Our 10-Year Experience with Atrial Myxomas: Is Concurrent Valve Intervention Really Warranted?

ABSTRACT Introduction: Primary cardiac myxomas are rare tumors. Concurrent valvular lesion is a common finding on evaluation which is thought to be due to annular dilatation secondary to tumor movement across the valve, functional obstruction across the valve, and severe pulmonary hypertension secondary to chronic obstruction. A common belief among surgeons is that excision of myxoma leads to abatement of symptoms, and further valve intervention may not be warranted. Methods: A 10-year retrospective descriptive study was designed to analyze patients who underwent excision of cardiac myxoma at our center. Data was analyzed regarding presenting features, echocardiographic findings of myxoma and valve morphology, intraoperative assessment, and postoperative outcome with/without valve repair/replacement in all patients. Results: A total of 22 patients underwent surgery for myxoma. Six patients underwent successful mitral valve repair with ring annuloplasty, two had moderate mitral regurgitation, three had severe mitral regurgitation, and one patient had no mitral regurgitation on preoperative assessment, but moderate mitral regurgitation was found intraoperatively. Four of these patients had no residual mitral regurgitation in follow-up period while two had mild residual mitral regurgitation. One patient had severe mitral stenosis of concurrent rheumatic etiology and successfully underwent mitral valve replacement. Conclusion: Cardiac myxomas are rare benign tumors commonly associated with mitral valve insufficiency. Mitral valve should be assessed intraoperatively after excision of mass as preoperative assessment might often be insufficient. Concomitant mitral valve intervention might be needed with a case-specific tailored approach, and mitral valve repair with ring annuloplasty offers best surgical outcome in such cases.

Comparison of Early and Mid-Term Outcomes After Classic and Modified Morrow Septal Myectomy in Patients with Hypertrophic Obstructive Cardiomyopathy

ABSTRACT Introduction: The aim of our study is to compare the early and mid-term outcomes of patients with hypertrophic obstructive cardiomyopathy who underwent classic and modified Morrow septal myectomy. Methods: Between 2014 and 2019, 48 patients (24 males; mean age 49.27±16.41 years) who underwent septal myectomy were evaluated. The patients were divided into two groups - those who underwent classic septal myectomy (n=28) and those who underwent modified septal myectomy (n=20). Results: Mitral valve intervention was higher in the classic Morrow group than in the modified Morrow group, but there was no significant difference (P=0.42). Mortality was found to be lower in the modified Morrow group than in the classic Morrow group (P=0.01). In both groups, the mean immediate postoperative gradient was significantly higher than the mean of the 3rd and 12th postoperative months. The preoperative and postoperative gradient difference of the modified Morrow group was significantly higher than of the classic Morrow group (P<0.001). Conclusion: Classic Morrow and modified Morrow procedures are effective methods for reducing left ventricular outflow tract obstruction. The modified Morrow procedure was found to be superior to the classic Morrow procedure in terms of reducing the incidence of mitral valve intervention with the reduction of the left ventricular outflow tract gradient.

Prognostic Impact of Residual Moderate Mitral Regurgitation Following Valve-in-Valve Transcatheter Aortic Valve Implantation

ABSTRACT Introduction: The impact of mitral regurgitation (MR) on valve-in-valve transcatheter aortic valve implantation (VIV-TAVI) in patients with failed bioprostheses remains unclear. The purpose of this study was to assess the prognostic impact of residual moderate MR following VIV-TAVI. Methods: We retrospectively analyzed 127 patients who underwent VIV-TAVI between March 2010 and November 2021. At least moderate MR was observed in 51.2% of patients before the procedure, and MR improved in 42.1% of all patients. Patients with postoperative severe MR, previous mitral valve intervention, and patients who died before postoperative echocardiography were excluded from further analyses. The remaining 114 subjects were divided into two groups according to the degree of postprocedural MR: none-mild MR (73.7%) or moderate MR (26.3%). Propensity score matching yielded 23 pairs for final comparison. Results: No significant differences were found between groups before and after matching in early results. In the matched cohort, survival probabilities at one, three, and five years were 95.7% vs. 87.0%, 85.0% vs. 64.5%, and 85.0% vs. 29.0% in the none-mild MR group vs. moderate MR-group, respectively (log-rank P=0.035). Among survivors, patients with moderate MR had worse functional status according to New York Heart Association (NYHA) class at follow-up (P=0.006). Conclusion: MR is common in patients with failed aortic bioprostheses, and improvement in MR-status was observed in over 40% of patients following VIV-TAVI. Residual moderate MR after VIV-TAVI is not associated with worse early outcomes, however, it was associated with increased mortality at five years of follow-up and worse NYHA class among survivors.

