Operative Outcomes with Myxomatous Mitral Valve Repair: Experience with 586 Patients

INTRODUCTION

American Heart Association (AHA) guidelines recommend mitral valve repair for myxomatous mitral regurgitation whenever possible to prevent LV dysfunction and early mortality. Here we review our early operative outcomes with mitral valve repair for myxomatous mitral regurgitation.

METHODS

We collected data from 586 consecutive patients that underwent mitral repair for myxomatous disease at the Prince Henry and Prince of Wales Hospitals Sydney between 1997 and 2012. All patients had pre- and postoperative transthoracic echocardiograms.

RESULTS

In the first 30 days postoperatively there were five deaths (0.9%), four strokes (0.7%) and five transient ischaemic attacks (TIAs) (0.9%). Repair involved resection in 55.5%, neochordal reconstruction in 41.6%, and in 2.9% a combination of both. There was increasing use of neochordae since 2006. At discharge 99% had mitral regurgitation (MR) ≤ mild and ≤ trivial in 79.5%. For posterior leaflet disease neochordae had improved MR at discharge compared with resection (85% vs 78%, P<0.05). Preoperative triscupid regurgitation (TR) and pulmonary hypertension > mild were associated with a greater degree of MR at discharge (P<0.05) for reasons that are unclear.

CONCLUSION

We have shown excellent early results for mitral repair with very low operative mortality and excellent freedom from significant MR. Successful mitral repairs with low morbidity have resulted in a pattern of early referral in keeping with the current guidelines.

Repair of Anterior Mitral Leaflet Prolapse: Comparison of Mid-Term Outcomes with Chordal Transposition and Chordal Replacement Techniques

BACKGROUND

The repair of anterior mitral leaflet prolapse is known to be challenging. Hence, the study aim was to compare the mid-term results of anterior leaflet prolapse (ALP) using chordal transposition with results obtained using chordal replacement with expanded polytetrafluoroethylene (ePTFE) sutures.

METHODS

Between 1999 and 2012, a total of 96 consecutive patients (mean age 62 years) with ALP underwent mitral valve repair at the authors' institution. Surgery involved either chordal transposition from the posterior to the anterior leaflet (n = 67), or chordal replacement using ePTFE sutures (n = 29). Clinical, operative and follow up data were recorded prospectively for each patient. The follow up was 100% complete (mean 3.4 years; range 0 to 12.9 years).

RESULTS

Mitral valve repair was accomplished in all patients, with no operative mortality. The durations of cardiopulmonary bypass and aortic cross-clamp were significantly longer in the chordal replacement group. Actuarial overall survival at one, five and 10 years was 95 ± 3%, 87 ± 5% and 82 ± 7% versus 89 ± 6%, 89 ± 6% and 89 ± 6% in the chordal transposition and chordal replacement groups, respectively (p = 0.84). Freedom from reoperation in the two groups at five years was 95 ± 3% and 91 ± 7%, respectively (p = 0.24). The recurrence of moderate or severe mitral regurgitation (MR) (grade ≤2+) and of severe (grade ≤3+) MR was significantly higher in patients who underwent chordal replacement compared to chordal transposition (p = 0.04 and p = 0.01, respectively).

CONCLUSIONS

Provided that chordal quality is preserved, chordal transposition is easier and quicker to achieve for ALP repair, and is also durable in the mid term. Chordal replacement offers a satisfying durability even if the recurrence of severe MR appears to be higher. Preferably, both surgical techniques should be mastered to allow valve repair when anatomic conditions prevent chordal transposition.

Outcomes of mitral valve repair for bileaflet prolapse

OBJECTIVE

Repair of bileaflet prolapse has been considered to be technically demanding and challenging. To assess the reliability and durability of mitral valve repair for bileaflet prolapse, the present study compared the outcomes of mitral valve repair for bileaflet prolapse with those for posterior prolapse.

METHODS

From January 1991 to April 2010, 191 consecutive patients with bileaflet prolapse (group B) underwent mitral valve repair using a combination procedure of expanded polytetrafluoroethylene chordal reconstruction for anterior prolapse, resection suture technique with/without sliding technique for posterior prolapse, and ring annuloplasty. During the same period, 323 patients with posterior prolapse (group P) underwent standard mitral valve repair. Serial echocardiograms were obtained at discharge and 1, 3, 5, and 10 years postoperatively.

RESULTS

The mean age in group B (54 ± 15 years) was significantly younger than that in group P (61 ± 12 years). Survival, including hospital death at 10 years, was superior in group B (group B, 90% ± 3%; group P, 83% ± 3%; P = .046). At 10 years, no significant differences were found between the groups in terms of freedom from recurrent mitral regurgitation of more than mild (group B, 89% ± 3%; group P, 90% ± 2%), freedom from reoperation (group B, 97% ± 2%; group P, 97% ± 1%), and event-free survival (group B, 79% ± 5%; group P, 83% ± 3%).

CONCLUSIONS

The reproducibility and reliability of mitral valve repair for bileaflet prolapse compares favorably with that of posterior leaflet prolapse. Early surgery might be recommended for patients with severe mitral regurgitation owing to bileaflet prolapse.

Local suture annuloplasty for posterior mitral valve repair: 18-year experience

We retrospectively reviewed 128 consecutive patients who underwent quadrangular resection of a prolapsed posterior mitral leaflet and local suture annuloplasty. The median age was 68.1 ± 10.0 years (range, 30-84 years) and 63.3% were male. Mean left ventricular ejection fraction was 63.8% ± 10.2% (range, 25%-80%). The etiology of mitral regurgitation was fibroelastic degeneration in 94 (73.4%) patients, myxomatous degeneration in 26 (20.3%), myxomatous infective endocarditis in 7 (5.5%), and post-infarction papillary rupture in one. There was 1 (0.8%) hospital death. The median follow-up was 4.7 ± 4.7 years (range, 0.01-18.29 years). The freedom from reoperation was 98%, 94%, 87%, and 79% at 1, 5, 10, and 15 years, respectively, improving for the most recent 107 patients, subsequent to technical modification, to: 100%, 96%, 94%, and 90% at 1, 5, 10, and 14 years, respectively. Ten- and 15-year freedom from severe mitral regurgitation was 91%, and 88%, respectively. The overall actuarial 1-, 5-, 10-, and 15-year survival rates were 98%, 90%, 70%, and 52%, respectively, similar to that of the age- and sex-matched United Kingdom population. The long-term results of this technique in selected patients with prolapsed posterior leaflet were considered acceptable.

Frequency and surgical management of complex posterior leaflet prolapse of the mitral valve

BACKGROUND AND AIM OF THE STUDY

Isolated posterior leaflet prolapse of the mitral valve may present with more complex anatomy than limited middle scallop prolapse (P2). The study aim was to describe the incidence and surgical management of extensive or commissural posterior leaflet prolapse, in addition to long-term outcomes following repair.

METHODS

Between October 2001 and May 2008, among 481 patients operated on for mitral valve prolapse, 201 consecutive patients underwent mitral valve repair for isolated posterior leaflet prolapse. Of the latter patients, only 81 (40%) had limited P2 prolapse, while the remaining 120 (60%) showed complex posterior leaflet prolapse, including either extensive (n = 105) or commissural (n = 15) prolapse. Extensive leaflet prolapse was treated with aggressive leaflet resection and sliding plasty, combined with a longitudinal annular plication using polytetrafluoroethylene running sutures. Commissural prolapse was repaired with an edge-to-edge technique or commissuroplasty. The clinical and echocardiographic follow up was complete for all patients, and extended up to 6.8 years (mean 2.4 +/- 1.9 years).

RESULTS

There was no hospital mortality. Repair was successful in 200 patients (99%), who showed no or trivial mitral regurgitation (MR) intraoperatively. The five-year freedom from recurrent MR (grade > 1+) was 91.5 +/- 4.2% in patients with isolated P2 prolapse, compared to 98.8 +/- 1.2% in patients with complex posterior leaflet prolapse (p = 0.07). The repair of complex posterior leaflet prolapse was also similar to that of isolated P2 prolapse with regard to five-year freedom from reoperation (98.9 +/- 5.9% versus 100%; p = 0.4), and survival (92.1 +/- 3.3% versus 88.9 +/- 8.0%; p = 0.9).

CONCLUSION

In the present series, posterior leaflet prolapse offered more complexity than usually reported, requiring surgical skills beyond simple quadrangular resection. However, the surgical approach, which typically involved extensive leaflet resection and sliding plasty, offered high repair rates and acceptable durability, considering the initial severity of the prolapse anatomy.

