The added value of computed tomography (CT) follow-up after elective proximal aortic surgery is unclear. We evaluated the benefit of CT follow-up by assessing the incidence of aorta-related ...complications and reinterventions detected during routine CT follow-up.
Data on 314 patients undergoing first time elective proximal aortic surgery between 2000 and 2015 were collected. The primary study end points were aorta-related complications and reinterventions, detected during routine CT follow-up. Secondary study endpoints included all aorta-related complications and reinterventions, irrespective of the mode of detection and survival.
Median CT follow-up time was 6.8 (IQR 4.1-9.8) years, during which a total of 1303 routine follow-up CT-scans (median 4, IQR 3-5) were performed. During CT follow-up, aorta-related complications were detected in 18 (5.7%) patients, of which 6 (1.6%) underwent reintervention. In total, 28 aorta-related complications were observed in 23 (7.3%) patients, of which 9 led to reintervention. In order to detect 1 aorta-related complication leading to reintervention, 218 routine follow-up CT-scans were required. The unadjusted and EuroSCORE II adjusted hazard ratios of not undergoing CT follow-up on mortality were 1.260 (95% CI 0.705-2.251) and 0.830 (95% CI 0.430-1.605), respectively.
Following first time elective proximal aortic surgery, aorta-related complications are uncommon, are not always detected during CT follow-up and, if detected, often do not result in reintervention. Therefore, a more conservative CT follow-up protocol could be considered in selected patients to reduce lifetime radiation burden and health care costs.
Abstract Mitral valve repair techniques in ventricular functional mitral regurgitation are controversial due to ongoing debates about long-term repair durability in the setting of left ventricular ...remodelling. To address the limitations of conventional annuloplasty, subannular techniques, such as papillary muscle relocation, have been developed. However, the limited reproducibility of these techniques has hindered their widespread adoption. In this context, we introduce a simplified and reproducible method for papillary muscle relocation. This method utilizes transesophageal echocardiographic guidance and premeasured polytetrafluoroethylene loops to streamline the procedure.
The objective of this study was to assess the performance of a tissue engineering process–treated bovine pericardium patch (CardioCel, Admedus Regen Pty Ltd, Perth, Australia) in the setting of ...reconstructive mitral valve surgical procedures.
Between March 2014 and April 2016, 30 patients (57.2 ± 14.3 years of age; 27% female) underwent mitral valve leaflet repair with a CardioCel patch.
Perioperative mortality was 7% (2 patients, non–graft related). In the 28 remaining patients, predischarge echocardiography demonstrated good repaired valve function. At a mean follow-up of 1.7 ± 0.9 years, three additional deaths occurred (two resulting from infective endocarditis and one non–cardiac related). On follow-up echocardiography (follow-up time of 1.7 ± 0.8 years; available for 26 of 28 93% hospital survivors), recurrent regurgitation was seen in 2 patients (both with infective endocarditis), and 1 patient underwent reoperation (no infection at the level of patch repair was observed). In the remaining patients, the most recent echocardiogram demonstrated no regurgitation or mild regurgitation and stable gradients. The thickness and echodensity of the implanted patch on follow-up echocardiograms were comparable with postoperative echocardiograms.
Initial results with the CardioCel patch in mitral valve repair operations were satisfactory. The resistance to infection and late degeneration will need to be assessed in the future.
Abstract
OBJECTIVES
The risk factors and clinical effect of elevated mitral valve (MV) gradients after valve repair for degenerative valve disease remain insufficiently understood.
METHODS
Between ...January 2004 and December 2015, a total of 484 patients underwent valve repair for degenerative disease. A true-sized full annuloplasty ring was implanted in all cases. We analysed the effect of preoperative and intraoperative factors on the postrepair gradient. Additionally, we explored the effect of postrepair gradients on long-term outcomes.
