Early- and Long-Term Outcomes of Mitral Valve Repair in a Low-Volume Centre in the Caribbean

Abstract Introduction: This study examines early- and long-term outcomes of mitral valve repairs in a low-volume cardiac surgery centre in the Caribbean. Methods: Ninety-six consecutive patients underwent mitral valve repair from April 2009 to December 2018. Patients were divided into two groups: functional mitral regurgitation requiring simple mitral annuloplasty (FMR, n=63) or structural degenerative mitral regurgitation requiring more complex repair (DMR, n=33). Data collected prospectively were retrospectively analysed from the unit-maintained cardiac surgery database. Results: Thirty-day mortality in the whole series was 2.1%, with 3% in the FMR group and 0% in the DMR group. Early post-operative echocardiography in the FMR group demonstrated 51 patients (83.6%) without mitral regurgitation, 8 patients (13.1%) with trivial to mild regurgitation, and 2 patients (3.3%) with moderate regurgitation. However, at a mean follow-up of 98.2±50.8, only 21 patients (42.8%) were in NYHA class I, with 7 (14.2%) in class II, 16 (32.6%) in class III, and 5 (10.2%) in class IV. There were 9 cardiac-related deaths at final follow-up, with freedom from re-operation and survival of 98% and 75.6%, respectively. In the DMR group, early post-operative echocardiography demonstrated 29 patients (87.9%) without mitral regurgitation, 3 patients (9.1%) with trivial regurgitation and 1 patient (3.0%) with mild regurgitation. At a mean follow-up of 114.1±25.4 months, there was a good functional post-operative status in this group with 93.3% in NYHA class I, and 6.7% in class II. No patient required reintervention, 96.3% of patients had mild or no mitral regurgitation and survival was 90.9%. Conclusion: Despite challenges of maintaining skills in a low-volume centre, mitral valve repair can be performed safely with good early- and long-term results.

Dual-Valve Repair in Dextrocardia and Situs Inversus Totalis / 日本心臓血管外科学会雑誌

A 59-year-old man, diagnosed with severe mitral regurgitation, moderate tricuspid regurgitation, and chronic atrial fibrillation with situs inversus totalis, was referred to our hospital. A median sternotomy approach was performed. The surgeon operated from the left side of the operating table, and had an excellent exposure to the mitral and tricuspid valves during the operation. The mitral valve was repaired with the posterior cusp plication technique and ring annuloplasty. The tricuspid valve was repaired with ring annuloplasty. We use a conventional semi rigid ring turned over, because the tricuspid valve has an asymmetric configuration. FullMAZE, and left atrial appendage closure were performed, too. The postoperative course was uneventful.

Valvuloplasty Without Prosthetic Ring or Band in Patients with Degenerative Mitral Regurgitation: Long-Term Results and Predictive Factors for Outcomes

Abstract Introduction: Mitral valvuloplasty including ring/band support is widely performed despite potential drawbacks of rings. Unsupported valvuloplasty is performed in only a few centers. This study aimed to report long-term outcomes of patients undergoing unsupported valvuloplasty for degenerative mitral regurgitation (MR) and to identify predictive factors for outcomes. Methods: This is a retrospective cohort including patients undergoing mitral valve repair for degenerative MR from 2000 to 2018. The main techniques were Wooler annuloplasty and quadrangular resection. Kaplan-Meier curves and Cox regression models were used for statistical analysis. Results: One hundred fifty-eight patients were included (median age: 64.0 years). In-hospital mortality was 2.5%. Maximum follow-up was 19.6 years, with a median of 4.7 years (992 patient-years). Overall survival at 5, 10, and 15 years was 91.0% (95% confidence interval [CI]: 85.7-96.3), 87.6% (95% CI: 80.7-94.5), and 78.1% (95% CI: 65.9-90.3), respectively. The European System for Cardiac Operative Risk Evaluation (EuroSCORE) II was an independent predictor of late death (hazard ratio [HR] 1.42; P=0.016). Freedom from mitral reoperation at 5, 10, and 15 years was 88.1% (95% CI: 82.0-94.2), 82.4% (95% CI: 74.6-90.2), and 75.7% (95% CI: 64.1-87.3), respectively. Left atrial diameter > 56 mm was associated with late reintervention in univariate analysis (HR 1.06; P=0.049). Conclusion: Degenerative MR can be successfully treated with repair techniques without annular support, thus avoiding the technical and logistical drawbacks of ring/band implantation while maintaining good long-term results. EuroSCORE II was a risk factor for late death, and larger left atrium was associated with late reoperation.

