and Mitral Regurgitation: A Patient-Level, Multicenter Analysis

OBJECTIVES

The aim of this study was to evaluate the outcome of transcatheter mitral valve repair (TMVr) in patients with cardiogenic shock and significant mitral regurgitation (MR).

BACKGROUND

Patients in cardiogenic shock with severe MR have a poor prognosis in the setting of conventional medical therapy. Because of its favorable safety profile, TMVr is being increasingly used as an acute therapy in this population, though its efficacy remains unknown.

METHODS

A multicenter, collaborative, patient-level analysis was conducted. Patients with cardiogenic shock and moderate to severe (3+) or severe (4+) MR who were not surgical candidates were treated with TMVr. The primary outcome was in-hospital mortality. Secondary outcomes included 90-day mortality, heart failure (HF) hospitalization, and the combined event rate of 90-day mortality and HF hospitalization following dichotomization by TMVr device success.

RESULTS

Between January 2011 and February 2019, 141 patients across 14 institutions met the inclusion criteria. In-hospital mortality occurred in 22 patients (15.6%), at 90 days in 38 patients (29.5%), and at one year in 55 patients (42.6%). Median length of hospital stay following TMVr was 10 days (interquartile range: 6 to 20 days). HF hospitalization occurred in 26 patients (18.4%) at a median of 73 days (interquartile range: 26 to 546 days). When stratified by TMVr procedural results, successful TMVr reduced rates of in-hospital mortality (hazard ratio [HR]: 0.36; 95% confidence interval [CI]: 0.13 to 0.98; p = 0.04), 90-day mortality (HR: 0.36; 95% CI: 0.16 to 0.78; p = 0.01), and the composite of 90-day mortality and HF hospitalization (HR: 0.41; 95% CI: 0.19 to 0.90; p = 0.03).

CONCLUSIONS

TMVr may improve short- and intermediate-term mortality in high-risk patients with cardiogenic shock and moderate to severe MR. Randomized studies are needed to definitively establish MR as a therapeutic target in patients with cardiogenic shock.

Randomized, Controlled Trial Comparing Mitral Valve Repair With Leaflet Resection Versus Leaflet Preservation on Functional Mitral Stenosis

Background:

Equipoise exists between the use of leaflet resection and preservation for surgical repair of mitral regurgitation caused by prolapse. We therefore performed a randomized, controlled trial comparing these 2 techniques, particularly in regard to functional mitral stenosis.

Methods:

One hundred four patients with degenerative mitral regurgitation surgically amenable to either leaflet resection or preservation were randomized at 7 specialized cardiac surgical centers. Exclusion criteria included anterior leaflet or commissural prolapse, as well as a mixed cause for mitral valve disease. Using previous data, we determined that a sample size of 88 subjects would provide 90% power to detect a 5–mm Hg difference in mean mitral valve gradient at peak exercise, assuming an SD of 6.7 mm with a 2-sided test with α=5% and 10% patient attrition. The primary end point was the mean mitral gradient at peak exercise 12 months after repair.

Results:

Patient age, proportion who were female, and Society of Thoracic Surgeons risk score were 63.9±10.4 years, 19%, and 1.4±2.8% for those who were assigned to leaflet resection (n=54), and 66.3±10.8 years, 16%, and 1.9±2.6% for those who underwent leaflet preservation (n=50). There were no perioperative deaths or conversions to replacement. At 12 months, moderate mitral regurgitation was observed in 3 subjects in the leaflet resection group and 2 in the leaflet preservation group. The mean transmitral gradient at 12 months during peak exercise was 9.1±5.2 mm Hg after leaflet resection and 8.3±3.3 mm Hg after leaflet preservation ( P =0.43). The participants had similar resting peak (8.3±4.4 mm Hg versus 8.4±2.6 mm Hg; P =0.96) and mean resting (3.2±1.9 mm Hg versus 3.1±1.1 mm Hg; P =0.67) mitral gradients after leaflet resection and leaflet preservation, respectively. The 6-minute walking distance was 451±147 m for those in the leaflet resection versus 481±95 m for the leaflet preservation group ( P =0.27).

Conclusions:

In this adequately powered randomized trial, repair of mitral prolapse with either leaflet resection or leaflet preservation was associated with similar transmitral gradients at peak exercise at 12 months postoperatively. These data do not support the hypothesis that a strategy of leaflet resection (versus preservation) is associated with a risk of functional mitral stenosis.