Midterm outcome of leaflet folding plasty for mitral regurgitation due to posterior leaflet prolapse

OBJECTIVE

Leaflet folding plasty was introduced as an effective technique to avoid systolic anterior motion (SAM) after mitral valve repair. The purpose of this study was to investigate the midterm outcome of leaflet folding plasty following a review of our 10-year experience.

METHODS

Between October 1997 and May 2008, a total of 45 patients with mitral valve regurgitation due to posterior leaflet prolapse were operated on using leaflet folding plasty (63% of posterior leaflet repair and 28% of overall mitral valve repair during the same period). The group comprised 29 men and 16 women, with a mean age of 63.2 years. There were 44 patients with degenerative valve disease and 1 with healed infective endocarditis. The prolapsed scallop were P1 in 1, P2 in 33, and P3 in 11 patients. Anterior mitral leaflet involvement was seen in two patients.

RESULTS

Mitral valve repair was performed in all patients. SAM with residual mitral regurgitation was observed in two patients, with one requiring intraoperative revision. The 30-day mortality was 2.2% (one patient died from intestinal complications). The mean follow-up period for survivors was 38.1 months (range 1-127 months). The 1- and 5-year actuarial survival rates were 97.8% and 93.7%, respectively. None of the patients required reoperation during follow-up.

CONCLUSION

Midterm outcome of leaflet folding plasty for mitral valve repair was satisfactory. This technique accomplishes mitral valve repair safely in patients with mitral regurgitation due to posterior prolapse, with acceptable intermediate-term freedom from reintervention.

Non-myxomatous flail mitral valve: clinical and echocardiographic characteristics and long-term clinical outcome

BACKGROUND AND AIM OF THE STUDY

Chordal rupture leading to flail mitral valve and mitral regurgitation (MR) is considered to be caused primarily by myxomatous mitral valve disease. The study aim was to determine the prevalence and clinical and echocardiographic characteristics of non-myxomatous versus myxomatous flail mitral valve.

METHODS

A total of 96 patients with flail mitral valve was identified from an echocardiography database and classified as either myxomatous (n = 36; 37%) or non-myxomatous (n = 60; 63%), based on echocardiographic mitral valve anatomy (systolic leaflet buckling). In 10 other patients the etiology was indeterminate. The clinical and echocardiographic characteristics and outcome at five years were compared between groups.

RESULTS

Patients with non-myxomatous mitral valve were older than those with myxomatous mitral valve (mean age 76 +/- 9 versus 61 +/- 12 years; p <0.0001), and were more likely to have aortic sclerosis, mitral annulus and papillary muscle calcification (odds ratio 3.6, 95% CI 1.2-10.8, p = 0.02) and to have short duration of symptoms (< or =1 month, p <0.02). There was no inter-group difference in MR severity, but non-myxomatous patients had higher systolic pulmonary artery pressure (52 +/- 16 versus 42 +/- 13 mmHg, p = 0.008). During the five-year follow up period, non-myxomatous patients had a poorer crude survival and survival free from rehospitalization for heart failure (p = 0.02), and were less likely to have mitral valve surgery (p = 0.015). However, these differences were abolished when data were adjusted for age.

CONCLUSION

Among patients with flail mitral valve referred for echocardiography, more than half were non-myxomatous in origin, most likely due to wear and tear. Non-myxomatous flail mitral valve was associated with older age, degenerative calcific valvular changes, and more recent onset of symptoms. Age-adjusted survival free of heart failure was similar in both non-myxomatous and myxomatous patients.

Mitral valve repair for degenerative mitral regurgitation

Mitral valve repair for degenerative mitral regurgitation is nowadays one of the most common valvular procedures. Different technical modifications were added to the original Carpentier's method, trying to maximise the stability of the results and to reduce the incidence of immediate complications and of late failure of the correction. Survival is good, even if recent reports showed that recurrence of mitral regurgitation can be higher than expected. Prolapse of the anterior leaflet remains challenging and is related to higher reintervention rates. Nevertheless, the overall success rate is high, and the increasing experience of the different surgical teams approaching this procedure will help maintain satisfactory and stable long-term results.

Survival Advantage and Improved Durability of Mitral Repair for Leaflet Prolapse Subsets in the Current Era

BACKGROUND

Factors predicting long-term survival and reoperative risk after mitral valve repair for subsets with prolapse involving the anterior leaflet in the current era are unclear.

METHODS

Between January 1, 1980 and December 31, 1999, surgical correction of mitral regurgitation was performed in 2,219 patients. We analyzed a subset of 1,411 patients with isolated mitral regurgitation due to leaflet prolapse undergoing mitral repair or replacement (+/- coronary bypass).

RESULTS

Mean age was 64 years, and 1,003 (71%) were men. Mitral repair was performed in 1,173 (83%) patients. Factors independently predicting overall long-term survival included valve repair, younger age, better functional class, and the absence of significant coronary artery disease. After adjusting for these, smaller preoperative left ventricular end-systolic dimension and greater preoperative ejection fraction were associated with superior survival. Mitral reoperation occurred in 97 patients (75 repairs, 22 replacements), at a mean of 4.8 years after initial procedure. Cumulative risk of reoperation was similar for patients having valve repair or replacement. Factors predictive of need for reoperation after initial repair were younger age, anterior leaflet prolapse, chordal shortening, no leaflet resection, no prosthetic annuloplasty, greater than mild residual mitral regurgitation, and coronary artery disease. After valve replacement, the sole determinant of reoperation was use of a biological prosthesis. The durability of repair for prolapse of the anterior leaflet improved significantly during the second decade of the study.

CONCLUSIONS

Mitral repair affords superior long-term survival, with permanence comparable with mechanical valve replacement. In all categories of mitral leaflet prolapse, durability of valve repair has improved over the past decade.

Long-term follow-up of mitral valve repair: a single-center experience

BACKGROUND

Our aim was to conduct a long-term follow-up of patients after mitral valve repair for incompetence. We identified determinants for mortality and compared mortality with standardized mortality rates of the Dutch population.

MATERIAL/METHODS

We included in this single-center retrospective study 119 patients operated from March 1976 to February 1981. Patients with previous mitral valve surgery, isolated mitral stenosis, and congenital heart disease were excluded. Routine echocardiography was performed every 6 to 12 months. The cumulative probability of survival was calculated (Kaplan-Meier). The variables that statistically significantly associated with mortality were selected for multivariate analysis. Maximum follow-up was 27 years and complete in 98%. Mean age was 49.4 years, and 55% were preoperatively in New York Heart Association (NYHA) class III. Concomitant cardiac procedures were performed in 49%.

RESULTS

The 30-day postoperative mortality was 6.7% and the 20-year overall mortality was 63%. The standardized mortality rate was 30%, which was based on survival rates of the general Dutch population. In 27 cases (22.7%), re-operation was performed. Independent predictors for mortality were, after univariate and multivariate analysis, concomitant coronary artery bypass grafting (p=0.002), renal impairment (p=0.027), age above 60 years (p=0.05), and ejection fraction<or=40% (p=0.05).

CONCLUSIONS

The observed mortality exceeded the expected mortality. Concomitant coronary artery bypass grafting, renal impairment, age above 60 years, and reduced left ventricular function were independent predictors of mortality in patients with surgical repair for mitral valve regurgitation.

Operative and long-term survival of elderly is significantly improved by mitral valve repair

BACKGROUND

We review our 10-year experience of mitral valve (MV) repair in comparison with MV replacement in the elderly for floppy mitral valves/mitral valve prolapse (FMV/MVP). The use of MV repair for this entity has not been fully utilized by surgeons.

METHODS

Two hundred ninety-two consecutive patients aged > or = 70 years receiving mitral surgery for regurgitation due to FMV/MVP were reviewed from our prospective database between January 1, 1992, and December 31, 2002. Patients receiving concomitant coronary artery bypass grafting (CABG) were included. Two hundred eighteen patients underwent repairs and 74 replacements. Postoperative and long-term follow-up data were obtained. Mean follow-up time for survivors was 6.2 +/- 2.5 years for MV repair and 6.8 +/- 2.7 years for MV replacement.

RESULTS

Patients with isolated MV repair showed lower inhospital mortality compared with MV replacement (0.7% vs 13.9%, P = .002) with reduced length of stay (8.7 +/- 7.6 vs 9.6 +/- 5.2 days, P = .049). There was improvement in 5-year mortality favoring repair versus replacement (81% +/- 3% vs 63% +/- 3%, P = .001). With concomitant CABG, there was minimal difference in survival up to 5 years. Freedom from valve replacement was 93.9% +/- 1.3% for MV repair and 98.2% +/- 0.4% for MV repair with CABG at 10 years. Mitral valve repair was an independent protector of long-term mortality within multivariate correlates (hazard ratio 0.43, 95% CI 0.19-0.97, P = .041).

