Surgical correction of commissural mitral valve prolapse can be challenging. Several surgical techniques, including commissural closure, leaflet resection with sliding plasty and chordal replacement, ...remain commonly in use. Conversely, papillary muscle head repositioning remains uncommonly utilized for the treatment of commissural prolapse.
Between January 2003 and December 2015, 518 patients underwent primary mitral valve repair for severe degenerative mitral valve regurgitation at our institution. Among them, 116 patients had non-isolated commissural prolapse (14 anterolateral, 82 posteromedial and 20 bicommissural prolapse). Eighty-eight patients underwent papillary muscle head repositioning and presented the study cohort.
The mean patient age was 62.8 ± 12.5 years, and 32 (36%) patients were women. Postoperative echocardiography showed no residual mitral regurgitation in all but 1 (1%) patient in whom Grade 2+ regurgitation was seen. The freedom from late reintervention rates at 5 and 10 years were 96.1% 95% confidence interval (CI) 91.8-100% and 92.7% (95% CI 86.4-99.0%), respectively. Upon reoperation, no recurrent commissural prolapse was observed. Echocardiographic follow-up demonstrated excellent valve repair durability. The freedom from Grade ≥2+ mitral regurgitation rates at 5 and 10 years were 92.6% (95% CI 86.3-98.9%) and 86.1% (95% CI 76.7-95.5%), respectively.
Papillary muscle head repositioning for the treatment of commissural mitral valve prolapse is a reproducible and reliable technique that provides excellent long-term results.
Abstract Transapical valve-in-valve mitral valve implantation (TA-MVI) has been described as an alternative treatment option in patients with degenerated bioprostheses in the mitral position. We ...report the first case of prosthesis dislocation and migration into the left atrium after TA-MVI. A new prosthesis was implanted using the same approach. The dislocated prosthesis was successfully removed through the left atrial appendage through an extended anterolateral thoracotomy without the use of cardiopulmonary bypass.
Abstract
OBJECTIVES
Standardized outcome reporting is of critical importance for performance monitoring, improvement of existing techniques and introduction of novel technologies. Whether outcome ...reporting for surgical treatment of degenerative mitral valve disease complies with the guidelines has not been assessed to date.
METHODS
A systematic review of PubMed, EMBASE, Web of Science and the Cochrane Library was conducted for articles published between 1 January 2009 and 7 March 2016. Inclusion criteria were adult patient population (n ≥ 200) and surgical intervention for degenerative mitral valve disease. The quality of reported outcome was compared with the standard recommended by the guidelines on reporting morbidity and mortality after cardiac valve interventions.
RESULTS
Forty-two non-randomized clinical studies were included: 4 provided early and 38 provided early and late outcome data. Early echocardiographic outcome was reported in 49% of studies. Freedom from reintervention, the indication for reintervention and the follow-up echocardiographic outcome were reported in 97%, 59% and 79% of studies providing late outcome data, respectively. The Kaplan–Meier method was used to assess the freedom from recurrent mitral regurgitation in 60% (18/30) of studies, whereas 7% (2/30) of studies applied a longitudinal data analysis. Recurrent mitral regurgitation was most commonly defined as moderate (Grade 2+; 60%) or severe (Grade 4+; 37%) regurgitation.
CONCLUSIONS
There is a significant discordance between the guidelines-based recommendations and actual reporting of outcome for surgical treatment of degenerative mitral valve disease. Better adherence to the guidelines would raise the quality and generalizability of clinical data reporting.
Comparative studies of outcomes between different biological mitral valve prostheses are scarce. This study compares the late clinical results of valve replacement with the Epic and Mosaic ...bioprostheses.
Patients undergoing isolated elective mitral valve replacement (MVR) between 2005 and 2019 were eligible for inclusion. Primary outcomes were freedom from mitral valve reintervention and overall survival. Inverse probability of treatment weighting and competing risk analyses were performed.
MVR was performed in 247 (73.7%) patients with the Epic prosthesis and in 88 (26.3%) patients with the Mosaic prosthesis. The median follow-up was 3 (interquartile range, 0.20-5.64) years. At 10 years postoperative, the estimated survival rates were 86.1% (95% CI, 80.5%-91.9%) and 73.5% (95% CI, 60.6%-89.3%) for the Epic and Mosaic groups, respectively (P = .40). On inverse probability of treatment weighted analysis, no significant intergroup difference was found (hazard ratio, 1.20; 95% CI, 0.54-2.66; P = .70. At 10 years, the cumulative incidence functions of mitral valve reintervention with death as competing risk were 34.4% (95% CI, 32.7%-36.1%) and 17.6% (95% CI, 16.2%-18.9%) for the Epic and Mosaic groups, respectively. On multivariable Fine-Gray analysis, the type of implanted mitral valve prosthesis just failed to reach a statistically significant difference in mitral valve reintervention (hazard ratio, 0.43 for Mosaic valve; 95% CI, 0.18-1.06; P = .067). Structural valve deterioration was an uncommon indication for reintervention in the first 10 years postoperative.
Clinical results of MVR with the Epic or Mosaic prosthesis are satisfactory. Our results suggest that the Mosaic bioprosthesis might offer better freedom from reintervention.