Clover technique for the treatment of complex tricuspid valveinsufficiency / 中华胸心血管外科杂志

Objective:This study assesses the results of the clover technique for the treatment of tricuspid regurgitation(TR) due to severe prolapse or tethering.Methods:From March 2016 to November 2018, 28 patients with severe TR due to prolapsing or tethered or adhesion leaflets underwent clover technique. Annuloplasty was associated in 27 patients(97%). The aetiology of TR was rheumatic in 19 cases(68%), subacute bacterial endocarditis in 4(14%), degenerative in 3(11%) and ischemia of right ventricular(the peacing leads compress the septum leaflet in 1 case) in 2(7%). The main mechanism of TR was prolapse/flail of one leaflet in 7 patients(23%), of two leaflets in 13 patients(46%) and of all three leaflets in 6 patients(21%). The remaining 2 patients(7%) presented with severe leaflets’tethering.Results:None deaths occurred during hospitalisation and one patient dischargedvoluntary 12 days after surgery. Follow-up of the 27 hospital survivors was 100% complete[mean length(1.2±0.8)years, range 0.25-1.70 years]. At the last echocardiogram, no or mild TR was detected in 25 patients(88.7%), moderate(2+ /4+ ) in two(9.6%) and severe(4+ /4+ ) in one patient(3.6%). Mean tricuspid valve area and gradient were(4.3±0.6 )cm 2 and(2.8±1.4)mmHg(1 mmHg=0.133 kPa). There was no obvious valve stenosis in all cases. In all patients, echocardiography was performed and no signs of tricuspid stenosis were detected. At the multivariable analysis, the degree of TR at hospital discharge was identified as the only predictor of TR 2+ at follow-up. Conclusion:Clover procedure is simple and safe in the surgical management of various causes of TR besides severe tethering and calcification, it is an effective supplementary measure for annuloplasty.

Reemplazo valvular mitral en pacientes con anillo calcificado / Mitral Valve Replacement in Patients with Mitral Annulus Calcification

RESUMEN Introducción: El anillo mitral calcificado es un proceso degenerativo que, de encontrarse presente en pacientes con indicación de tratamiento quirúrgico de la válvula mitral, implica un problema técnico de difícil resolución, que genera un aumento de probabilidad de complicaciones graves como accidente cerebrovascular, fugas perivalvulares, sangrado y muerte. Objetivo: El propósito del estudio es describir nuestra experiencia con cirugía valvular mitral en el contexto de calcificación grave del anillo mitral. Material y métodos: entre julio de 2010 y julio de 2020, 28 pacientes fueron intervenidos por patología valvular mitral en presencia de anillo mitral gravemente calcificado. La mediana de edad de la población fue de 77 años y el 68% fue de sexo femenino. Se realizó reemplazo valvular mitral en todos los casos asociado con reemplazo valvular aórtico en el 36%, con plástica tricuspídea en el 11% y con cirugía de revascularización miocárdica en el 21% de los casos. Resultados: Dos pacientes fallecieron en el hospital. Las complicaciones posoperatorias más frecuentes fueron la fibrilación auricular y la insuficiencia renal aguda. No se observaron fugas perivalvulares ni complicaciones asociadas con la prótesis. Conclusiones: La cirugía valvular mitral en presencia de anillo mitral calcificado puede realizarse con resultados aceptables para el perfil de riesgo de la población con la patología y de acuerdo con lo informado en publicaciones internacionales.

ABSTRACT Background: Mitral annulus calcification is a degenerative process which poses a challenging technical problem in patients undergoing surgical treatment of the mitral valve, increasing the probability of severe complications as stroke, perivalvular leaks, bleeding and death. Objective: The aim of this study was to describe our experience in mitral valve surgery with severe mitral annulus calcification. Methods: Between July 2010 and July 2020, 28 patients underwent surgery due to mitral valve disease with severe mitral annulus calcification. Median age was 77 years and 68% of patients were female. Mitral valve replacement was performed in all patients, associated with aortic valve replacement in 36%, tricuspid valve repair in 11% and coronary artery bypass graft surgery in 21% of cases. Results: Two patients died during hospitalization. The most frequent postoperative complications were atrial fibrillation and acute kidney failure. No perivalvular leaks or prosthesis-associated complications were observed. Conclusions: Mitral valve surgery in the presence of mitral annulus calcification can be performed with acceptable results for the risk profile of the population with the disease and according to international publications.