RESULTS
On linear regression analysis, postrepair MV gradients were associated with patient age (coefficient = −0.110, standard error = 0.005, P = 0.034), body surface area (coefficient = 0.905, standard error = 0.340, P = 0.008), implanted annuloplasty ring size (coefficient = −0.181, standard error = 0.018, P < 0.001) and the use of Physio I ring (coefficient = 0.414, standard error = 0.122, P = 0.001). On multivariable analysis, postrepair MV gradient was not associated with overall survival hazard ratio (HR) 1.034, 95% confidence interval (CI) 0.889–1.203; P = 0.66 or freedom from atrial fibrillation (HR 0.849, 95% CI 0.682–1.057; P = 0.14), but did emerge as a risk factor for MV reintervention (HR 1.378, 95% CI 1.033–1.838; P = 0.029). Two out of 11 reinterventions were performed due to MV stenosis and in both patients, high postrepair gradients were seen readily on predischarge echocardiography.
CONCLUSIONS
Following valve repair for degenerative MV disease, elevated gradients occur even when true-sized annuloplasty is performed. The late clinical results of valve repair with elevated postrepair gradient are impaired and further studies are needed to explore preventive measures aimed at resolving the issue.
Abstract
OBJECTIVES
Native mitral valve infective endocarditis (IE) is a complicated disease with high mortality and morbidity rates. Mitral valve repair (MVRep) is feasible when limited valve ...destruction is present. However, recurrent valve dysfunction and reintervention are common.
METHODS
Between January 2000 and March 2016, 83 patients underwent surgery for isolated active native mitral valve IE. We applied an early surgery, MVRep-oriented approach with progressive utilization of patch techniques to secure a durable repair; MVRep was attempted in 67% of patients. Fifty-one (61%) patients underwent MVRep (including full-ring annuloplasty in 94%) and 32 (39%) patients underwent mitral valve replacement.
RESULTS
Early mortality was 13%. No cases of early recurrent IE occurred. Predischarge echocardiography demonstrated good MVRep function in all, except 1 patient with residual (Grade 2+) regurgitation. The mean duration of follow-up was 3.7 years (interquartile range 1.5–8.4). For hospital survivors, 8-year overall survival rates were 92.4% (95% confidence interval 84.0–100%) and 74.2% (95% confidence interval 53.8–94.6%) for the MVRep and mitral valve replacement groups, respectively. Propensity score-adjusted Cox regression analysis revealed no significant difference in survival between the 2 groups (hazard ratio 0.359, 95% confidence interval 0.107–1.200; P = 0.096). Four reinterventions occurred, 2 in each group. Echocardiographic follow-up demonstrated excellent MVRep durability; no cases of mitral regurgitation and 1 case of mitral valve stenosis were seen.
CONCLUSIONS
Native mitral valve IE is linked to high mortality and morbidity rates. A durable MVRep is feasible in most patients and provides excellent mid-term durability. Mitral valve replacement is a reasonable alternative when a durable repair is not likely.
Abstract
OBJECTIVES
Following mitral valve repair for Barlow’s disease, recurrent mitral regurgitation (MR) is believed to occur frequently and is mainly attributed to disease progression.
METHODS
...Between January 2000 and December 2015, 180 patients (40% women, mean age 58.7 ± 13.5 years) with Barlow’s disease underwent mitral valve repair. To provide a longitudinal assessment of mitral valve repair durability, a multistate model for interval-censored observations (4 states: 1, Grade 0/1+ MR; 2, Grade 2+ MR; 3, Grade 3+/4+ MR; 4, reintervention/death) was developed. The mechanism of recurrent MR was assessed echocardiographically.
RESULTS
Early mortality was 1.7%. After hospital discharge, 6 late reinterventions were performed. With death as a competing risk, the 10-year overall reintervention-free survival and reintervention rates were 79.8% (95% confidence interval 72.7–87.6%) and 4.5% (95% confidence interval 2.0–10.2%), respectively. Echocardiographic follow-up was available for 165 (93%) of hospital survivors with a total of 480 examinations. The incidence of both recurrent Grade 2+ and Grade 3+/4+ MR was relatively low up to 10 years after surgery. Grade 2+ MR did not always progress to higher regurgitation grade during the follow-up period. Grade 3+/4+ regurgitation was highly associated with valve-related morbidity and mortality. Recurrent MR (≥Grade 2+) was predominantly related to the technical aspects of valve repair.
CONCLUSIONS
Despite the complex valve abnormalities observed in patients with Barlow’s disease, mitral valve repair can be performed with good early and late outcomes and low rates of recurrence of MR up to 10 years after surgery. Early and late valve repair durability is good and remains stable over time, suggesting that underlying disease progression has limited clinical significance.
