For degenerative mitral disease, repair is superior to replacement; however, the best operative strategy for rheumatic mitral disease remains unclear. We evaluated the association between ...decision-making in choosing repair versus replacement and outcomes across 2 decades of rheumatic mitral surgery.
Patients undergoing isolated, first-time rheumatic mitral surgery were identified. Era 1 (1997-2008) and Era 2 (2009-2018) were distinguished by intraoperative assessment of anterior leaflet mobility/calcification (Era 2) in deciding between mitral repair versus replacement. Primary outcome was a composite of death, reoperation, and severe valve dysfunction.
Among 180 patients, age was 59 ± 14 years, and ejection fraction was 58% ± 10%. A higher proportion in Era 1 (n = 56) compared with Era 2 (n = 124) had preoperative atrial fibrillation (68% vs 46%; P = .006); the groups were otherwise similar. Primary indication was mitral stenosis in 69% (124 out of 180; pure = 35, mixed = 89) and did not differ by era (P = .67). During Era 1, 70% (39 out of 56) underwent repair, compared with 33% (41 out of 124) during Era 2 (P < .001). Freedom from death, reoperation, or severe valve dysfunction at 5 years was higher in Era 2 (72% ± 9%) than Era 1 (54% ± 13%; P = .04). Five-year survival was higher in Era 2 than Era 1, but did not differ between repair versus replacement. Five-year cumulative incidence of reoperation with death as a competing risk did not differ by era, but was higher after repair than replacement.
Careful assessment of anterior leaflet mobility/calcification to determine mitral repair or replacement was associated with improved outcomes. This decision-making strategy may alter the threshold for rheumatic mitral replacement in the current valve-in-valve era.
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The aim of this study was to evaluate the predictors of left ventricular outflow tract (LVOT) obstruction after transcatheter mitral valve replacement (TMVR).
LVOT obstruction is a major concern with ...TMVR, but limited data exist regarding its predictors and impact on outcomes.
Patients with pre-procedural multidetector row computed tomography (MDCT) undergoing TMVR for failed mitral bioprosthetic valves (valve-in-valve), annuloplasty rings (valve-in-ring), and mitral annular calcification (valve-in-MAC) were included in this study. Echocardiographic and procedural characteristics were recorded, and comprehensive assessment with MDCT was performed to identify the predictors of LVOT obstruction (defined as an increment of mean LVOT gradient ≥10 mm Hg from baseline). The new LVOT (neo-LVOT) area left after TMVR was estimated by embedding a virtual valve into the mitral annulus on MDCT, simulating the procedure.
Among 194 patients with pre-procedural MDCT undergoing TMVR (valve-in-valve, 107 patients; valve-in-ring, 50 patients; valve-in-MAC, 37 patients), LVOT obstruction was observed in 26 patients (13.4%), with a higher rate after valve-in-MAC than valve-in-ring and valve-in-valve (54.1% vs. 8.0% vs. 1.9%; p < 0.001). Patients with LVOT obstruction had significantly higher procedural mortality compared with those without LVOT obstruction (34.6% vs. 2.4%; p < 0.001). Receiver-operating characteristic curve analysis showed that an estimated neo-LVOT area ≤1.7 cm2 predicted LVOT obstruction with sensitivity of 96.2% and specificity of 92.3%.
LVOT obstruction after TMVR was associated with higher procedural mortality. A small estimated neo-LVOT area was significantly associated with LVOT obstruction after TMVR and may help identify patients at high risk for LVOT obstruction.
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The durability of mitral valve repair (MVr) is usually defined by the absence of recurrent significant mitral regurgitation. Postrepair mitral stenosis (MS) is a less frequent and less studied mode ...of failure of MVr. We analyzed our experience in patients who underwent reoperation for postrepair MS to characterize mechanisms resulting in MS and to summarize reoperative surgical strategies and mid-term outcomes.
Using a prospective database, we retrospectively analyzed data on 35 consecutive patients who underwent reoperation for symptomatic moderate to severe MS between January 1, 2011, and February 1, 2020.
The mean patient age was 61.4 ± 11.4 years, and 69% were female. The median annuloplasty ring size used at the initial repair was 28 mm (interquartile range, 26-30 mm). Additional repair techniques at the initial operation included leaflet resection in 12 patients (34%) and commissuroplasty or edge-to-edge repair in 6 patients (18%). At reoperation, the most common mechanism of MS was pannus ingrowth in 20 patients (57%), leaflet calcification in 12 (34%), commissural fusion in 5 (14%), and tunnel effect (functional MS) in 3 (9%). Twenty-two patients (63%) underwent valve replacement, and 13 (37%) underwent valve re-repair. In patients who underwent re-repair, annuloplasty revision was performed in all patients, with 6 patients (46%) converted from complete ring to band, 4 (11%) converted from ring to pericardial annuloplasty, 2 (6%) converted to no annuloplasty, and 1 (8%) with annuloplasty ring upsizing. There were no in-hospital or 1-year mortalities. Survival at the 5-year follow-up was 93.9%.