Early Outcomes of Modified De Vega Annuloplasty for Functional Tricuspid Regurgitation at a Brazilian Hospital

Abstract Background: Right valve diseases are not benign, the tricuspid regurgitation has a significant impact on morbidity and mortality of patients. Objectives: This study aimed to report the short-term results of tricuspid annuloplasty using the De Vega technique modified by Manuel Antunes. Methods: A descriptive-analytical study was performed to evaluate the results of the tricuspid valvuloplasty performed at the Instituto de Medicina Integral Professor Fernando Figueira between 2012 and 2017. Data were collected by reviewing charts and databases of the Department of Cardiology and Cardiovascular Surgery of the institution. Those with rheumatic diseases or infective endocarditis with tricuspid valve involvement, or reoperation of the tricuspid valve were excluded. Student's t-test and McNemar's were used for statistical analysis. A p-value < 0.05 was considered statistically significant. Results: A total of 87 patients were studied, most of them were women (56.3%). The most associated heart valve diseases were mitral regurgitation (27.6%) and aortic regurgitation (20.7%). There was a significant decrease in the degree of tricuspid regurgitation in the postoperative period, with 83.3% of patients with none or mild regurgitation and only 1.1% with severe regurgitation (p = 0.0077). Conclusions: In the current study, tricuspid valve annuloplasty using the modified De Vega technique was shown to be effective in the short term. Further studies are needed to evaluate the long-term results.

Risk factors of postoperative acute kidney injury and the impact on outcome in non-senile patients undergoing cardiac valvular surgery / 中华心血管病杂志

Objective@#To investigate the risk factors of postoperative acute kidney injury (AKI) in patients aged between 40 and 50 years old undergoing cardiac valvular surgery and the impact on outcome.@*Methods@#The clinical data of 286 patients aged between 40 and 50 years old undergoing cardiac valve surgery in Guangdong Provincial People′s Hospital from January 2012 to December 2016 were analyzed retrospectively. Preoperative coronary angiography was performed in all patients. All patients enrolled were divided into AKI group and non-AKI group according to the existence or not of postoperative AKI. Patients with AKI were further divided into AKI stage 1, stage 2, and stage 3 groups according to KDIGO guideline. Demographic characteristics, preoperative clinical data including serum creatinine, estimated glomerular filtration rate, hemoglobin, uric acid, urinary protein, presence or absence of chronic kidney disease, left ventricular ejection fraction, pulmonary artery pressure, New York Heart Association (NYHA) functional classification, preoperative co-morbidity (hypertension, diabetes, anemia, cerebrovascular disease, peripheral artery disease), preoperative medication(vasoactive drugs, diuretic, renin-angiotensin system inhibitor (RASI), surgical data (contrast dosage in coronary angiography, type of cardiac valve surgery) were recorded and analyzed in this retrospective study. The risk factors for postoperative AKI and its impact on clinical outcomes (mortality, hospitalization expenses and Intensive Care Unit stay duration) were evaluated. Logistic regression analysis was used to determine the risk factors for postoperative AKI and the adjusted variables with P<0.2 were selected for the multivariate logistic regression analysis to define the independent determinants for AKI.@*Results@#AKI was defined in 106 out of 286 enrolled patients, including 96 patients with AKI stage 1, 10 patients with AKI stage 2 and no patients with AKI stage 3. The proportion of coexisting cerebrovascular diseases was higher in AKI group than in non-AKI group (9(8.49%) and 5(2.78%), χ2=4.677, P=0.031), while there was no difference among other baseline data between the two groups. Multivariate logistic regression analysis showed that preoperative complications of cerebral vascular disease was an independent risk factor of postoperative AKI (OR=3.578, 95%CI 1.139-11.242, P=0.029). Five out of 106 AKI patients died during hospitalization while there was only 1 patient died among 180 patients without AKI. Patients with AKI after cardiac valve operation experienced higher mortality than patients without AKI (χ2=5.625, P=0.028). Further analysis showed that there was no difference in hospitalization mortality between patients with AKI stage 2 and stage (χ2=0.686, P=0.408) while the hospitalization mortality in patients with AKI stage 2 was higher than those without AKI (χ2=8.113, P=0.004). The hospitalization expenses in patients with AKI were 10.38(8.59,12.54) ×104 RMB, significantly higher than that in patients without AKI (9.72(8.03,11.93) ×104 RMB)(P=0.043). There was no difference in hospitalization expenses between patients with AKI stage 1 and without AKI (P=0.635). The hospitalization expenses in patients with AKI stage 2 was higher than those without AKI (P=0.023). Intensive Care Unit stay duration in patients with AKI was 3(1,4) days, significantly higher than those without AKI (P=0.044). There was no difference in Intensive Care Unit stay duration in patients with AKI stage 1 and without AKI (P=0.978), while Intensive Care Unit stay duration in patients with AKI stage 2 was significantly longer than those without AKI (P=0.006).@*Conclusions@#Preoperative complications of cerebral vascular disease is an independent risk factor of postoperative AKI. Non-senile patients with AKI after cardiac valvular surgery is associated with a higher proportion of mortality, hospitalization expenses and Intensive Care Unit stay duration as compared patients without postoperative AKI.