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Left atrial (LA) dilatation is associated with worse outcomes in primary mitral regurgitation (MR). However, the effects of mitral valve repair on LA size and its prognostic implications are not well ...known. In the current study, LA volume index (LAVi) and LA reservoir strain (LASr) were evaluated immediately before and after surgery, and during long-term follow-up in 226 patients undergoing mitral valve repair for primary MR (age 62 ± 13 years, 66% male). Mean LAVi was reduced significantly after surgery and at long-term follow-up (from 56 ± 28 to 38 ± 21 to 32 ± 17 mL/m2; p < 0.001). LASr reduced significantly after surgery but increased again during the long-term (from 23.6 ± 9.4 to 11.5 ± 5.0 to 17.3 ± 7.5%; p < 0.001). Age, pre-operative LAVi, MR severity, and postoperative transmitral pressure gradient were associated with LA reverse remodeling by the long-term check-up. During a median follow-up of 72 (40−114) months, 43 (19%) patients died. Patients with LAVi ≥ 42 mL/m2 at long-term follow-up showed significant higher mortality rates compared to patients with LAVI < 42 mL/m2 (p < 0.001), even after adjusting for clinical covariates. In conclusion, significant LA reverse remodeling was observed both immediately and at long-term follow-up after mitral valve repair. LA dilatation at long term follow-up after surgery was still associated with all-cause mortality.
Reply to Prestipino et al Tomšič, Anton; Li, Wilson W L; de Mol, Bas A J M
European journal of cardio-thoracic surgery,
02/2017, Volume:
51, Issue:
2
Journal Article
Poškodbe sprednje križne vezi kolenskega sklepa postajajo vse pogostejši problem aktivne ženske populacije v primerjavi v moškimi. Poleg začasno ali celo trajno okrnjene funkcije sklepa povečujejo ...tudi tveganje za nastanek zgodnje artroze. Prepoznava dejavnikov tveganja za nastanek tovrstnih poškodb v povezavi z razlikami med spoloma bi bila smiselna pri razvoju preventivnih ukrepov pred tovrstnimi poškodbami. Pregledane laboratorijske in epidemiološke raziskave v letih 1992-2012 so poleg anatomskih in biomehanskih razlik potrdile povezavo med nihanjem hormonov menstrualnega cikla in tveganjem za poškodbo sprednje križne vezi. Preovulatorna faza predstavlja obdobje največjega tveganja zaradi povečane koncentracija estrogena. Kljub navedenim ugotovitvam je videti pomen mesečnega nihanja hormonov premajhen, da bi na njem lahko učinkovito gradili preventivne programe pred poškodbami kolenskih vezi pri ženskah.
ObjectiveLeft atrial (LA) and left ventricular (LV) mechanics are impaired in patients with atrial functional mitral regurgitation (AFMR), but their prognostic value in this subset of patients ...remains unknown. The present study aimed to evaluate the association between LA and LV longitudinal strain and clinical outcomes in patients with AFMR.MethodsA total of 197 patients (mean age 73±10 years, 44% men) with at least moderate AFMR were retrospectively identified. LV global longitudinal strain (GLS) and left atrial reservoir strain (LAS) were calculated by two-dimensional speckle tracking echocardiography. All-cause mortality was the primary endpoint of the study. The threshold value of LV GLS (≤16.3%) to identify impaired LV mechanics was defined based on the risk excess of the primary endpoint described with a spline curve analysis.ResultsImpaired LV GLS (≤16.3%) was found in 89 (45%) patients. During a median follow-up of 69 months, 45 (23%) subjects experienced the primary endpoint. Patients with impaired LV GLS (≤16.3%) had a significantly lower cumulative survival rate at 5 years, as compared with patients with LV GLS (>16.3%) (74% vs 93%, p<0.001). On multivariable Cox regression analysis, LV GLS expressed as continuous variable was independently associated with the occurrence of all-cause mortality (HR 0.856, 95% CI 0.763 to 0.960; p=0.008) after adjustment for age, LAS, pulmonary artery systolic pressure and severe tricuspid regurgitation. Conversely, LAS was not significantly associated with patients’ outcome.ConclusionsIn patients with significant AFMR, the impairment of LV GLS was independently associated with worse outcomes.
This study sought to investigate whether left ventricular (LV) global longitudinal strain (GLS) is associated with long-term outcome after mitral valve (MV) surgery for primary mitral regurgitation ...(MR) and assess the differences in outcome according to MR etiology: Barlow’s disease (BD), fibroelastic deficiency (FED), and forme fruste (FF).
Appropriate timing of MV surgery for primary MR is still challenging and may differ according to the etiology. In these patients, LV-GLS has been proposed as more sensitive measure to detect subtle LV dysfunction as compared with LV ejection fraction.
Echocardiography was performed in 593 patients (64% men, age 65 ± 12 years) with severe primary MR who underwent MV surgery, including assessment of LV-GLS. The etiology (BD, FED, or FF) was defined based on surgical observation. During follow-up, primary endpoint was all-cause mortality and a secondary endpoint included cardiovascular death, heart failure hospitalizations, and cerebrovascular accidents.
During a median follow-up of 6.4 (interquartile range: 3.6 to 10.4) years, 146 patients died (16 within 30 days after surgery), 46 patients were hospitalized for heart failure, and 13 patients had a cerebrovascular accident. Age (hazard ratio HR: 1.08; 95% confidence interval CI: 1.05 to 1.11; p < 0.001) and LV-GLS (HR: 1.13; 95% CI: 1.06 to 1.21; p < 0.001) were independently associated with all-cause mortality. Patients with LV-GLS >–20.6% (more impaired) showed significant worse survival than did patients with LV-GLS ≤–20.6%; of interest, patients with BD showed similar prognosis compared with FED and FF. In addition, previous atrial fibrillation (HR: 1.70; 95% CI: 1.01 to 2.86; p = 0.045) and LV-GLS (HR: 1.01; 95% CI: 1.01 to 1.15; p = 0.019) were independently associated with the secondary endpoint.
LV-GLS is independently associated with all-cause mortality and cardiovascular events after MV surgery for primary MR and might be helpful to guide surgical timing. Importantly, patients with BD showed similar prognosis when corrected for age, compared with patients with FED or FF.
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