CONCLUSIONS

In elderly patients, MV repair reduced in-hospital mortality and length of stay and increased long-term survival. With concomitant CABG, survival was similar to replacement. The preferred option for elderly patients with FMV/MVP is MV repair, especially in those without coronary artery disease.

Management of commissural lesions in native mitral valve endocarditis: long-term results of valve repair and partial homograft replacement

BACKGROUND AND AIM OF THE STUDY

Commissural lesions in the context of native mitral valve endocarditis are a technically challenging condition for conservative surgery. Herein are reported the authors' 10-year results for mitral valve repair (MVRep) or partial homograft replacement (PHR) performed in this setting.

METHODS

Data were reviewed from 19 consecutive patients who underwent MVRep using either Carpentier's technique (n = 14) or PHR (n = 5) for endocarditis at the authors' institution between 1989 and 1994.

RESULTS

There was one operative death (5%; 95% CI 0-15.5%). Two reoperations were performed in each subgroup for recurrence of endocarditis (n = 2) and mitral valve failure (n = 2). The 10-year survival rate and freedom from mitral valve reoperation were 95% (95% CI 84-100%) and 78% (95% CI 59-97%), respectively. At 10 years, 13 (93%) surviving and non-reoperated patients were in good functional status (NYHA class I-II), and 14 (100%) were in sinus rhythm. Although echocardiographic results were excellent in the MVRep group, all PHR patients had moderate or severe mitral valve dysfunction.

CONCLUSION

Commissural reconstruction using Carpentier's techniques demonstrated excellent long-term results in patients with native mitral valve endocarditis. In contrast, the results for PHR were rather disappointing.

A comparison of outcomes of mitral valve repair for degenerative disease with posterior, anterior, and bileaflet prolapse

OBJECTIVE

We sought to compare the clinical and echocardiographic outcomes of mitral valve repair for mitral regurgitation in patients with degenerative disease of the mitral valve with posterior, anterior, or bileaflet prolapse.

METHODS

Patients underwent operations from 1981 through 2001: 359 had posterior (mean age, 60.4 years), 92 had anterior (mean age, 53.3 years), and 250 had bileaflet (means age, 56.4 years) prolapse. Patients with anterior prolapse were younger (P = .04) and had more associated aortic valve disease (P = .02), particularly bicuspid aortic valve disease (P < .001). Anterior prolapse was corrected by using chordal replacement with Gore-Tex sutures in most patients, but early on in this series, leaflet resection, chordal shortening, and chordal transfer were also used. Echocardiograms were done annually, and clinical follow-up was complete at a mean of 6.9 +/- 4.0 years (range, 0-23 years).

RESULTS

The overall survival at 12 years was 75% +/- 5%, with no difference among the posterior, anterior, and bileaflet prolapse groups (P = .3). The freedom from reoperation at 12 years was 96% +/- 2% for posterior, 88% +/- 4% for anterior, and 94% +/- 2% for bileaflet prolapse (P = .019). Anterior prolapse was the only independent predictor of reoperation. The freedom from moderate or severe mitral regurgitation at 12 years was 80% +/- 4% for posterior, 65% +/- 8% for anterior, and 67% +/- 6% for bileaflet prolapse (P = .001). Anterior and bileaflet prolapse, age, ejection fraction of less than 40%, and aortic valve disease were independent predictors of recurrent moderate or severe mitral regurgitation.

CONCLUSIONS

The pathophysiology of mitral regurgitation affects the durability of mitral valve repair for degenerative disease, and the results of posterior prolapse are better than those of anterior and bileaflet prolapse. This study indicates that rates of reoperation underscore the rates of failure of mitral valve repair.

Mitral valve repair for commissural prolapse: surgical techniques and long term results

OBJECTIVE

The aim of this study was to describe the pattern of lesions responsible for commissural prolapse, the techniques of valve repair and their long-term results.

METHODS

Between 1992 and 2004, 128 mitral valve repairs were consecutively performed for commissural prolapse. There were 86 males and 42 females, the median age was 57.5 years (range 14-84 years). Forty-six percent of patients were in NYHA III or IV, mean ejection fraction was 61+/-9.4%. The diagnosis of commissural prolapse was recognized by preoperative echocardiography in 32% of the patients and was revealed by intraoperative inspection of the valve in the other cases. The site of the prolapse was the posteriomedial commissure (n=94), the anterior commissure (n=30) or both (n=4). The aetiologies were: infective endocarditis (n=56), degenerative (n=46), ischemic (n=25), congenital mitral regurgitation (n=1). The commissural prolapse was associated with another mitral valvular lesion requiring a specific treatment in 61 cases (47.7%). An associated procedure was carried out in 45 patients.

RESULTS

The operative treatment of the commissural prolapse included: commissural closure 65 (50.8%), leaflet resection 31 (24.2%), transposition or shortening of chordae 19 (14.8%), reimplantation or shortening of papillary muscles 3 (2.3%), and replacement of the commissural area by a partial mitral homograft 10 (8%). In-hospital mortality included three deaths (2.3%) and four patients (3.1%) were reoperated: three pericardial drainages for hemopericardium and one for mediastinitis. During the follow-up, one patient died (0.8%) from myocardial infarction and eight patients (6.3%) were reoperated including six (4.7%) for recurrent mitral regurgitation. After a median follow-up time of 76.9 months (range from 15 days to 160 months), 116 patients (90.1%) were in NYHA I. Echocardiographs showed no or minimal insufficiency in 112 patients (87.5%) and mild or moderate insufficiency in 10 patients (7.8%).

CONCLUSIONS

The diagnosis of commissural prolapse is difficult by preoperative echocardiography. The aetiology of the mitral disease is variable (endocarditis, degenerative or ischemic mitral regurgitation). Using a variety of techniques, commissural prolapse can be repaired with excellent clinical and echographic long-term results.

Acute severe mitral regurgitation during first attacks of rheumatic fever: clinical spectrum, mechanisms and prognostic factors

BACKGROUND AND AIM OF THE STUDY

The study aim was to describe the clinical spectrum and mechanism of acute severe mitral regurgitation (MR) observed during first episodes of rheumatic fever (RF), and to identify prognostic factors related to the short-term outcome.

METHODS

Since 1990, 44 patients (mean age 9.2 +/- 0.1 years; range: 4-17 years) have been admitted to the authors' institution with severe MR related to a first episode of RF, fulfilling revised Jones' criteria. Twenty-three patients admitted between 1995 and 2002 were included prospectively, and 21 admitted before 1994 were studied retrospectively.

RESULTS

Left ventricular end-diastolic and end-systolic dimensions were 51 +/- 2 mm (46 +/- 3 mm/m2 BSA) and 32 +/- 2 mm (28 +/- 2 mm/m2 BSA), respectively; mean fractional shortening of the left ventricle was 39.0 +/- 1.0% (range: 31-52%); Doppler-derived pulmonary arterial systolic pressure (PAPS) was 51 +/- 6 mm (range: 27-90 mm). The mitral valve annulus was enlarged in all patients (mean diameter 31 +/- 2 mm; 27 +/- 4 mm/m2 BSA). MR resulted from prolapse of the anterior mitral valve leaflet (P of AMVL) in 16 patients (36%), and from prolapse of the posterior mitral valve leaflet (P of PMVL) in nine (20%); the other 19 patients (43%) had restrictive motion of the PMVL, with normal motion of the AMVL, resulting in a 'false prolapse' of the AMVL (FP of AMVL). During the six-month interval following the RF episode, mitral valve surgery was required in 11 patients (25%); three patients (7%) died from cardiogenic shock before they could undergo surgery, while the other 30 patients were stabilized under medical treatment. Using univariate analysis, death or mitral valve surgery was associated with PAPS > 50 mm (OR = 1.7, p = 0.04), male gender (OR = 1.88, p = 0.008), clinical signs of congestive heart failure at admission (OR = 2.7, p < 10(-4)), and prolapse of the PMVL (OR = 5.2, p = 0.01). Death occurred, or mitral valve surgery was necessary, in eight patients with P of PMVL (89%), in four with P of AMVL (25%), and in two with FP of AMVL (11%) (p < 0.001). Despite limitations due to co-linearities and small sample size, multivariate analysis identified P of PMVL as the most potent predictor of adverse outcome. The long-term follow up (mean 6.3 years) of patients without P of PMVL, alive and not operated on during the first six-month interval after an RF episode, demonstrated a sharp decrease in the mean severity of MR (from grade 4 to 1.7; range: 1-3).