Assessment of left ventricular diastolic function by vector flow mapping in patients with mitral valve plasty / 中华超声影像学杂志

Objective To assess left ventricular diastolic function by vector flow mapping ( VFM ) in patients with mitral valve plasty . Methods A total of 30 patients undergoing mitral valve plasty were enrolled . The dissipative energy loss ( EL) of basal ,middle ,apical and global left ventricular segments in rapid filing phase ,slow filling phase ,and atria contract period were measured by VFM ,and the EL above were compared in 1 week preoperatively ,1 week and 1 month postoperatively . Results Compared with 1 week preoperatively ,EL in all diastole in basal and middle left ventricular segments were significantly increased at 1 week after operation (all P <0 .05) ,EL in some diastole in apical and global left ventricular segments were significantly increased at 1 week after operation ( all P <0 .05) ,and EL in all diastole in all left ventricular segments were significantly increased at 1 month after operation (all P <0 .05) . Compared with 1 week postoperatively ,EL in all diastole in all left ventricular segments were significantly increased at 1 month after operation ( all P < 0 .05) . Conclusions VFM can quantitatively evaluate left ventricular diastolic function ,and helps to evaluate treatment response at preoperative and postoperative .

Reparación de la insuficiencia tricuspídea: resultados a largo plazo en 114 pacientes / Repair of tricuspid valve insufficiency: long-term results in 114 patients

Resumen Antecedentes la reparación de la insuficiencia tricuspídea funcional está indicada en casos de insuficiencia cardíaca, generalmente, asociada a enfermedades de las válvulas cardíacas izquierdas y en algunos casos de enfermedad coronaria o cardiopatías congénitas. Objetivo : evaluar los resultados a largo plazo de la reparación tricuspídea en pacientes operados en la región centro sur de Chile. Pacientes y métodos : estudio retrospectivo de registros clínicos y operatorios en 114 pacientes con edad promedio 57.8 (DE 13) años (72 mujeres) sometidos a reparación tricuspídea asociada a otros procedimientos quirúrgicos entre 2009 y 2017. Resultados : la etiología de la insuficiencia tricuspídea fue debida a enfermedad reumática inactiva en 45% y a endocarditis infecciosa en 2.6%. 63% estaban en fibrilación auricular y 75% en capacidad funcional NYHC III. 15.8% tenían cirugía valvular cardíaca previa. El ecocardiograma mostró insuficiencia severa en 56% de los casos y había hipertensión pulmonar severa en 39.5%. La cirugía consistió en la implantación de un anillo semi-rígido en forma concomitante a reemplazo o reparación de lesión valvular mitral, reemplazo valvular aórtico, cierre de comunicación interauricular, cirugía coronaria o resección de tumor intra cardíaco. La mortalidad post operatoria global fue 16%, debido a falla multisistémica en 6%, insuficiencia cardíaca en 5% y hemorragia cerebral en 4.3%. El seguimiento promedio fue 78.8 (DS 7.2) meses. La supervivencia actuarial fue 74% a los 60 y 68% a los 96 meses. Conclusión : La cirugía de reparación de la insuficiencia tricuspídea moderada o severa, asociada a otras enfermedades cardíacas provee una buena recuperación sintomática, con excelente sobrevida alejada.

Abstract Background : Surgery for functional tricuspid valve insufficiency is indicated in cases of congestive heart failure usually associated to left heart valve diseases or as a concomitant surgery for other causes such as congenital or coronary disease. Aim : To assess and report the long-term results of tricuspid valve repair in adult patients in a regional cardiac surgery center in south Chile. Patients and Methods : Retrospective review of clinical and operative records of 114 patients aged 57.8 +/- 13 years (72 women) subjected to tricuspid reparative surgery concomitant with other cardiac procedures between 2009 to 2017. Results : In 45% of cases etiology was due to inactive rheumatic disease and 2.6% was due to endocarditis. 63% presented with atrial fibrillation and 75% were in NYHC CFIII. 15.8% had a previous cardiac valve surgery. Preoperative echocardiography showed severe tricuspid insufficiency in 56% of cases and pulmonary hypertension was severe in 39.5%. In all cases tricuspid repair was performed through the insertion of a semi rigid ring as a concomitant procedure for mitral repair/replacement in most cases, aortic valve replacement, surgical closure of an ASD, CABG surgery and the resection of cardiac tumors. Overall postoperative mortality was 16% due to multi-organic dysfunction in 6%, cardiac failure in 5% and cerebral hemorrhage in 4.3%. Mean long term follow up was 78.8+/- 7.2 months. Actuarial survival was 74% at 60 and 68% at 96 months. Conclusion: Surgical tricuspid valve repair for moderate to severe tricuspid insufficiency isolated or associated to other cardiac diseases provides a good symptomatic recovery, with an excellent long term survival.