Registration:

URL: https://www.clinicaltrials.gov ; Unique identifier NCT02552771.

Dismal Outcomes and High Societal Burden of Mitral Valve Regurgitation in France in the Recent Era: A Nationwide Perspective

Background Although US recent data suggest that mitral regurgitation (MR) is severely undertreated and carries a poor outcome, population-based views on outcome and management are limited. We aimed to define the current treatment standards, clinical outcomes, and costs related to MR at the nationwide level. Methods and Results In total, 107 412 patients with MR were admitted in France in 2014 to 2015. Within 1 year, 8% were operated and 92% were conservatively managed and constituted our study population (68% primary MR and 32% secondary MR). The mean age was 77±15 years; most patients presented with comorbidities. In-hospital and 1-year mortality rates were 4.1% and 14.3%, respectively. Readmissions were common (63% at least once and 37% readmitted ≥2 times). Rates of 1-year mortality or all-cause readmission and 1-year mortality or heart failure readmission were 67% and 34%, respectively, and increased with age, Charlson index, heart failure at admission, and secondary MR etiology; however, the event rate remained notably high in the primary MR subset (64% and 28%, respectively). The mean costs of hospital admissions and of readmissions were 5345±6432 and 10 080±10 847 euros, respectively. Conclusions At the nationwide level, MR was a common reason for admission and affected an elderly population with frequent comorbidities. Less than 10% of patients underwent a valve intervention. All subsets of patients who were conservatively managed incurred high mortality and readmissions rates, and MR represented a major societal burden with an extrapolated annual cost of 350 to 550 million euros (390-615 million US dollars). New strategies to improve the management and outcomes of patients with both primary and secondary MR are critical and warranted.

Direct Implant of a Transcatheter Aortic Valve Prosthesis for Prosthetic Mitral Valve Endocarditis

We describe the case of a 64-year-old woman presenting with severe prosthetic mitral valve endocarditis 1 year after coronary artery bypass grafting and double valve replacement. Echocardiogram revealed high-pressure gradients through the bioprosthetic MV with a bulky vegetation. As the patient had presented operative difficulties due to severe mitral annular calcification, was in renal failure, and in the absence of any perivalvular involvement, an open-heart surgical catheter-based valve implantation was successfully performed after removal of the infected leaflets, leaving the stent frame and sewing cuff behind. Albeit controversial, this case represents an alternative approach for select high-risk reoperative mitral cases with mitral annular calcification.

Presentation and management of calcific mitral valve disease

Little is known about the prevalence, presentation and management of calcific mitral valve disease (CMVD). We identified 167 patients (80 ± 10 years; 79% women) with significant CMVD undergoing transthoracic echocardiography at our institution in 2016. Patients presented with significant co-morbidities, 47% had moderate/severe mitral stenosis, 38% had 3+/4+ mitral regurgitation and 15% had a combination of both. Fifty-eight percent were symptomatic. Most symptomatic patients were managed conservatively and incurred higher mortality and mortality/heart failure admission rates than those managed surgically. These data highlight the importance of gaining mechanistic insights into CMVD to prevent its occurrence and avoid the need for high-risk surgery, which is seldom performed in contemporary practice.

Can heat therapy help patients with heart failure?

To review and analyze the clinical outcomes of thermal therapy (≤1.4°C increase in core body temperature) in patients with heart failure (HF). A systematic review and meta-analysis regarding the effects of thermal therapy on HF was done by searching PubMed, Ovid Medline, Ovid Embase, Scopus, and internal databases up to date (2019). Improvement in the New York Heart Association (NYHA) class: Ten studies with 310 patients showed significant improvement in NYHA class. Only 7 among 40 patients remained in Class IV and 99 patients in Class III from 155 patients. Increased patients in lower classes indicate that more patients showed improvement. Sixteen studies on 506 patients showed an overall improvement of 4.4% of left ventricular ejection fraction (LVEF). Four studies reported improved endothelial dysfunction by 1.7% increase in flow-mediated dilation (FMD) on 130 patients. Reduction in blood pressure: Thermal therapy reduced both systolic blood pressure (SBP) and diastolic blood pressure by 3.1% and 5.31%, respectively, in 431 patients of 15 studies. Decrease in cardiothoracic ratio (CTR): Eight studies reported an average of 5.55% reduction of CTR in a total of 347 patients. Improvement in oxidative stress markers: Plasma brain natriuretic peptide (BNP) levels significantly decreased (mean difference of 14.8 pg/dL) in 303 patients of 9 studies. Improvement of quality of life: Among 65 patients, thermal therapy reduced cardiac death and rehospitalization by 31.3%. A slight increase in core body temperature is a promising, noninvasive, effective, and complementary therapy for patients with HF. Further clinical studies are recommended.