CONCLUSION

In contrast to previous reports of chronic rheumatic MR, acute severe MR due to RF is more frequently related to P of AMVL or P of PMVL, than to FP of AMVL. Patients with P of AMVL or FP of AMVL tend to improve with medical treatment; however, those with P of PMVL carry a poor medical prognosis, and most often require early mitral valve surgery.

Ischemic mitral valve prolapse: mechanisms and implications for valve repair

OBJECTIVE

The aim of this study was to assess the mechanisms of prolapse in ischemic mitral valve regurgitation (MR) and the techniques of valve repair.

METHODS

Out of 121 patients operated upon for ischemic MR, a prolapse was present in 44 patients (36.4%). The operation was performed emergently in four cases (9.1%) and electively in 40 patients (90.9%). Fifteen patients (34.1%) were operated upon within 60 days following acute myocardial infarction.

RESULTS

The diagnosis of prolapse had been overlooked by echography in five cases (11.4%). A commissural area was involved as the site of prolapse in 31 cases (70.4%). The mechanism of prolapse was a papillary muscle (PM) lesion in 38 cases (86.4%) (anterior PM: n=8, posterior PM n=36) or a chordal lesion in six cases (13.6%). PM injury was elongation (n=16), or rupture (total n=1, partial n=21, incomplete n=4). The operative technique was mitral valve repair with Carpentier's techniques in 42 cases (95.5%) or replacement in two cases (4.5%). Hospital mortality was 11.4% (n=4). The mean follow-up was to 44.7+/-29.6 months. Overall survival and freedom from reoperation were 68.3+/-9.0 and 89.9+/-5.7% at 5 years, respectively. Freedom from MR equal or > grade 2 was 69.7+/-9.5% at 5 years.

CONCLUSIONS

The mechanisms of ischemic mitral valve prolapse were variable and tightly linked to the PM anatomy. A reliable mitral valve repair could be achieved in most cases with acceptable mid-term results.

Transcatheter radiofrequency ablation of atrial fibrillation in patients with mitral valve prostheses and enlarged atria

OBJECTIVES

Few data have been published on transcatheter ablation of atrial fibrillation (AF) in patients with mitral valve prostheses. Thus, we sought to report our experience.

BACKGROUND

Ablation is an effective treatment for AF. Patients with prosthetic mitral valves represent a special group because of an increased risk from the ablation procedure due to the possibility of damage to the prosthetic valve.

METHODS

Between July 2001 and July 2003, 26 patients with mitral valve prostheses (MVP) underwent circumferential pulmonary vein ablation for AF. A matched group of 52 ablated patients without MVP acted as control subjects. After a blanking period of three months, a follow-up of 12 months was considered for MVP patients and controls. Holter recordings were performed in all subjects at 3, 6, and 12 months.

RESULTS

Radiation exposure was higher in the MVP group, with fluoroscopy times of 35.3 +/- 21 min versus 20.9 +/- 15 min in controls. At the end of follow-up, 73% of MVP patients were in sinus rhythm, compared with 75% of controls. Atrial tachycardia occurred in six (23%) MVP patients, requiring repeat ablation in three, and one (2%) control subject, which settled without treatment. One transient ischemic attack and one femoral pseudoaneurysm occurred in the MVP group. No complications occurred in the control group.

CONCLUSIONS

Ablation of AF in patients with MVP is feasible, with outcomes similar to those of standard patients. Complications were higher among MVP patients with a greater radiation exposure and a higher incidence of post-ablation atrial tachycardia.

Long-term Assessment of Mitral Valve Reconstruction With Resection of the Leaflets: Triangular and Quadrangular Resection

BACKGROUND

The procedure of quadrangular resection and suture for prolapsed posterior leaflet of the mitral valve is a reliable and reproducible method that achieves excellent long-term results. However, triangular resection and suture of a prolapsed anterior leaflet is not widely supported and different techniques have been advocated. The aim of this study was to review our experience of mitral valve repair in which resection of the anterior and/or posterior leaflets was performed.

METHODS

Between October 1991 and September 2003, 105 patients with mitral regurgitation underwent mitral valve reconstruction with leaflet resection, including 55 patients with quadrangular resection of the posterior leaflet (P), 32 patients with triangular resection of the anterior leaflet (A), and 18 patients with resection of both leaflets (A+P).

RESULTS

The mean follow-up period was 63.6 (1 to 139) months. Reoperation was required in 2 patients, each after resection of the anterior or posterior leaflet. The freedom from reoperation rates at 10 years in 93% +/- 5% of patients after triangular resection of the anterior leaflet, 96% +/- 3% after quadrangular resection of the posterior leaflet, and 100% after resection of both leaflets. There were no significant differences of survival or risk of reoperation among these three groups. The postoperative mitral valve area was significantly smaller than the preoperative area in all three groups, but remained large enough (A: 2.84 +/- 1.07; P: 2.6 +/- 0.87; A+P: 3.09 +/- 1.20 cm2) for adequate valve function.

CONCLUSIONS

Triangular resection of a prolapsed anterior mitral leaflet is a reliable, reproducible, and durable procedure, like quadrangular resection of a prolapsed posterior leaflet.

Surgical repair of the prolapsing anterior leaflet with chordal shortening

The purpose of this study was to review the results of mitral valve repair for prolapse of the anterior repaired with chordal shortening or shortening of the papillary muscle. Sixty three patients operated from June 1988 through June 2003, form the cohort of this study. The etiology was degenerative disease in 30 patients (47%) and rheumatic disease in 23 (37%). All patients survived the operation. Predischarge echocardiography showed no or trivial regurgitation in 61 patients (97%). Mean follow-up was 6.57 +/- 0.65 years. Twenty patients died during the follow-up for an actuarial survival of 62% at 14 years. Five patients required reoperation on the mitral valve; 88% of the patients were free from reoperation at 14 years. In conclusion, shortening plasty of the subvalvular apparatus provides good and stable results after repair of anterior leaflet prolapse.

“Edge-to-edge” repair for anterior mitral leaflet prolapse

The aim of this study is to report our results in a series of 150 consecutive patients (mean age 53 +/- 15.4 years) in whom mitral regurgitation (MR) due to isolated anterior mitral leaflet (AML) prolapse was corrected using the edge-to-edge (E to E) technique over a period of more than 10 years. At admission, 49 (32.6%) patients were in NYHA class I, 46 (30.6%) in II, 51 (34%) in III and 4 (2.6%) in IV. In the great majority of the cases (111 patients, 74%), degenerative disease was the cause of MR. Hospital mortality was 0.6% (1/150). There were 7 late deaths. The actuarial overall survival and freedom from reoperation at 9 years were 91.6% +/- 3.16% and 96.6% +/- 1.74%, respectively. At follow-up (4.5 +/- 3.21 years, range 2 months-12 years), the mean mitral valve area was 2.7 +/- 0.5 cm(2) and mitral regurgitation was absent or mild in 132 patients (88%). The results of this study demonstrate the effectiveness and durability of the E to E repair in the setting of AML prolapse. In our institution, this technique, in conjunction with annuloplasty, remains the method of choice to correct segmental prolapse of the AML.

Long-term results of cusp-level chordal shortening for anterior mitral leaflet prolapse

The technique and early results of cusp-level chordal shortening for isolated anterior mitral leaflet prolapse in rheumatic mitral regurgitation were presented by us earlier. Here we present our experience from January 1989 through December 2000. Two hundred twenty-six patients underwent this procedure. The mean age was 18 +/- 7.22 years. Preoperatively, 38 (16.8%) patients were in New York Heart Association functional class 11, 160 (70.8%) were in class IIl, and 28 (12.4%) were in class IV. All patients underwent chordal shortening at the cusp level. In addition, 8 patients (3.5%) underwent chordal transfer, and 4 patients (1.8%) received neochordae. Two hundred twenty-one (97.8%) patients underwent posterior annuloplasty using a C-shaped polytetrafluoroethylene collar. In 85 (37.6%) patients, cuspal thinning was also performed. Early mortality was 3.5% (8 patients). Follow-up ranged from 1 to 144 months (mean, 53.02 +/- 31.10 months) and was 94% complete. In 68% of survivors, there was no or trivial mitral regurgitation. Ten patients required reoperation. There were 8 late deaths. Actuarial survival, mitral regurgitation-free survival, and event-free survival were 93.3% +/- 1.7%, 41.8% +/- 8.4%, and 73.6% +/- 6.6%, respectively. Among the 210 survivors, 159 (75.7%) were in New York Heart Association class I, 26 (12.4%) were in class II, 22 (10.5%) were in class III, and 3 (1.4%) were in class IV. We conclude that cusp-level chordal shortening for isolated anterior mitral leaflet prolapse is an effective procedure for correction of anterior mitral leaflet prolapse.