OPCABG for moderate cimr in elderly patients: a superior option?

Abstract Objective: To compare the early and late outcomes of off-pump coronary artery bypass grafting and coronary artery bypass graft + mitral valve repair in elderly patients with moderate chronic ischemic mitral regurgitation. Methods: One hundred and fifty elderly (age > 70 years) patients with moderate chronic ischemic mitral regurgitation who underwent off-pump coronary artery bypass grafting (n=95) or coronary artery bypass graft + mitral valve repair (n=55) between January 2007 and December 2014 were studied. They were subdivided according to presence or absence of high operative risk. Peri-operative variables and early operative outcomes were retrospectively studied. Survival, mitral regurgitation grade, and functional outcomes were prospectively analysed. Results: Both groups were comparable in terms of age (P=0.23), sex (P=0.74), left ventricle ejection fraction (P=0.6) and preoperative functional class (P=0.52). The mean number of grafts for off-pump coronary artery bypass grafting group was 3.14 and coronary artery bypass graft + mitral valve repair was 3.21. Off-pump coronary artery bypass grafting group had statistically significant better early operative outcomes i.e perioperative blood transfusions, intraaortic balloon pump usage, arrhythmias, renal dysfunction, liver dysfunction, sepsis, mean hours of ventilation, intensive care unit stay and operative mortality. On a prospective follow up of 5±2.33 years (1-9 years), coronary artery bypass graft + mitral valve repair in low operative risk subgroup had better improvements in mitral regurgitation grade than off-pump coronary artery bypass grafting. Both groups had similar improvements in functional class and cumulative survival was also comparable (63.2% vs. 54.5%). Conclusion: Off-pump coronary artery bypass grafting is a safer alternative to coronary artery bypass graft + mitral valve repair with better early operative outcomes and comparable late survival and functional outcomes in elderly patients with moderate chronic ischemic mitral regurgitation, especially those with higher operative risk.

Long-term results of mitral valve repair

Abstract Introduction: Current guidelines state that patients with severe mitral regurgitation should be treated in reference centers with a high reparability rate, low mortality rate, and durable results. Objective: To analyze our global experience with the treatment of organic mitral regurgitation from various etiologies operated in a single center. Methods: We evaluated all surgically treated patients with organic mitral regurgitation from 2004-2017. Patients were evaluated clinically and by echocardiography every year. We determined early and late survival rates, valve related events and freedom from recurrent mitral regurgitation and tricuspid regurgitation. Valve failure was defined as any mitral regurgitation ≥ moderate degree or the need for reoperation for any reason. Results: Out of 133 patients with organic mitral regurgitation, 125 (93.9%) were submitted to valve repair. Mean age was 57±15 years and 52 patients were males. The most common etiologies were degenerative disease (73 patients) and rheumatic disease (34 patients). Early mortality was 2.4% and late survival was 84.3% at 10 years, which are similar to the age- and gender-matched general population. Only two patients developed severe mitral regurgitation, and both were reoperated (95.6% at 10 years). Freedom from mitral valve failure was 84.5% at 10 years, with no difference between degenerative and rheumatic valves. Overall, late ≥ moderate tricuspid regurgitation was present in 34% of the patients, being more common in the rheumatic ones. The use of tricuspid annuloplasty abolished this complication. Conclusion: We have demonstrated that mitral regurgitation due to organic mitral valve disease from various etiologies can be surgically treated with a high repair rate, low early mortality and long-term survival that are comparable to the matched general population. Concomitant treatment of atrial fibrillation and tricuspid valve may be important adjuncts to optimize long-term results.

Early Clinical Outcomes of Tricuspid Valve Repair with a Tri-Ad Annuloplasty Ring in Comparison with the Outcomes Using an MC³ Ring