MS causing late failure of MVr is frequently associated with smaller ring sizes and inflammatory or calcific changes in the valve. Highly selected patients may be good candidates for mitral valve re-repair.
Mitral inflow stenosis following previous valve reconstruction and annuloplasty is caused by fibrocalcific degeneration and/or annuloplasty size–leaflet tissue mismatch. The extent of pathology and residual leaflet mobility will influence the feasibility of re-repair and reoperative strategy. Display omitted
The purposes of this study are to compare outcomes of mitral valve repair (MV-repair) and mitral valve replacement for patients with severe mitral regurgitation with preserved ventricular function ...and no congestive heart failure (CHF) symptoms and to examine variations in surgeon choice of procedure and outcomes by surgeon volume.
In total, 2259 consecutive patients in 42 New York State hospitals with the characteristics mentioned previously who underwent mitral valve repair (1801, 79.7%) or replacement between January 1, 2008, and December 31, 2014, were identified from a mandatory statewide clinical registry. Propensity-matching was used to compare mortality and competing risk analyses were used to compare nonfatal outcomes. Median follow-up was 4.0 years. The use of mitral repair and risk-adjusted mortality for surgery were also examined as a function of individual surgeon mitral case volume.
Propensity-matched patients who underwent MV-repair experienced a significantly lower mortality rate at 4 years (3.5% vs 12.1%, P < .001). Greater-volume surgeons were more likely to perform MV-repairs (92% vs 84%, 74%, and 69% in lower volume quartiles, respectively). No significant differences in mortality were observed among volume quartiles.
Patients with chronic severe primary mitral valve regurgitation with preserved ventricular function and no CHF symptoms who underwent MV-repair experienced lower mortality and no different reoperation, CHF, or stroke readmission rates than patients who underwent replacement. Greater-volume surgeons were more likely than their lower volume counterparts to choose mitral repair. Repair should be considered as the surgical option for these patients whenever possible.
Treatment of ischemic mitral regurgitation (IMR) is in evolution, as percutaneous procedures and complex surgical repair have been recently investigated in randomized clinical trials and matched ...studies. This study aims to review and compare the current treatment options for IMR.
A comprehensive literature search was conducted using electronic databases. The primary outcome was all-cause long-term mortality. The secondary outcomes were perioperative mortality, unplanned rehospitalization, reoperation, and composite end points as defined in the original articles.
A total of 12 articles met the inclusion criteria and were included in the final meta-analysis. The MitraClip procedure did not confer a significant benefit in mortality and repeated hospitalization compared with medical therapy alone. In patients with moderate IMR, the adjunct of mitral procedure over coronary artery bypass graft is not associated with clinical improvements. When evaluating mitral valve (MV) replacement versus repair, hospital mortality was greater among patients undergoing replacement (odds ratio OR, 1.91; P = .009), but both reoperation and readmission rates were lower (OR, 0.60, P = .05; and OR, 0.45, P < .02, respectively). Comparing restrictive annuloplasty alone with adjunctive subvalvular repair, subvalvular procedures resulted in fewer readmissions (OR, 0.50; P = .06) and adverse composite end points (P = .009).
MitraClip procedure is not associated with improved outcomes compared with medical therapy. MV replacement is associated with increased early mortality but reduced reoperation rate and readmission rate compared with MV repair using annuloplasty in moderate-to-severe IMR. Despite no significant benefit in isolated outcomes comparing annular and adjunct subvalvular procedures, the adjunct of subvalvular procedures reduces the risk of major postoperative adverse events.
This study-level meta-analysis evaluates the currently available options for the treatment of ischemic mitral regurgitation. CABG, Coronary artery bypass graft; RCT, randomized controlled trial; PSM, propensity score–matched study. Display omitted
Echocardiographic quantitation of degenerative mitral regurgitation (DMR) is recommended whenever possible in clinical guidelines but is criticized and its scalability to routine clinical practice ...doubted. We hypothesized that echocardiographic DMR quantitation, performed in routine clinical practice by multiple practitioners, predicts independently long-term survival and thus is essential to DMR management.