Late outcomes of mitral valve repair for floppy valves: Implications for asymptomatic patients

OBJECTIVES

We sought to evaluate the long-term results of mitral valve repair in patients with mitral regurgitation caused by floppy mitral valves and compare the outcomes of asymptomatic patients with those of symptomatic patients.

METHODS

A retrospective review of 488 consecutive patients who had mitral valve repair for floppy mitral valve disclosed 199 patients who were asymptomatic or had minimal symptoms and 289 patients who were symptomatic at the time of the operation. Asymptomatic patients were younger, had better ventricular function, had a lower incidence of coronary artery disease, and had higher rates of atrial fibrillation than symptomatic patients.

RESULTS

Survival at 15 years was 61% for all patients. Survival was 76% for asymptomatic patients, which was identical to that for the general population matched for age and sex, whereas the survival of symptomatic patients was 53% and significantly lower than that of the general population. Cox regression analyses validated by means of bootstrap methodology identified the following predictors of late death: age by increments of 5 years (risk ratio = 1.2), New York Heart Association functional classes 3 and 4 (risk ratio = 3.0), left ventricular ejection fraction of less than 40% (risk ratio = 2.7), preoperative stroke or transient ischemic attack (risk ratio = 3.1), previous cardiac operation (risk ratio = 4.6), and severe chronic obstructive pulmonary disease (risk ratio = 3.1). Freedom from reoperation at 15 years was 91%, and it was similar for asymptomatic and symptomatic patients. Freedom from mitral regurgitation of greater than 2+ at 15 years was 85% for all patients, 96% for asymptomatic patients, and 76% for symptomatic patients.

CONCLUSIONS

This study supports the recommendation of surgical intervention in asymptomatic patients with mitral regurgitation caused by a floppy mitral valve if mitral valve repair is feasible and associated with low operative mortality and morbidity.

Natural history of asymptomatic mitral valve prolapse in the community

BACKGROUND

The outcome of mitral valve prolapse (MVP) is controversial, with marked discrepancies in reported complication rates.

METHODS AND RESULTS

We conducted a community study of all Olmsted County, Minn, residents first diagnosed with asymptomatic MVP between 1989 and 1998 (N=833). Diagnosis, motivated by auscultatory findings (n=557) or incidental (n=276), was always confirmed by echocardiography with the use of current criteria. End points analyzed during 4581 person-years of follow-up were mortality (n=96, 19+/-2% at 10 years), cardiovascular morbidity (n=171), and MVP-related events (n=109, 20+/-2% at 10 years). The most frequent primary risk factors for cardiovascular mortality were mitral regurgitation from moderate to severe (P=0.002, n=131) and, less frequently, ejection fraction <50% (P=0.003, n=31). Secondary risk factors independently predictive of cardiovascular morbidity were slight mitral regurgitation, left atrium > or =40 mm, flail leaflet, atrial fibrillation, and age > or =50 years (all P<0.01). Patients with only 0 or 1 secondary risk factor (n=430) had excellent outcome, with 10-year mortality of 5+/-2% (P=0.17 versus expected), cardiovascular morbidity of 0.5%/y, and MVP-related events of 0.2%/y. Patients with > or =2 secondary risk factors (n=250) had mortality similar to expected (P=0.20) but high cardiovascular morbidity (6.2%/y, P<0.01) and notable MVP-related events (1.7%/y, P<0.01). Patients with primary risk factors (n=153) showed excess 10-year mortality (45+/-9%, P=0.01 versus expected), high morbidity (18.5%/y, P<0.01), and high MVP-related events (15%/y, P<0.01).

CONCLUSIONS

Natural history of asymptomatic MVP in the community is widely heterogeneous and may be severe. Clinical and echocardiographic characteristics allow separation of the majority of patients with excellent prognosis from subsets of patients displaying, during follow-up, high morbidity or even excess mortality as direct a consequence of MVP.

Hemodynamic performance of an unstented xenograft mitral valve substitute

OBJECTIVE

Stentless mitral xenografts offer potential clinical benefits because they mimic the normal bileaflet mitral valve. How best to implant them and their hemodynamic performance and durability, however, remain unknown.

METHODS

A stentless porcine mitral xenograft valve (Medtronic physiologic mitral valve) was implanted in 7 sheep with papillary muscle sewing tubes attached with transmural left ventricular sutures. Radiopaque markers were inserted on the leaflets, annular cuff, papillary tips, and left ventricle. After 10 +/- 5 days, the animals were studied with biplane videofluoroscopy to determine 3-dimensional marker coordinates at baseline and during dobutamine infusion. Transesophageal echocardiography assessed mitral regurgitation and valvular gradients. Mitral annular area was calculated from the annular markers. Physiologic mitral valve leaflet and annular dynamics were compared with 8 native sheep valves.

RESULTS

Average mitral regurgitation grade at baseline was 1.2 +/- 1.0 (range, 0-4), and the mean transvalvular pressure gradients were 3.6 +/- 1.3 and 6.2 +/- 2.2 mm Hg during baseline and dobutamine infusion, respectively. Xenograft mitral annular area contraction throughout the cardiac cycle was reduced (6% +/- 6% vs 13% +/- 4% for physiologic mitral valve and control valve, respectively; P =.03). Physiologic mitral valve leaflet geometry during closure differed from the native valve, with the anterior leaflet being convex to the atrium and with little motion of the posterior leaflet. Three animals survived more than 3 months; good healing of the annular cuff and papillary muscle tubes was demonstrated.

CONCLUSION

This stentless xenograft mitral valve substitute had low gradients at baseline and during stress conditions early postoperatively, with mild mitral regurgitation. Preliminary analysis of healing characteristics appeared favorable at 3 months. Additional studies are needed to determine long-term xenograft mitral valve performance and resistance to calcification.

The long-term outcome of mitral valve repair for mitral valve prolapse

The rationale of early surgery for severe chronic mitral regurgitation (MR) due to mitral valve prolapse (MVP) has been developed over the past decade on the basis of the understanding of the natural history of this disease and the predictors of outcomes after surgical correction of MR. The important decrease in operative mortality associated with the advancements in myocardial preservation, and more importantly the improved reparability of the myxomatous mitral valve, were an additional incentive to develop the concept of early surgery. Previous studies showed that mitral valve repair offers a survival advantage at short- and 10-year follow-up, and therefore suggested that it should be the treatment of choice for severe MR due to MVP. Moreover, very recent data provided new insight on the very long-term follow up, ie, beyond the usual first 10 years in which the initial survival benefit of repair may be negated by a late deterioration.

Lacunar stroke: transoesophageal echocardiographic factors influencing long-term prognosis

OBJECTIVE

Since little is known concerning factors which may influence long-term prognosis of patients presenting with lacunar stroke, we conducted a longitudinal study of this stroke subtype. Variables likely to affect outcome were assessed at baseline, including those from transoesophageal echocardiographic studies.

METHODS

Consecutive patients presenting with first-ever lacunar stroke underwent diagnostic workup that included brain CT or MRI, carotid duplex, and transthoracic and transoesophageal echocardiography. An assessment of patients was planned at entry (baseline), and thereafter every 12 months (clinic visit or telephone call), drop-out, or endpoint. The primary endpoint was nonfatal or fatal stroke. Secondary endpoint was death due to any cause.

RESULTS

Among 60 consecutive lacunar patients with the mean follow-up period of 3.9 years, 12 patients (20%) had stroke recurrence. The mean annual rate for stroke was 5.2%, and for death 2.8%. For multivariate Cox proportional hazards analysis, the following three variables with the values of p < 0.1 after univariate testing were chosen: age (p = 0.095); aortic atheroma (p = 0.066); and any source of embolism from heart (p = 0.007). Any source of embolism from heart was the only factor which significantly enhanced the risk of stroke recurrence (p = 0.015). Using Kaplan-Meier life table analysis, the curves of percent free of recurrent stroke were significantly different (log rank test p = 0.002).

CONCLUSIONS

Until the mechanism of lacunar stroke is better understood, it is reasonable to suggest that its investigation and prevention should be directed at all potential causes of future strokes including cardioembolism.

Comparison of survival after mitral valve replacement with biologic and mechanical valves in 1139 patients

OBJECTIVE

We sought to compare 10-year survival in patients after mitral valve replacement with biologic or mechanical valve prostheses.

METHODS

Retrospective survival analysis was performed on data from 1139 consecutive patients older than 18 years of age undergoing mitral valve replacement with Carpentier-Edwards (n = 495; Baxter Healthcare Corp, Irvine, Calif) or St Jude Medical (n = 644; St Jude Medical, Inc, St Paul, Minn) prostheses.