BACKGROUND: We evaluated the early clinical outcomes of tricuspid valve annuloplasty (TAP) with the Tri-Ad annuloplasty ring for functional tricuspid regurgitation (TR). METHODS: From January 2015 to March 2017, 36 patients underwent TAP with a Tri-Ad ring for functional TR. To evaluate the early clinical outcomes of TAP with the Tri-Ad ring, we conducted a propensity score-matched analysis comparing the Tri-Ad and MC3 tricuspid annuloplasty rings (n=34 in each group). The follow-up duration was 11.0±7.07 months. RESULTS: There was 1 case of operative mortality (2.8%) and no cases of late mortality. Postoperative complications occurred in 15 patients (41%), including acute kidney injury in 6 patients (16%), bleeding requiring reoperation in 4 patients (11%), and low cardiac output syndrome in 4 patients (11%). There were no ring-related complications, such as atrioventricular block or ring dehiscence. The TR grade decreased significantly (from 2.03±1.06 to 1.18±0.92, p < 0.01), as did the systolic pulmonary artery pressure (from 43.53±13.84 to 38.00±9.72 mm Hg, p=0.03). There were no cases of severe residual TR, but moderate TR was observed in 3 patients, all of whom had severe TR preoperatively. Severe preoperative TR was also associated with moderate in the univariate analysis (p < 0.01). In the propensity score-matched analysis comparing the Tri-Ad and MC3 rings, there was no significant difference in early clinical outcomes. CONCLUSION: TAP with the Tri-Ad ring corrected functional TR effectively and provided good early clinical and echocardiographic results without ring-related complications. However, severe preoperative TR was associated with moderate or severe residual TR in the immediate postoperative period. A follow-up study is necessary to confirm the stability of this procedure.

Quantitative evaluation of mitral valve structure and function in patients with mitral valvuloplasty by real-time three-dimensional transesophageal echocardiography / 中华超声影像学杂志

Objective@#To quantitatively evaluate the variation of preoperative and postoperative structure and function of mitral valve after mitral valve annuloplasty(MVP) for mitral valve prolapse by real-time three-dimensional transesophageal echocardiography(RT-3D TEE).@*Methods@#Thirty patients with mitral valve prolapse for MVP were studied, the minimum area of the three-dimensional view of the annulus(A3Dmin), three dimensional circumference(C3D), anterolateal-to-posteromedial diameter(DAlPm), anterior-to-posteior diameter(DAP), height (H), the ratio of annulus height to anterolated-to-posteromedial diameter(H/DAlPm), aorto-mitral angle(θ), the ellipticity of the the anterior-to-posterior diameter and anterolateal-to-posteromedial diameter of the annulus(E2D), the three-dimensional exposed area of the leaflet(A3DE), prolapse height(HProl), prolapse volume(VProl), non-planarity angle(θNPA) were evaluated by RT-3D TEE before and after operation. Coaptation area(CoapA), coaptation index(CPI), annulus systolic function index were calculated.@*Results@#Compared with the preoperation, A3Dmin, C3D, DAlPm, DAP, H, H/DAlPm, A3DE, HProl, VProl, θNPA of postoperative were reduced, E2D, CoapA, CPI, annulus systolic function index of the postoperation increased, the difference of above parameters were statistically significant (P<0.05). CPI and annulus systolic function index were negatively correlated with the area of valve regurgitation area before and aftere operation (r=-0.79, P<0.01; r=-0.67, P<0.01). Furthermore, CPI was closely correlated with annulus systolic function index (r=0.63, P<0.01).@*Conclusions@#After MPV, mitral valve three-dimensional structural parameters are significantly changed, CPI and annulus systolic function are improved. CPI is closely correlated with annulus systolic function, and RT-3D TEE can quantitatively evaluate the structure and function of mitral valve before and after MPV.

Long-term outcomes of prophylactic autologous pericardium tricuspid annuloplasty:propensity score matching of 832 patients with rheumatic heart disease / 实用医学杂志

Objective To investigate the safety and longterm outcomes of prophylactic autologous pericardium tricuspid valve annuloplasty(TVA)in patients with rheumatic heart disease(RHD). Methods A total of 832 patients with RHD were enrolled in this study ,including 146 patients with mild FTR but without TVA(observation group);434 patients with mild FTR underwent TVA(control group A)and 434 patients with moderate or severe FTR underwent TVA(control group B). Propensity score and survival analysis were used to evaluate perioperative safety ,FTR progression ,CHF and MACCE incidence after prophylactic TVA. Results A total of 192 patients were successfully matched. There was no significant difference in the perioperative complications between the observation group and the control groups(P>0.05). The progression rate of FTR in the observation group was significantly lower than that in the control groups (P = 0.005 & 0.032 ). There was no significant difference in the incidence of CHF and MACCE events between the observation group and the control groups (P > 0.05). Conclusions The treatment strategy of prophylactic autologous pericardium TVA at the time of left heart valve surgery for patients with RHD doesn′t increase operation costs ,perioperative complications and mortality ,but effectively prevent postoperative FTR recurrence or progression.