We included patients diagnosed with isolated mitral valve prolapse from 2003 to 2011 and any degree of mitral regurgitation quantified by any physician/sonographer in routine clinical practice. Clinical/echocardiographic data acquired at diagnosis were retrieved electronically. The end point was mortality under medical treatment analyzed by Kaplan-Meier method and proportional hazard models.
The cohort included 3914 patients (55% male) mean age (±standard deviation) 62±17 years with left ventricular ejection fraction 63±8% and median after routinely-measured effective regurgitant orifice area (EROA) interquartile range, 19 0-40 mm
. During follow-up (6.7±3.1 years), 696 patients died under medical management, and 1263 underwent mitral surgery. In multivariate analysis, routinely-measured EROA was associated with mortality (adjusted hazard ratio, 1.19; 95% confidence interval, 1.13-1.24; P<0.0001 per 10 mm
) independently of left ventricular ejection fraction and end-systolic diameter, symptoms, and age/comorbidities. The association between routinely-measured EROA and mortality persisted with competitive risk modeling (adjusted hazard ratio, 1.15; 95% confidence interval, 1.10-1.20; P<0.0001 per 10 mm
), or in patients without guideline-based class I/II surgical triggers (adjusted hazard ratio, 1.19; 95% confidence interval, 1.10-1.28; P<0.0001 per 10 mm
) and in all subgroups examined (all P<0.01). Spline curve analysis showed that, compared with general population mortality, excess mortality appears for moderate DMR (EROA ≥20 mm
), becomes notable at EROA ≥30 mm
, and steadily increases with higher EROA levels (eg, higher EROA levels beyond the 40 mm
threshold).
Echocardiographic DMR quantitation is scalable to routine practice and is independently associated with clinical outcome. Routinely-measured EROA is strongly associated with long-term survival under medical treatment. Excess mortality versus the general population appears in the moderate DMR range and steadily increases with higher EROA. Hence, individual EROA values should be integrated into therapeutic considerations, in addition to categorical DMR grading.
Transcatheter edge-to-edge (TEER) mitral repair may be complicated by residual or recurrent mitral regurgitation. An increasing need for surgical reintervention has been reported, but operative ...outcomes are ill defined.
This study evaluated national outcomes of mitral surgery after TEER.
The Society of Thoracic Surgeons (STS) Adult Cardiac Surgery Database was used to identify 524 adults who underwent mitral surgery after TEER between July 2014 and June 2020. Emergencies (5.0%; n = 26), previous mitral surgery (5.3%; n = 28), or open implantation of transcatheter prostheses (1.5%; n = 8) were excluded. The primary outcome was 30-day or in-hospital mortality.
In the study cohort of 463 patients, the median age was 76 years (interquartile range IQR: 67 to 81 years), median left ventricular ejection fraction was 57% (IQR: 48% to 62%), and 177 (38.2%) patients had degenerative disease. Major concomitant cardiac surgery was performed in 137 (29.4%) patients: in patients undergoing isolated mitral surgery, the median STS-predicted mortality was 6.5% (IQR: 3.9% to 10.5%), the observed mortality was 10.2% (n = 23 of 225), and the ratio of observed to expected mortality was 1.2 (95% confidence interval CI: 0.8 to 1.9). Predictors of mortality included urgent surgery (odds ratio OR: 2.4; 95% CI: 1.3 to 4.6), nondegenerative/unknown etiology (OR: 2.2; 95% CI: 1.1 to 4.5), creatinine of >2.0 mg/dl (OR: 3.8; 95% CI: 1.9 to 7.9) and age of >80 years (OR: 2.1; 95% CI: 1.1 to 4.4). In a volume outcomes analysis in an expanded cohort of 591 patients at 227 hospitals, operative mortality was 2.6% (n = 2 of 76) in 4 centers that performed >10 cases versus 12.4% (n = 64 of 515) in centers performing fewer (p = 0.01). The surgical repair rate after failed TEER was 4.8% (n = 22) and was 6.8% (n = 12) in degenerative disease.
This study indicates that mitral repair is infrequently achieved after failed TEER, which may have implications for treatment choice in lower-risk and younger patients with degenerative disease. These findings should inform patient consent for TEER, clinical trial design, and clinical performance measures.