RESULTS

The 10-year survival was not statistically different between the patients receiving Carpentier-Edwards valves and those receiving St Jude Medical valves (P =.16). Adjusted survival estimates at 2, 5, and 10 years were 82% +/- 2% (95% confidence intervals, 79%-85%), 69% +/- 2% (95% confidence intervals, 64%-73%), and 42% +/- 3% (95% confidence intervals, 37%-48%), respectively, for the Carpentier-Edwards group and 83% +/- 2% (95% confidence intervals, 80%-86%), 72% +/- 2% (95% confidence intervals, 69%-76%), and 51% +/- 3% (95% confidence intervals, 45%-58%), respectively, for the St Jude Medical group. Predictors of worse survival after mitral valve replacement are older age, lower ejection fraction, presence of class IV congestive heart failure, coronary artery disease, renal disease, smoking history, hypertension, concurrent other valve surgery, and redo heart surgery.

CONCLUSION

Choice of biologic or mechanical prosthesis does not significantly affect long-term patient survival after mitral valve replacement.

Valvular heart disease: review and update

People with valvular heart disease are living longer, with less morbidity, than ever before. Advances in surgical techniques and a better understanding of timing for surgical intervention account for increased rates of survival. Echocardiography remains the gold standard for diagnosis and periodic assessment of patients with valvular heart disease. Generally, patients with stenotic valvular lesions can be monitored clinically until symptoms appear. In contrast, patients with regurgitant valvular lesions require careful echocardiographic monitoring for left ventricular function and may require surgery even if no symptoms are present. Aside from antibiotic prophylaxis, very little medical therapy is available for patients with valvular heart disease; surgery is the treatment for most symptomatic lesions or for lesions causing left ventricular dysfunction even in the absence of symptoms.

Repair of anterior leaflet prolapse by papillary muscle repositioning: a new surgical option

BACKGROUND

Although mitral valve repair is considered the gold standard for treating mitral regurgitation, anterior leaflet prolapse may still remain a challenging problem. This challenge is even greater for posterior commissural prolapse. We have used papillary muscle repositioning to treat anterior leaflet prolapse and suggest it as an alternative technique for all other methods previously described.

METHODS

From 1989 to 1999 we performed 253 mitral valve repairs, among which 132 involved anterior leaflet prolapse. In this population there were two groups: group I (n = 92) treated with papillary muscle repositioning and group II (n = 40) treated with chordal shortening. There was no statistical difference between the two groups concerning age, functional class, and left ventricular function. Etiology was similar in both groups, a degenerative process being predominant. At echocardiography, regurgitation was graded 3.4/4 in both groups. There was no statistical difference concerning preoperative ejection fraction, end-systolic and end-diastolic left ventricular diameter.

RESULTS

There were one in-hospital death in group I and two deaths in group II not related to mitral valve repair. Mean follow up is 36.4 +/- 29.2 months in group I and 70.5 +/- 9.5 months in group II. No patient was lost to follow-up. Mean regurgitation at follow-up was 0.75 +/- 0.67 in group I and 0.8 +/- 0.8 in group II (p = not significant). There was no statistical difference between the two groups concerning postoperative ejection fraction, end-systolic and end-diastolic left ventricular diameter. There was no late cardiac death in either group and there were no thromboembolic events. Actuarial survival rate is 98.9% and 96.3% in group I and 92.5% and 88.1% in group II at 3 and 8 years, respectively.

CONCLUSIONS

Therefore, we conclude that papillary muscle repositioning is a safe technique that provides excellent results at mid-term follow-up and facilitates treatment of anterior leaflet prolapse.

Is anterior leaflet repair always necessary in repair of bileaflet mitral valve prolapse?

BACKGROUND

Traditionally, bileaflet prolapse has been treated by posterior leaflet resection combined with one of a number of procedures designed to support the anterior leaflet. However, most patients with bileaflet prolapse do not have important anterior chordal pathology. This study was undertaken to evaluate the effectiveness of a strategy of posterior leaflet resection and annuloplasty alone for patients with bileaflet prolapse and no anterior chordal rupture or severe anterior chordal elongation.

METHODS

From 1993 to 1997, 93 patients with transesophageal echocardiography (TEE) demonstrated bileaflet prolapse and without anterior chordal rupture or important anterior chordal elongation had primary isolated mitral valve repair consisting only of posterior leaflet resection (quadrangular in 28 and sliding in 65) and annuloplasty (Cosgrove-Edwards in 83, pericardial in 9, and Carpentier-Edwards in 1). All patients had severe mitral regurgitation documented by intraoperative TEE. Mean age was 55+/-13 years; 60% were men.

RESULTS

Postrepair, mitral regurgitation was 0 to trace in 93% and 1+ in 7%. There were no operative deaths. Late follow-up was available in all patients, with 277 patient-years of follow-up available for analysis. Five-year actuarial survival was 95%. At a mean interval of 2.3+/-1.3 (SD) years, echocardiography demonstrated no or trace mitral regurgitation in 65%, 1+ in 28%, and 2+ in 7%. No correlates of late mitral regurgitation were identified by multivariable analysis. No patient has required reoperation.

CONCLUSIONS

In the absence of significant anterior chordal pathology, a strategy of posterior leaflet resection and annuloplasty corrects anterior leaflet prolapse and mitral regurgitation, and provides a durable repair without the necessity of additional procedures on the anterior leaflet.

Mitral valve prolapse: gender differences in evaluation and management

Mitral valve prolapse is a common clinical disorder that affects approximately 3-4% of the adult population. Prolapse occurs more commonly in women and has been associated with a variety of cardiac complications including mitral regurgitation, endocarditis, arrhythmias, and sudden death, as well as noncardiac manifestations including stroke. Much of our earlier understanding has been influenced by significant referral biases and lack of controlled studies. Our understanding of mitral prolapse has evolved considerably since the initial descriptions nearly 3 decades ago. This review on the current knowledge regarding diagnosis and management of primary mitral valve prolapse focuses on gender-related issues that influence clinical presentation, prognosis, and therapeutic strategies.

Mitral valve repair for isolated prolapse of the anterior leaflet: an 11-year follow-up

OBJECTIVE

Mitral valve insufficiency (MVI) because of involvement of the anterior mitral leaflet may pose additional risks for late outcome after mitral valve repair, because of more complex techniques. We retrospectively reviewed our experience in patients operated on for isolated anterior mitral leaflet prolapse approached by various techniques.

METHODS

Between 1986 and 1997, 616 patients underwent mitral valve repair at our Institution. Isolated pathology of the anterior mitral leaflet was the cause of MVI in 84 patients (13.6%). Age ranged from 23 to 74 years (mean 50 +/- 14). Etiology of MVI was predominantly degenerative (57 patients, 67.8%), and the mechanism of the regurgitation was mainly due to a chordal rupture (58 patients, 69%). Annular dilatation was present in 75 patients (89.5%). A variety of surgical techniques were applied including chordal shortening (five patients, 5.9%), chordal transposition (three patients, 3.5%), artificial chordae (11 patients, 13%). Since 1992, however, the majority of procedures was performed using the 'edge to edge' technique (52 patients, 51.9%). Annular dilatation was treated mainly by means of a prosthetic ring (46 patients, 61.3%) whereas 18 patients (24%) underwent posterior annuloplasty using gluteraldehyde-treated native pericardium.

RESULTS

Follow-up ranged from 3 to 122 months (mean 46 +/- 24 months). There were three hospital deaths (3.5%) and five late deaths (5.9%) for a Kaplan-Meier estimated survival of 87.6% at 8 years. Three patients underwent early reoperation within 30 days (3.5%), and six patients underwent late reoperation (7.1%), for a cumulative freedom from reoperation of 85.4% at 8 years. Seventy-four percent of the survivors (50 patients) are still in New York Heart Association Class I, and 92% of survivors (62 patients) have no or trivial (1+) residual mitral regurgitation at echocardiographic follow-up.

CONCLUSION

In spite of the greater complexity, conservative surgery to correct anterior mitral valve prolapse pertains high success rate of long term. Recent technical modifications ('edge-to-edge' technique) may allow more expeditious and reproducible procedures with expected favorable influence of mitral valve repair applicability.

Durability of mitral valve repair for degenerative disease

BACKGROUND

Degenerative mitral valve disease is the most common cause of mitral regurgitation in the United States. Mitral valve repair is applicable in the majority of these patients and has become the procedure of choice.

OBJECTIVE

This study was undertaken to identify factors influencing the durability of mitral valve repair.

PATIENTS AND METHODS

Between 1985 and 1997, 1072 patients underwent primary isolated mitral valve repair for valvular regurgitation caused by degenerative disease. Repair durability was assessed by multivariable risk factor analysis of reoperation. It was supplemented by a search for valve-related risk factors for death before reoperation. Three hospital deaths occurred (0.3%); complete follow-up (4152 patient-years) was available in 1062 of 1069 hospital survivors (99.3%).