EDUCATIONAL SERIES ON THE SPECIALIST VALVE CLINIC: Challenges in the diagnosis and management of valve disease: the case for the specialist valve clinic

Valvular heart disease (VHD) is responsible for a major societal and economic burden. Incidence and prevalence of VHD are high and increase as the population ages, creating the next epidemic. In Western countries, the etiology is mostly degenerative or functional disease and strikes an elderly population with multiple comorbidities. Epidemiological studies have shown that VHD is commonly underdiagnosed, leading to patients presenting late in their disease course, to an excess risk of mortality and morbidity and to a missed opportunity for intervention. Once diagnosed, VHD is often undertreated with patients unduly denied intervention, the only available curative treatment. This gap between current recommendations and clinical practice and the marked under-treatment is at least partially related to poor knowledge of current National and International Societies Guidelines. Development of a valvular heart team involving multidisciplinary valve specialists including clinicians, imaging specialists, interventional cardiologists and surgeons is expected to fill these gaps and to offer an integrated care addressing all issues of patient management from evaluation, risk-assessment, decision-making and performance of state-of-the-art surgical and transcatheter interventions. The valvular heart team will select the right treatment for the right patient, improving cost-effectiveness and ultimately patients' outcomes.

Perioperative THR-184 and AKI after Cardiac Surgery

AKI after cardiac surgery is associated with mortality, prolonged hospital length of stay, use of dialysis, and subsequent CKD. We evaluated the effects of THR-184, a bone morphogenetic protein-7 agonist, in patients at high risk for AKI after cardiac surgery. We conducted a randomized, double-blind, placebo-controlled, multidose comparison of the safety and efficacy of perioperative THR-184 using a two-stage seamless adaptive design in 452 patients between 18 and 85 years of age who were scheduled for nonemergent cardiac surgery requiring cardiopulmonary bypass and had recognized risk factors for AKI. The primary efficacy end point was the proportion of patients who developed AKI according to Kidney Disease Improving Global Outcomes (KDIGO) criteria. The proportion of patients who developed AKI within 7 days of surgery was similar in THR-184 treatment groups and placebo groups (range, 74%-79%; P=0.43). Prespecified secondary end point analysis did not show significant differences in the severity of AKI stage (P=0.53) or the total duration of AKI (P=0.44). A composite of death, dialysis, or sustained impaired renal function by day 30 after surgery did not differ between groups (range, 11%-20%; P=0.46). Safety-related outcomes were similar across all treatment groups. In conclusion, compared with placebo, administration of perioperative THR-184 through a range of dose exposures failed to reduce the incidence, severity, or duration of AKI after cardiac surgery in high-risk patients.

The inflammatory response to cardiopulmonary bypass: a therapeutic overview

The demographic of cardiac surgery patients continues to evolve to include older, sicker candidates, all the while maintaining an expectation of excellent outcomes. These latter results can only be achieved by the parallel advancement and re-examination of the technology of cardiopulmonary bypass (CPB); the key tool used daily by surgical teams worldwide. In this review, we will provide an overview of integrated therapeutic strategies that can be utilized to minimize the complex and myriad changes related to inflammation after CPB with the understanding that this may abrogate the detrimental end-organ and systemic effects of blood activation. Therapeutic strategies specifically related to the technology can be classified into those targeting biomaterial dependent or independent processes. The former can be addressed by the utilization of currently available biocompatible surfaces such as with heparin-coated circuits, phosphorylcholine-coated circuits (‘biomembrane mimicry’) and circuits composed of copolymers containing surface-modifying additives. The most important strategies related to biomaterial independent activation include the modification of techniques related to cardiotomy blood management and blood filtration. Finally, all of these strategies must be integrated and tailored with complementary pharmacologic agents such as aprotinin and steroids to optimize anti-inflammatory synergism. Only if we are armed with a comprehensive knowledge of the molecular and cellular basis for these strategies will we be able to continue to evolve our treatment in parallel with our patients to achieve these goals.