To the Editor:
Gammie et al. (Jan. 27 issue)
1
report on the role of concomitant tricuspid annuloplasty (TA) in patients with moderate or less-than-moderate regurgitation with annular dilatation who ...were undergoing mitral-valve surgery for degenerative mitral regurgitation. It is important to note that the results for the primary end point were driven by the between-group difference in the progression of tricuspid regurgitation; mortality, New York Heart Association class, quality of life, and readmissions did not differ significantly between the two groups. The progression in tricuspid regurgitation was seen mostly in the 10 of 11 patients who had moderate tricuspid regurgitation . . .
Abstract
OBJECTIVES
Barlow’s disease is the most severe form of degenerative mitral valve disease, commonly characterized by bileaflet prolapse. Abnormal mitral annular dynamics is typically present ...and results in functional prolapse of the mitral leaflets that may be addressed with annular stabilization alone.
METHODS
Between January 2001 and December 2015, 128 patients with Barlow’s disease and bileaflet prolapse underwent valve repair. This included anterior mitral valve leaflet (AMVL) repair in 70 patients, whereas 58 patients were identified as having functional prolapse and underwent no specific AMVL repair. During the course of the study, the proportion of patients undergoing specific AMVL repair decreased (77% in the first and 33% in the second 64 patients). Semirigid ring annuloplasty was performed in all cases. The median clinical and echocardiographic follow-up duration was 6.5 years interquartile range (IQR) 2.9–10.5 years; 93.9% complete and 4.7 years (IQR 2.2–10.2 years; 94.4% complete), respectively.
RESULTS
Early mortality was 1.6%. Postoperative echocardiogram demonstrated no residual mitral regurgitation in all but 1 patient (AMVL repair group). There was no significant difference in the overall survival rate at 6 years after operation between both groups. At 6 years, the freedom from recurrent ≥Grade 2+ mitral regurgitation rate was 90.7% (IQR 82.9–98.5%) and 89.1% (IQR 75.8–100%) for patients with and patients with no AMVL repair, respectively (P = 0.43). Three patients required late mitral valve reintervention, all from the AMVL repair group.
CONCLUSIONS
Annular stabilization can effectively resolve the functional prolapse of the AMVL. Careful discrimination between functional and true AMVL prolapse allows for a technically less challenging operation that provides excellent repair durability.
Objective
The hemodynamic effect and early and late survival impact of prosthesis–patient mismatch (PPM) after mitral valve replacement remains insufficiently explored.
Methods
Pubmed, Embase, Web of ...Science, and Cochrane Library databases were searched for English language original publications. The search yielded 791 potentially relevant studies. The final review and analysis included 19 studies compromising 11,675 patients.
Results
Prosthetic effective orifice area was calculated with the continuity equation method in 7 (37%), pressure half‐time method in 2 (10%), and partially or fully obtained from referenced values in 10 (53%) studies. Risk factors for PPM included gender (male), diabetes mellitus, chronic renal disease, and the use of bioprostheses. When pooling unadjusted data, PPM was associated with higher perioperative (odds ratio OR: 1.66; 95% confidence interval CI: 1.32–2.10; p < .001) and late mortality (hazard ratio HR: 1.46; 95% CI: 1.21–1.77; p < .001). Moreover, PPM was associated with higher late mortality when Cox proportional‐hazards regression (HR: 1.97; 95% CI: 1.57–2.47; p < .001) and propensity score (HR: 1.99; 95% CI: 1.34–2.95; p < .001) adjusted data were pooled. Contrarily, moderate (HR: 1.01; 95% CI: 0.84–1.22; p = .88) or severe (HR: 1.19; 95% CI: 0.89–1.58; p = .24) PPM were not related to higher late mortality when adjusted data were pooled individually. PPM was associated with higher systolic pulmonary pressures (mean difference: 7.88 mmHg; 95% CI: 4.72–11.05; p < .001) and less pulmonary hypertension regression (OR: 5.78; 95% CI: 3.33–10.05; p < .001) late after surgery.
Conclusions
Mitral valve PPM is associated with higher postoperative pulmonary artery pressure and might impair perioperative and overall survival. The relation should be further assessed in properly designed studies.
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