RESULTS

At 10 years, freedom from reoperation was 93%. Among 30 patients who required reoperation for late mitral valve dysfunction, the repair failed in 16 (53%) as a result of progressive degenerative disease. Durability of repair was adversely affected by pathologic conditions other than posterior leaflet prolapse, use of chordal shortening, annuloplasty alone, and posterior leaflet resection without annuloplasty. Durability was greatest after quadrangular resection and annuloplasty for posterior leaflet prolapse and was enhanced by the use of intraoperative echocardiography. Death before reoperation was increased in patients having isolated anterior leaflet prolapse or valvular calcification and by use of chordal shortening or annuloplasty alone.

CONCLUSIONS

Repair durability is greatest in patients with isolated posterior leaflet prolapse who have posterior leaflet resection and annuloplasty. Chordal shortening, annuloplasty alone, and leaflet resection without annuloplasty jeopardize late results.

Arrhythmias and sudden cardiac death in elite athletes. American College of Cardiology, 16th Bethesda Conference

With the recent high visibility deaths of Hank Gathers and Reggie Lewis, two nationally recognized elite basketball players due to cardiovascular disease and arrhythmias, our awareness of the most optimal ways to manage athletes with known arrhythmias has become heightened. In making medical decisions we physicians come to rely in large measure on data, in addition to clinical acumen and experience. Unfortunately, we are at a disadvantage with respect to athletes since previously published data on the natural history and outcome of such individuals with known arrhythmias are sparse. Furthermore, the tragedies of Lewis, Gathers, Pete Maravich and others are also poignant reminders that the denominator of this equation is not defined and that we do not really know precisely how many athletes experience important arrhythmias, nor their relation to sports activity. In the decade since the 16th Bethesda Conference, an American College of Cardiology sponsored consensus panel that developed standards and recommendations for the disqualification from competition of athletes with known cardiovascular disease, little new data have been developed to make objective decisions in these areas (including arrhythmias) much easier. Nevertheless, while such decision-making in athletes involves situations that are relatively rare, the consequences of misjudgement are substantial. Unfortunately, to complicate matters, even if the precise likelihood of sudden death for a given athlete with arrhythmias were known, many (if not most) professional and elite college athletes might still regard any risk as acceptable and withdrawal from formal competition as highly unacceptable from a financial and psychological standpoint. In this review, consideration will be given to the state of our medical knowledge in these areas. Many controversies persist with regard to arrhythmias, most notably for the athlete who has Wolff-Parkinson-White, mitral valve prolapse, myocarditis, or complex ventricular arrhythmias. Finally, consideration will be given to the broader issues of how, ad physicians and members of society, we may deal with these complex issues.

Long-term results of artificial chordae implantation in patients with mitral valve prolapse

BACKGROUND AND AIMS OF THE STUDY

In terms of valve-related complication and ventricular function, mitral valve repair (MVR) is superior to valve replacement. To date, chordae shortening and transposition have been used for diffuse prolapses. We have used artificial chordae implantation for MVR since 1986, and here review our long-term results.

METHODS

Pericardial strips were used in nine patients, and e-PTFE (Gore-Tex) sutures in 58. A degenerative lesion was present in 69% of cases, endocarditis in 16% and rheumatic valvulitis in 7%. Implantation of artificial chordae was indicated for treatment of diffuse prolapse. Annuloplasty was performed in patients with or without prosthetic ring.

RESULTS

Actuarial survival rate was 78% for the pericardial chordae group at nine years, and 94% for the Gore-Tex chordae group at eight years. Thromboembolic events occurred in two pericardial chordae patients, and three Gore-Tex chordae patients required reoperation. Freedom from reoperation was 100% for pericardial chordae after nine years and 96% for Gore-Tex chordae after eight years. Quality of life among survivors is good: 83% are in NYHA class I, 89% are free from anticoagulation, and 60% require no medication. Mitral valve orifice area, estimated echocardiographically, was similar in both groups at discharge and at follow up.

CONCLUSIONS

MVR with artificial chordae provided satisfactory valve function for up to nine years. Gore-Tex chordae are less prone to deterioration than pericardial chordae. Follow up observations support the use e-PTFE chordae to correct diffuse leaflet prolapse.

Green Lane Hospital experience with mitral valve repair for prolapse: adverse outcomes for highly symptomatic patients

BACKGROUND AND AIMS OF THE STUDY

Valve repair, where suitable, is the preferred option in patients who require mitral surgery. A number of studies have shown excellent long-term results, but most were undertaken in tertiary referral centers with a high throughput of patients.

METHODS

We present our experience in 60 patients, aged 60 +/- 14 years, undergoing repair between 1984 and 1993. Most patients (83%) were in New York Heart Association (NYHA) class II or III at the time of surgery; 27% had concomitant ischemic heart disease. Almost all (98%) had posterior leaflet repair and 18% had anterior leaflet repair. Eight surgeons each performed a mean of 7.5 operations during this period.

RESULTS

The 30-day mortality rate was 3.3%. There were seven late deaths. Five patients underwent reoperation for mitral regurgitation (two early, three late). At six years, 60% of patients were alive, or free of stroke or reoperation. Late follow up was obtained in 45 of 47 surviving patients: 95% were in NYHA class I or II; one-third were on anticoagulants for atrial fibrillation; 90% had mild (or less) mitral regurgitation on echocardiography.

CONCLUSIONS

These data show that most patients have a very good outcome from valve repair surgery and encourage the trend towards operating earlier in the course of the disease. Adverse outcomes occurred mainly in patients who were highly symptomatic at the time of surgery. The high proportion of patients on postoperative anticoagulants underscores the importance of operating before atrial fibrillation becomes permanent.

Artificial chordae in the treatment of anterior mitral leaflet pathology

This report describes the authors' clinical experience with expanded polytetrafluorethylene (e-PTFE) sutures to replace the anterior mitral leaflet chordae for valve repair. Between November 1986 and July 1995, 203 patients underwent operations with e-PTFE chordae insertion. Among these, 122 had artificial chordae utilized for anterior mitral leaflet repair. Four patients had the valve replaced during the same operation because of an unsatisfactory result. One patient died from respiratory insufficiency 16 days after operation. Transoesophageal echocardiography at discharge from hospital showed no evidence of regurgitation in 81 cases, and trivial regurgitation in 36. During a mean follow-up of 36.6 (range 1-106) months two other patients died from causes unrelated to the valve repair, while one patient had a transient ischaemic attack returning to sinus rhythm. Two patients were reoperated on 12 and 18 months respectively after their initial operation for progression of valvular degeneration causing natural chordae rupture. Among the remaining 113 patients, 111 are in New York Heart Association functional class I and yearly transoesophageal echocardiography has shown absent or trivial regurgitation. The utilization of e-PTFE as artificial chordae for anterior mitral leaflet pathology is a safe and reliable procedure, yielding excellent results and increasing the number of candidates for valve repair.

Chordal transposition for anterior mitral prolapse: early and long-term results

OBJECTIVE

Chordal transposition was advocated for correction of anterior mitral prolapse. We have evaluated the early and late results of this technique in different anatomical presentations.

METHODS

From 1986 to 1995, 185 mitral valve repairs were carried out for pure mitral regurgitation due to a degenerative disease. Eighty-nine patients had either an anterior prolapse (39) or prolapse of both leaflets (50) at initial presentation and underwent chordal transposition from the mural leaflet to the anterior leaflet. The corrective procedure was completed by polytetrafluoroethylene or pericardial posterior annuloplasty. Twenty patients presented a complex pathology and 26 had chordal elongation of mural leaflet. Annular calcifications were found in 9 patients. Seven patients required shortening of transposed chordae and two patients the additional shortening of an anterior chorda.

RESULTS

Operative mortality was 3.3% and follow-up was 95% complete (average 41 months). There were five postreconstruction valve replacements (two earlier and three later) for a probability of freedom from late reoperation or 3+ mitral regurgitation of 88.6 +/- 4.8% at 5 years. Of the patients 79% presented no or trivial residual MR, 17% moderate MR and 4% severe MR. The presence of a complex pathology or posterior chordal elongation did not influence the entity of postoperative residual regurgitation. On the contrary, the patients with annular calcifications had a residual regurgitation/left atrium area ratio greater than patients without annular calcification (15.8 +/- 11.5% vs. 6.1 + 9.9%; P = 0.009).