Left Ventricular Outflow Tract Obstruction and Systolic Anterior Motion of the Mitral Valve in the Absence of Hypertrophic Cardiomyopathy

Systolic anterior motion of the mitral valve is a mechanism for the development of left ventricular outflow tract (LVOT) obstruction. While often associated with left ventricular hypertrophy (LVH), a case is reported of symptomatic LVOT obstruction due to intrinsic mitral valve pathology in the absence of hypertrophy or cardiomyopathy. This case highlights the importance of recognizing isolated mitral valve pathology as a treatable cause of LVOT obstruction.

The evolution of mitral valve prolapse: insights from the Framingham Heart Study

The Framingham Heart Study group has described the non-diagnostic variants may evolve into mitral valve prolapse over time. These non-diagnostic variants include minimal systolic displacement, and abnormal anterior coaptation which is measured on surface echocardiography. Computed tomography and cardiac magnetic resonance imaging are evolving and can assess the degree of mitral regurgitation (MR); imaging techniques aside, genetic and proteomic detection of mitral prolapse is also evolving. However, the genetic basis for mitral prolapse is complex and likely involves multiple genetic loci. The same is also true for work determining possible biomarkers associated with mitral prolapse. The present study may be useful in counseling patients with a family history of mitral prolapse. Registry data is therefore of paramount importance in providing unbiased insight into this common disease.

Severe Lower Limbs Lymphedema Following Breast Carcinoma Treatment Revealing Radiation-Induced Constrictive Pericarditis

In patients treated for breast carcinoma, unilateral lymphedema of the upper limb is usual. However, to the authors’ knowledge, lower limb lymphedema has never been reported as a complication of breast carcinoma therapy. They report here the first case of a radiation-induced constrictive pericarditis revealed by severe lower limbs lymphedema. A 60-year-old woman was treated for left breast carcinoma with quadrantectomy, axillary lymphadenectomy, and combined radio chemotherapy (60 grays). Three and a half years later she suffered from a diffuse and increasing lower limbs lymphedema, which became huge and disabling. Radiation-induced constrictive pericarditis was evidenced by right cardiac cavities catheterization. A dramatic improvement was rapidly obtained after pericardectomy. Histopathologic analysis of the pericardium did not reveal neoplastic cells. Radiation-induced constrictive pericarditis is usually responsible for lower limbs edema, but lymphedema is exceptional. This case highlights the need to search for a constrictive pericarditis also in the case of lower limbs lymphedema, particularly in a patient treated with mediastinal radiotherapy or combined radio chemotherapy.

Long-Term Follow-Up of Outcomes With F-18-Fluorodeoxyglucose Positron Emission Tomography Imaging–Assisted Management of Patients With Severe Left Ventricular Dysfunction Secondary to Coronary Disease

Background—

Whether viability imaging can impact long-term patient outcomes is uncertain. The PARR-2 study (Positron Emission Tomography and Recovery Following Revascularization) showed a nonsignificant trend toward improved outcomes at 1 year using an F-18-fluorodeoxyglucose positron emission tomography (PET)–assisted strategy in patients with suspected ischemic cardiomyopathy. When patients adhered to F-18-fluorodeoxyglucose PET recommendations, outcome benefit was observed. Long-term outcomes of viability imaging–assisted management have not previously been evaluated in a randomized controlled trial.

Methods and Results—

PARR-2 randomized patients with severe left ventricular dysfunction and suspected CAD being considered for revascularization or transplantation to standard care (n= 195) versus PET-assisted management (n=197) at sites participating in long-term follow-up. The predefined primary outcome was time to composite event (cardiac death, myocardial infarction, or cardiac hospitalization). After 5 years, 105 (53%) patients in the PET arm and 111 (57%) in the standard care arm experienced the composite event (hazard ratio for time to composite event =0.82 [95% confidence interval 0.62–1.07]; P =0.15). When only patients who adhered to PET recommendations were included, the hazard ratio for the time to primary outcome was 0.73 (95% confidence interval 0.54–0.99; P =0.042).

Conclusions—

After a 5-year follow-up in patients with left ventricular dysfunction and suspected CAD, overall, PET-assisted management did not significantly reduce cardiac events compared with standard care. However, significant benefits were observed when there was adherence to PET recommendations. PET viability imaging may be best applied when there is likely to be adherence to imaging-based recommendations.

Clinical Trial Registration—

URL: http://www.clinicaltrials.gov . Unique identifier: NCT00385242.