Significance of real-time three-dimensional transesophageal echocardiography in mitral valvuloplasty / 中华医学超声杂志（电子版）

Objective To evaluate the value of real-time three-dimensional transesophageal echocardiography (TEE) in the diagnosis of mitral valve structure in mitral valve prolapse, the significance of determining the prosthetic mitral valve ring size in the surgical treatment and the evaluation of immediate postoperative effect. Methods From November 2016 to March 2017, 19 patients with mitral prolapse performed with surgical treatment were diagnosed by transthoracic echocardiography at the echocardiography and vascular ultrasound center in the First Affiliated Hospital of Zhejiang University. All 19 patients underwent real-time three-dimensional TEE examination after anesthesia and before cardiopulmonary bypass. When the heart was recovered immediately after the operation, TEE was performed again to check the valve and the images were recorded in real time. During the whole examination, the images were observed by sonologists, surgeons and anesthesiologists, and the sonographic results were compared with the intraoperative findings. Totally 19 patients with moderate to severe mitral valve prolapse were examined and measured with real time three-dimensional ultrasound reconstruction. The mitral valve and tendons were observed and the mitral valve ring, the length of the valve and the diameter of the fiber triangle were measured. Results Intraoperative TEE examination could clearly display the anatomical structure and movement of mitral valve, annulus, chordae tendineae and papillary muscles from any angle. Real time observation of mitral valve thickness, mobility, calcification, vegetations and chordae tendineae rupture was effective. It was able to diagnose the thrombosis and patent foramen ovale. In the 19 patients, the TEE diagnosis of mitral valve prolapse was almost consistent with operative findings, and P2 was the most common area. The etiology was detected in 15 cases caused by rupture of mitral chordae tendineae, which was consistent with operative findings, and the accuracy rate was 100%. The size of the prosthetic ring provided by TEE in 14 cases was consistent with operative findings among 19 patients. The accuracy rate was 73.7% (4/9). Four cases were selected 1 size down than TEE, and 1 case was selected 1 size up than TEE. Conclusions The application of real-time three-dimensional ultrasound reconstruction can objectively reflect the pathogeny and pathological changes of prolapse, and provide a visual stereoscopic image, which is of great reference value for the formulation of the operation scheme. It also provides a basis for selecting the size of the forming ring and saves the operative time. It has practical clinical guiding significance. The function of the autologous valve is evaluated immediately after the operation, and the ventricular wall movement and left ventricular systolic function are detected in real time, and the left heart gas could be monitored. It is helpful to the intraoperative monitoring of the anesthesiologist and increase the success rate of the operation.

Comparison of perioperative and recent efficacy of different mitral valve treatment strategies for mitral regurgitation caused by infective endocarditis / 中国医师进修杂志

Objective To compare the perioperative and recent efficacy of different mitral valve treatment strategies for mitral regurgitation caused by infective endocarditis. Methods From January 2009 to December 2014, 168 patients with mitral regurgitation caused by infective endocarditis underwent surgical treatment. Among them, mitral valve repair was performed in 65 patients (group A) and mitral valve replacement was performed in 103 patients (group B). Preoperative clinical profiles, perioperative details and follow-up data were reviewed retrospectively. Results There was no operative death in both groups. The cardiopulmonary bypass time and aorta clamp time were similar between the two groups. Intensive care stay was significantly shorter in group A [(1.4 ± 0.6) d] compared with group B [(1.9 ± 0.9) d](P＜0.05), and hospital stay had no significant difference between two groups (P＞0.05). Perioperative cerebral hemorrhage was observed in no patient in group A and 2 patients (1.9%) in group B. There was no in-hospital death in group A, and 2 patients (1.9%) in-hospital deaths occurred in group B. The difference was not statistically significant (P＞0.05). The incidence of heart-related adverse events in group A and group B was 6.2%(4/65) and 7.9%(8/101), and the incidence of infection related events was 0 and 3.0% (3/101) 3 years after operation (P＞0.05). Conclusions Mitral valve repair for patients with mitral regurgitation caused by infective endocarditis is safe and reliable, and the short-term effect is satisfactory. However, infection tissue should be eliminated thoroughly, and the related complications of valve replacement can be avoided and the risk of anticoagulation can be reduced.

Therapeutic effect of simultaneous CABG and HVR on CHD patients with heart valve disease and its in-fluence on prognosis / 心血管康复医学杂志