CONCLUSIONS

Chordal transposition is an effective and easily carried out technique for the correction of anterior mitral prolapse. The presence of a complex pathology or posterior chordal elongation do not rule out the procedure. The absence of annular calcification is important in order to obtain a satisfactory correction.

Long-term results of mitral valve reconstruction for regurgitation of the myxomatous mitral valve

The myxomatous, degenerated, prolapsed or "floppy" mitral valve is the most common cause of mitral regurgitation in North America. Mitral valve reconstruction for mitral regurgitation was carried out in 219 consecutive patients with a myxomatous mitral valve from 1984 to 1993. Of the 139 men and 80 women, 23 to 84 years of age (mean 63 years), 36% of patients were 70 years of age or older, 77% were in New York Heart Association functional class III or IV, and 29% had coronary artery disease necessitating coronary bypass. The most common operation was posterior leaflet resection (161 patients [73%]). The anterior leaflet was resected in 14 patients, and both the anterior and posterior leaflets were resected in 15 patients. A variety of other techniques were used, including commissuroplasty and use of annuloplasty rings. A flexible Duran ring was used in 111 patients (51%), a Carpentier-Edwards ring in 44 patients (20%), and no ring was used in 64 patients (29%). Five operative deaths occurred (2.3%); four of the five deaths occurred in patients 70 years of age or older (5.1%); and one in 141 patients (0.7%) was younger than 70 years of age. In the late postoperative period (mean follow-up 2 years), 90% of patients had no symptoms, two had endocarditis, and seven patients had thromboemboli (transient in four, permanent in three). Structural valve degeneration requiring reoperation occurred late in 12 patients; eight were in posterior leaflet resection and two in anterior or anterior and posterior; six of 12 had no annuloplasty ring. The incidence of structural valve degeneration was less than 5% from 1990 to 1993. No systolic anterior motion of the mitral valve was seen with postoperative echocardiography before discharge. Actuarial analysis at 5 years for overall survival was 86% +/- 5%, freedom from infectious valve degeneration 97% +/- 2%, and freedom from thromboembolism 94% +/- 3%. Freedom from structural valve degeneration overall was 83% +/- 4%, with a flexible ring it was 89% +/- 6%, with a rigid ring it was 88% +/- 6%, and with no ring it was 67% +/- 12% (p = 0.03). Mitral valve reconstruction for complicated myxomatous disease of the mitral valve, regardless of leaflet involvement, is feasible and offers excellent early and late results.

Mitral valve repair in patients over the age of 70 years

The question of whether to repair or replace the mitral valve in the elderly remains unanswered. The purpose of our study is to describe our experience with mitral valve repair (MVR) using Carpentier's technique in patients 70 years and older. Fifty consecutive patients underwent MVR between 1984-1992. There were 30 female patients. All had 2 + or more mitral regurgitation (MR). The valve pathology included ischemic (n = 28), myxomatous (n = 7) and rheumatic (n = 6), leaflet prolapse (n = 11) and healed bacterial endocarditis (n = 3). The clinical findings included: myocardial infarction (n = 17), congestive heart failure (n = 18), atrial fibrillation (n = 14) and pulmonary hypertension (n = 10). The surgical technique involved placement of a Carpentier ring (n = 41) or Duran ring (n = 3), resection of leaflets (n = 9), shortening of the chordae (n = 8) and commissurotomy (n = 6). At surgery, coronary bypass was carried out in 32 patients while the aortic valve was replaced in five and repaired in one. Postoperative complications included atrial fibrillation (n = 14), transient neurologic events (n = 4), heart block requiring pacemaker (n = 3) and prolonged intubation (n = 4). Echocardiogram carried out postoperatively showed 2 + MR in three patients, 1 + in four, and a trace or none in the remaining (n = 39). No patient required re-operation for MR. Three patients (6%) died within 30 days after surgery due to low output (n = 1), malignant ventricular arrhythmia (n = 1) and heart block with cardiac arrest (n = 1).(ABSTRACT TRUNCATED AT 250 WORDS)

Valve-related events and valve-related mortality in 340 mitral valve repairs. A late phase follow-up study

To assess the early and late valve-related events, 340 consecutive patients undergoing mitral valve repair from 1969 to 1988 were evaluated. Follow-up was complete, with a mean of 7.5% years and range from 2 to 22 years (cumulative 2456 patient-years). There were 221 (65%) female patients. Rheumatic valvular disease was present in 246 (68%) patients. The remaining patients had ischemic or congenital valve disease, floppy valve or infective endocarditis. At surgery, 47% of the patients had pure mitral incompetence, 43% had mixed mitral stenosis and incompetence and 10% had predominant mitral stenosis. Seventy-three percent of the patients were in functional class III or IV. Twelve percent had had prior heart surgery. Concomitant valve procedures including coronary revascularization were performed in 62.3%. There were 23 hospital deaths (6.8%) but only 3 of these (0.8%) were valve-related in patients who died at reoperation for valve repair failure. There were 4 other early repair failures who survived early reoperation. Of the 317 hospital survivors, there were 127 late deaths, and an actuarial survival of 44 +/- 3.7% (70% CL) at 14 years. Of these, 13 were valve-related or 0.5% patient-year. Late events included thromboembolism (TE) 1% patient-year, anticoagulant bleeding 0.4% patient-year, infective endocarditis (IE) 0.2% patient-year and late reoperation for mitral valve repair failure in 63 patients or 2.8% patient-year. At the late follow-up, 88% of the hospital survivors were in functional class I or II.(ABSTRACT TRUNCATED AT 250 WORDS)

Mitral valve repair for ischemic mitral insufficiency

Over a 5-year period, 1,292 patients had operation on their native mitral valves. Ischemia was the cause of mitral insufficiency in 84 patients (6.5%). Sixty-five patients (77.4%) had mitral valve repair. Mean age was 66 +/- 10 years; 35 patients (53.8%) were women. Mean degree of preoperative insufficiency was 3.2 +/- 0.7; mean preoperative New York Heart Association functional class was 3.3 +/- 0.7. Eleven patients (16.9%) had acute and 54 (83.1%) had chronic mitral insufficiency. Valve prolapse was present in 26 patients (40%). Restrictive leaflet motion secondary to regional or global left ventricular dilatation occurred in 39 patients (60%). All patients had associated myocardial revascularization followed by transatrial valvuloplasty. Multiple techniques were employed to achieve valve competence: leaflet resection (3), chordal shortening (15), papillary muscle reimplantation (10), papillary muscle shortening (3), and annuloplasty (63). There were six (9.2%) hospital deaths (acute, 9.1%; chronic, 9.3% [not significant]; prolapse, 11.5%; restrictive, 7.7% [not significant]). The mean degree of postoperative mitral insufficiency was 0.6 +/- 0.8 in 51 patients. At a mean follow-up of 3.1 +/- 1.6 years, patient survival was 96% for patients with valve prolapse and 48% for those with restrictive leaflet motion (p = 0.02). New York Heart Association functional class was improved in all groups. Ischemic mitral insufficiency is an uncommon cause of mitral valve disease that is amenable to repair in the majority of cases of both acute and chronic onset. The operative mortality is low, and operation is associated with superior survival in patients with valve prolapse.

[Incidence of sudden heart arrest in mitral valve prolapse syndrome]

Among 1500 consecutive forensic autopsy cases 4 cases of sudden cardiac death due to a mitral valve prolapse syndrome could be found. Postmortem diagnosis depends on severe macroskopic changes of the valve leaflets. According to literature there is no increased risk of sudden cardiac death in cases of "silent" mitral valve prolapse. Only in 2%-4% of all cases severe mitral regurgitation or leaflet thickening above 5 mm leads to an increased incidence of sudden cardiac death. The 4 presented cases belong to this subgroup.

Mitral valve prolapse: cardiac arrest with long-term survival

Cardiac arrest has been reported in patients with mitral valve prolapse; however, clinical characteristics and survival information are limited since most of the cases reported include autopsy data. Nine patients (2 male, 7 female) with mitral valve prolapse were identified who had cardiac arrest; ventricular fibrillation was documented in 8 patients; resuscitation was unsuccessful in 2. Eight had a history of palpitations (months to 15 years duration) and ventricular arrhythmias, 3 had a history (5-15 years) of recurrent syncope, and 1 was totally asymptomatic. Cardiac catheterization-angiographic studies in 8 patients demonstrated normal coronary artery anatomy and mitral valve prolapse. All 9 patients had auscultatory and echocardiographic evidence of mitral valve prolapse. Seven survivors (6 still alive) were followed from 3 to 14 years after cardiac arrest. A subset of patients with mitral valve prolapse and cardiac arrest is described in whom past medical history is compatible with cardiac arrhythmias or syncope, and whose long-term prognosis appears better than patients with other causes of cardiac arrest.