Determinants of persistent or recurrent congestive heart failure after contemporary surgical aortic valve replacement

BACKGROUND AND AIM OF THE STUDY

Although one of the goals of surgical aortic valve replacement (AVR) is to alleviate congestive heart failure (CHF), the latter often occurs after AVR. Surprisingly, the incidence of CHF after AVR remains unclear, as outcomes are reported according to valve-related complications, each of which may result in CHF. The study aim was to: (i) validate a previously described model predicting persistent or recurrent CHF after AVR in a contemporary cohort; and (ii) apply the model to predict late outcomes following AVR with the Trifecta valve.

METHODS

A previously described statistical model was validated in a cohort of 1,014 patients who received the St. Jude Trifecta prosthesis between 2007 and 2009. A sensitivity analysis was performed to determine the influence of risk factors associated with late CHF. Model prediction was verified with a Monte Carlo simulation employing 10,000 iterations.

RESULTS

The model accurately predicted late CHF events in a contemporary cohort. Sensitivity analysis identified mean transprosthesis gradient (MTG), body surface area (BSA), and preoperative NYHA class as important CHF risk factors. Based on the model, a 5 mmHg decrease in MTG was associated with 2.5% and 10.4% reductions in late CHF at five and 15 years, respectively. A 10% decrease in mean BSA and preoperative NYHA class IV symptoms were associated with a 1% decrease and a 5% increase in CHF events at 15 years after AVR.

CONCLUSION

The authors' previously described model predicting persistent or recurrent CHF after AVR was validated in a contemporary cohort. This model may be applied to predict outcomes in patients who receive modern prostheses, without long-term follow up.

Clinical impact of mild acute kidney injury after cardiac surgery

BACKGROUND

Dialysis-dependent renal failure occurs infrequently after cardiac surgery but leads to substantial morbidity and mortality. In contrast, milder degrees of acute kidney injury (AKI), based on small increases in serum creatinine, occur frequently but the independent impact of mild AKI on outcome remains unclear.

METHODS

Between January 2010 and December 2012, 3,869 consecutive patients undergoing cardiac surgery comprised the study cohort. Acute kidney injury was defined according to the AKI Network criteria as stage I, II, or III. A nonparsimonious multivariable logistic regression model including preoperative and intraoperative variables was constructed to determine a propensity score for the development of stage I AKI followed by a greedy matching algorithm to create 1:1 propensity-matched pairs.

RESULTS

The incidence of stage I AKI in the entire cohort was 22.4%. Stage I AKI patients were more likely to be older; to have diabetes mellitus, hypertension, preoperative renal dysfunction, and poorer left ventricle function; and to require more urgent surgery and longer cardiopulmonary bypass. After propensity matching, the 833 matched pairs were similar in terms of all of the above characteristics (all p > 0.5). Within the matched cohort, AKI patients had higher mortality (2.6% versus 1.2%, p = 0.01), higher incidence of neurologic dysfunction (15.2% versus 8.1%, p < 0.001), and longer duration of mechanical ventilation (41.7 ± 125.0 versus 19.3 ± 58.6 hours, p < 0.001). Intensive care unit stay (5.2 ± 10.7 versus 2.7 ± 3.8 days, p < 0.0001), and hospital length of stay (17.9 ± 20.1 versus 14.7 ± 18.3 days, p = 0.0007) was significantly longer for matched AKI patients.

CONCLUSIONS

Patients with even mild degrees of AKI have increased mortality and morbidity compared with their matched counterparts. Interventions that prevent or mitigate AKI after cardiac surgery can yield substantial clinical benefit.

Contemporary midterm echocardiographic outcomes of Bentall procedure and aortic valve sparing root replacement

BACKGROUND

Valve sparing root replacement (VSRR) and aortic valve repair (AVr) is an attractive treatment option compared with composite valve and root replacement (Bentall procedure) for patients with aortic root dilatation with or without aortic valve disease. While aortic valve preservation reduces the risk of valve-related complications, little is known about echocardiographic differences at follow-up between these 2 strategies.

METHODS

Consecutive nonemergent patients undergoing VSRR and AVr (n=68) were compared with contemporary historical controls undergoing the Bentall procedure for aortic root pathology with or without mixed aortic valve disease (insufficiency or stenosis) (n=96). The VSRR was performed preferentially using the reimplantation technique. Bentall procedure utilized a mechanical valve in 65% of patients, a biologic prosthesis in 22%, and a homograft in 13%. Clinical and echocardiographic data were obtained at baseline and at follow-up (median=30 months).