Chronic kidney disease (CKD) is a major risk factor for valvular heart disease (VHD). Mitral annular and aortic valve calcifications are highly prevalent in CKD patients and commonly lead to valvular ...stenosis and regurgitation, as well as complications including conduction system abnormalities and endocarditis. VHD, especially mitral regurgitation and aortic stenosis, is associated with significantly reduced survival among CKD patients. Knowledge related to VHD in the general population is not always applicable to CKD patients because the pathophysiology may be different, and CKD patients have a high prevalence of comorbid conditions and elevated risk for periprocedural complications and mortality. This Kidney Disease: Improving Global Outcomes (KDIGO) review of CKD and VHD seeks to improve understanding of the epidemiology, pathophysiology, diagnosis, and treatment of VHD in CKD by summarizing knowledge gaps, areas of controversy, and priorities for research.
This study explored the influence of prosthesis selection on long-term outcomes in patients who underwent mitral valve repair for mitral insufficiency (MI) due to type II dysfunction.
We ...retrospectively reviewed 452 patients with MI who underwent mitral valve repair for type II dysfunction between 2001 and 2014. Of these, 167 patients (37%) presented with anterior leaflet prolapse (anterior group) and 285 (63%) presented with posterior prolapse (posterior group). Full rings were applied in 95 patients (57%) in the anterior group and in 54 patients (19%) in the posterior group, and partial bands were applied in all others. We compared long-term outcome and change of MI severity over time between patients with partial-band and full-ring repair in the anterior and in the posterior groups using a mixed-effect model with repeated measures and propensity score-matched analysis.
Ten-year survival of the cohort was 90.5%. Echocardiography revealed MI ≥ 3 at follow-up in 58 patients (12.8%). Twenty-one patients (4.6%) required reoperation; freedom from reoperation was 92.1% at 10 years. The MI severity over time in patients in the anterior group was higher than that in patients in the posterior group (P < .0001). Moreover, MI severity over time in patients with the partial band was higher than patients with the full ring in the anterior group (P = .0176). Propensity score-matched analysis in the anterior group, but not in the posterior group, revealed a significantly higher MI severity in patients with the partial band than those with the full ring over the study period (P = .04).
Full-ring annuloplasty is indicated in the setting of anterior prolapse to prevent recurrent MI, whereas prosthesis type is not a determinant of recurrent MI in the setting of posterior prolapse.
Secondary mitral regurgitation (SMR) occurs in the absence of organic mitral valve disease and may develop as the left ventricle dilates or remodels or as a result of leaflet tethering with impaired ...coaptation, most commonly from apical and lateral distraction of the subvalvular apparatus, with late annular dilatation. The optimal therapy for SMR is unclear. This study sought to evaluate the 1-year adjudicated outcomes of all patients with SMR undergoing the MitraClip procedure in the EVEREST II (Endovascular Valve Edge-to-Edge Repair Study) Investigational Device Exemption program, which is comprised of the randomized clinical trial, the prospective High-Risk Registry, and the REALISM Continued Access Registry (Multicenter Study of the MitraClip System).
Patients with 3+/4+ SMR enrolled in EVEREST II were stratified by non-high surgical risk (non-HR) and high surgical risk (HR) status (defined as Society of Thoracic Surgeons risk of mortality ≥12% or predefined risk factors). Clinical, echocardiographic, and functional outcomes at 1 year were evaluated.
A total of 616 patients (482 HR, 134 non-HR; mean age, 73.3±10.5 years; Society of Thoracic Surgeons risk, 10.2±6.9%) with SMR underwent the MitraClip procedure. At baseline, 80.5% of patients were in New York Heart Association class III/IV. Major adverse events at 30 days included death (3.6%), stroke (2.3%), and renal failure (1.5%). At discharge, 88.8% had MR ≤2+. At 1 year, there were 139 deaths, and the Kaplan-Meier estimate of freedom from mortality was 76.8%. The majority of surviving patients (84.7%) remained with MR ≤2+ and New York Heart Association class I/II (83.0%). Kaplan-Meier survival at 1 year was 74.1% in HR patients and 86.4% in non-HR patients ( P=0.0175). At 1 year, both groups achieved comparable MR reduction (MR ≤2+, 84.0% versus 87.0%) and improvement in left ventricular end-diastolic volume (-8.0 mL versus -12.7 mL), whereas New York Heart Association class I/II was found in 80.1% versus 91.8% ( P=0.008) of HR and non-HR patients, respectively. In HR patients, the annualized rate of heart failure hospitalizations decreased from 0.68 to 0.46 in the 12 months before to 12 months after the procedure ( P<0.0001).
Transcatheter mitral valve repair with the MitraClip in patients with secondary MR is associated with acceptable safety, reduction of MR severity, symptom improvement, and positive ventricular remodeling.
https://www.clinicaltrials.gov . Unique identifiers: NCT00209274, NCT01940120, and NCT01931956.
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