Objective:To explore influence of simultaneous coronary artery bypass grafting (CABG) and heart valve replacement (HVR) therapy on ICU stay time,cardiac function and long-term prognosis in patients with coronary heart disease (CHD) complicated heart valve disease (HVD).Methods:A total of 94 CHD + HVD patients were selected from our hospital.They were randomly and equally divided into non-simultaneous treatment group (NST group) and simultaneous treatment group (ST group),according received CABG and HVR simultaneously.Postop-erative cardiac function,related indexes during and after operation,survival rate within five years and incidence rate of adverse reactions were compared between two groups.Results:Compared with NST group after operation,there were significant rise in LVEF [ (44.23 ± 11.03)% vs.(49.58 ± 11.39)%],left ventricular early diastolic peak flow velocity/late diastolic peak flow velocity (E/A) [ (0.87 ± 0.09) vs.(0.94 ± 0.12)] and percentage of NYHA classⅡ(46.81% vs.70.21%),and significant reductions in left atrial diameter (LAD) [ (39.47 ± 10.16) mm vs.(34.46 ± 8.72) mm],left ventricular end-diastolic dimension (LVEDd) [ (58.49 ± 10.65) mm vs.(53.17 ± 9.13) mm],left ventricular end-systolic dimension (LVESd) [ (48.69 ± 8.73) mm vs.(42.07 ± 8.36) mm],cardiotho-racic ratio (CTR) [ (0.66 ± 0.14) vs.(0.54 ± 0.09)],percentage of NYHA class Ⅲ(34.04% vs.12.77%),as-cending aorta block time,extracorporeal circulation time,ventilator assist time,ICU stay and hospitalization time in ST group,P＜0.05 or ＜0.01.Compared with NST group after five-year follow-up,there was significant reduction in incidence rate of major adverse cardiovascular events (40.43% vs.19.15%),and significant rise in five-year sur-vival rate (44.68% vs.68.08%) in ST group,P＜0.05 both.Conclusion:Simultaneous CABG and HVR can signifi-cantly shorten ICU stay time etc.postoperative observation index,improve cardiac function and long-term survival rate,reduce incidence rate of adverse reactions in CHD + HVD patients.

Minimally Invasive Mitral Valve Repair in a Woman with Marfan Syndrome and Type B Dissection / 대한흉부외과학회지

We report the case of a patient with mitral regurgitation complicated by type B dissection and Marfan syndrome (MFS) who was managed successfully with minimally invasive mitral valve repair. Without type A aortic dissection or aortic root dilation, MFS patients may develop mitral valve regurgitation, as in this case, and need valve surgery to improve their symptoms and long-term survival. However, it is not clear that a full sternotomy and prophylactic aortic surgery are necessary. Although retrograde perfusion to the dissected aorta is controversial, our approach minimizes the risk of future anticipated aortic surgery in MFS patients.

The Effect of Treatment Strategy of Chronic Ischemic Mitral Regurgitation on Long-Term Outcomes in Coronary Artery Bypass Grafting

Abstract Objective: To investigate the mid- and long-term outcomes of case-based selective strategy of mitral ring annuloplasty during coronary artery bypass grafting in patients with coronary artery disease accompanied by chronic ischemic mitral regurgitation. Methods: 132 patients who were diagnosed ischemic moderate to severe mitral regurgitation undergoing coronary artery bypass grafting in the same center with the same surgical team were divided into 2 groups and investigated retrospectively. Patients undergoing simultaneous mitral ring annuloplasty and coronary artery bypass grafting were enrolled to group 1 (n=58), patients undergoing isolated coronary artery bypass grafting were enrolled in group 2 (n=74). Results: The mean age of the patients were 65.0 ± 9.4 years and 39 (29.5%) of them were female. Preoperative New York Heart Association (NHYA) class (P=0.0001), atrial fibrillation (P=0.006) and the grade of mitral regurgitation (P=0.0001) were significantly different between the groups. Hospitalization for heart failure was required in 6 (10.6%) patients in group 1 and 19 (27.1%) patients in Group 2 (P=0.02). Hospital mortality and one-month postoperative mortality occurred in 2 (3.4%) patients in Group 1 and in 4 (5.4%) patients in Group 2 (P=0.69). Clinical follow-up was completed with 117 (88.6%) patients. Conclusion: Mitral ring annuloplasty in addition to the coronary artery bypass grafting is associated with improved NYHA functional class, increased ejection fraction, decreased residual mitral regurgitation. Further studies are needed to clarify the role of combined surgery on long-term outcomes. With proper tools and according to the decisions made by heart teams, both management strategies can be safely performed.

Repair of double orifice left av valve (dolavv) with endocardial cushion defect in adult

Abstract Double orifice left atrioventricular valve (DOLAVV) or double orifice mitral valve (DOMV) is a rare congenital cardiac anomaly manifesting either as an isolated lesion (mitral stenosis or mitral insufficiency) or in association with other congenital cardiac defects. Signs of mitral valve disease are usually present along with the symptoms of associated coexistent congenital heart diseases. Mitral insufficiency due to annular dilatation is seen when DOLAVV is associated with endocardial cushion defects. Surgical intervention like mitral valve repair or replacement is required in 50% of patients and yields good results. We report a case of a 56-year-old lady who successfully underwent surgical correction of DOLAVV with partial atrioventricular canal defect.