RESULTS

The 2 cohorts were similar with respect to all preoperative characteristics with the exception of disease etiology. The Bentall group had a higher proportion of degenerative valve and root disease (47.8% vs 27.9%) and a lower proportion of bicuspid aortic valve disease (22.8% vs 51.5%) as compared with the VSRR group (p=0.007). Postoperative echocardiographic outcomes were comparable between groups with the exception of higher peak (23.37±11.80 vs 18.0±12.04; p=0.02) and mean (13.07±7.53 vs 9.56±6.49; p=0.01) transvalvular aortic gradients in the Bentall group. Persistence of left ventricular dysfunction (8.4% vs 6.1%; p=0.61), presence of greater than moderate aortic valve (AV) insufficiency (3% vs 4.6%; p=0.32), and left ventricular mass (213.24±72.36 vs 207.38±63.07, p=0.61) were comparable between the Bentall and VSRR group, respectively. Finally, survival (p=0.21) and freedom from valve-related events (p=0.74) were similar between groups.

CONCLUSIONS

Valve sparing root replacement with AV repair provides similar mid-term echocardiographic and clinical outcomes compared with the Bentall.

Finite element analysis to model complex mitral valve repair

Although finite element analysis has been used to model simple mitral repair, it has not been used to model complex repair. A virtual mitral valve model was successful in simulating normal and abnormal valve function. Models were then developed to simulate an edge-to-edge repair and repair employing quadrangular resection. Stress contour plots demonstrated increased stresses along the mitral annulus, corresponding to the annuloplasty. The role of finite element analysis in guiding clinical practice remains undetermined.

Double-valve surgery in Shprintzen-Goldberg syndrome

We describe the challenging case of a 28-year-old Jehovah's Witness patient who presented with symptomatic mitral and tricuspid valve disease and Shprintzen-Goldberg syndrome. This is the first reported double-valve surgery in such a patient who, apart from chest deformity, had a small body size, severe lung disease, difficult airway and vascular access, and to add to the complexity, refused blood and blood product use. The patient underwent a successful mitral valve replacement and tricuspid valve repair through a right thoracotomy. Apart from atrial fibrillation, he had a smooth hospital course and was discharged home on postoperative day 9.

Mitral valve repair in acquired dextrocardia

Surgical correction of valvular heart disease in patients with dextrocardia is extremely rare. We report a surgical case of mitral valve repair in a patient with acquired dextrocardia. Successful mitral valve repair was performed through a right lateral thoracotomy. We describe our surgical strategy and summarize the literature.

Aortic valve preservation and repair in acute Type A aortic dissection

OBJECTIVES

Repair and preservation of the aortic valve in Type A aortic dissection (AAD) remains controversial. We performed a meta-analysis of outcomes for aortic valve (AV) repair and preservation in AAD focusing on long-term valve-related events.

METHODS

Structured searches were performed in Embase (1980-2013) and PubMed (1966-2013) for studies reporting AV repair or preservation in AAD. Early mortality and linearized rates for late mortality and valve-related events were derived. Outcome data were pooled with an inverse-variance-weighted random-effects model.

RESULTS

Of 5325 screened articles, 19 observational studies met the eligibility criteria consisting of 2402 patients with a median follow-up of 4.1 [range: 3.1-12.6 years, total 13 733 patient-years (pt-yr)]. The cohort was principally male (median = 68.1%, range: 39-89) with a median age of 59 (range: 55-68) years and Marfan's syndrome was present in 2.5%. AV resuspension was performed in 95% of the patients and the remainder underwent valve-sparing root replacement (reimplantation = 2.5% and remodelling = 2.5%). Pooled early mortality rate was 18.7% [95% confidence interval (95% CI): 12.2-26.2%], and linearized late mortality rate was 4.7%/pt-yr (95% CI: 3.4-6.3). Linearized rate for AV reintervention was 2.1%/pt-yr (95% CI: 1.0-3.6), recurrent aortic insufficiency (>2+) was 0.9%/pt-yr (95% CI: 0.3-2.2) and endocarditis was 0.2%/pt-yr (95% CI: 0.1-0.5). The composite rate of thromboembolism and bleeding was 1.4%/pt-yr (95% CI: 0.7-2.2).

CONCLUSIONS

Patients surviving an AAD have a limited long-term survival. Preservation and repair of the aortic valve is associated with a moderate risk of reoperation, but a low risk of thromboembolism, bleeding and endocarditis.