Application of Cut-and-Sew Technique in Thoracoscopic Minimally Invasive Mitral Valve Surgery and Concomitant Maze Procedure

ABSTRACT Introduction: Atrial fibrillation is one of the common complications of mitral valve disease. Currently, in the absence of freezing equipment, it's still impossible to fully conduct a minimally invasive Cox-maze IV procedure to treat atrial fibrillation. Methods: We analyzed the clinical data of 28 patients who underwent thoracoscopic minimally invasive mitral valve full maze surgery in our hospital from October 2021 to September 2022; 13 patients were male and 15 were female, three suffered from paroxysmal atrial fibrillation, and 25 suffered from permanent atrial fibrillation; average age was 61.88±8.30 years, and mean preoperative left atrial diameter was 47.12±8.34 mm. Isolation of left atrial posterior wall (box lesion) was completed in all patients by cut-and-sew technique and bipolar clamp ablation. Results: For these subjects, the median cardiopulmonary bypass time was 169 (109.75-202.75) minutes, aortic cross-clamping time was 106 (77.75-125.50) minutes, and ventilator assistance time was 6.5 (0-10) hours. Among them, eight subjects had the endotracheal tubes removed immediately after surgical operation. Three subjects were in the blanking period; two subjects still had atrial fibrillation at three months after operation, one of whom resumed sinus rhythm after electrical cardioversion therapy; and all the remaining 23 subjects had sinus rhythm. Conclusion: The minimally invasive cut-and-sew technique for electrical isolation of left pulmonary veins can improve sinus conversion rate of patients suffering from both mitral valve disease and atrial fibrillation. In selected subjects, it is safe and has good results in the short-term postoperative period.

Transcatheter Mitral Valve Implantation: Implications of Interventional Technique and 3D Echocardiography for Complex Valve?in?Valve Paravalvular Leak

Transcatheter mitral valve replacement (TMVR) has emerged as a feasible alternative to surgical reoperation in failed bioprostheses and rings. Residual mitral regurgitation following TMVR can present as a valve?in?valve paravalvular leak (PVL) and is associated with increased morbidity and mortality. Current therapies for valve?in?valve PVL are limited. We present a case of a symptomatic patient with severe valve?in?valve PVL after TMVR for a previous surgical bioprosthesis leak, who then underwent a second TMVR as a valve?in?valve?in?valve implantation with a 29 mm Edwards? SAPIEN 3 valve via transseptal approach using three?dimensional (3D) echocardiography. This unique case highlights the complexity of this clinical entity and recognizes 3D transesophageal echocardiography as a valuable tool to guide valve?in?valve PVL closures.echocardiography

The Effect of Postoperative Hepatic Fibrosis Factors on Morbidity in Mitral Valve Replacement Surgery: A Single Center Ten Years� Experience

Background: Previous studies have shown that hepatic fibrosis indices and rates can be used to predict cardiovascular mortality and morbidity. Our aim with this study was to investigate the effect of aspartate aminotransferase/alanine aminotransferase (AST/ALT) ratio and fibrosis?4 (FIB?4) index calculated with ALT, AST, and platelet biomarkers, which are simple, fast, and relatively inexpensive and were used in previous studies to predict cardiovascular disease prognosis, on the prediction of postoperative morbidity and early mortality after mitral valve replacement (MVR) surgery. Methods: By scanning the hospital electronic health record system, 116 patients who underwent isolated MVR or MVR + tricuspid valve intervention were identified from 178 patients who underwent MVR with the standard sternotomy procedure between 2011 and 2021. The study was completed with 81 of these patients. Patients were divided into AST/ALT <2 (Group 1) and >2 (Group 2). In addition, the same patients were divided into FIB?4 index <3.25 (Group 3) and >3.25 (Group 4), and a total of four groups were formed. Results: The mean age of Group 2 was significantly higher than Group 1 (P = 0.049). In addition, the mean age of Group 4 was significantly higher than Group 3 (P = 0.003). Postoperative complications did not differ between Groups 1 and 2 (P > 0.05). While noninvasive mechanincal ventilation (NIMV) requirements did not differ between Groups 3 and 4 (P > 0.05), MV duration and intensive care unit stay were significantly longer in Group 4 (P < 0.05). Conclusion: The AST/ALT ratio, which has been shown to be a predictor of cardiovascular mortality in various studies, was not useful in predicting mortality and morbidity in our study. However, a high FIB?4 index, another hepatic fibrosis index, was found to be associated with increased perioperative bleeding, duration of mechanical ventilation, and cardiac intensive care unit stay, which are important criteria in the prediction of morbidity in cardiovascular surgery.

Stenosing Intracardiac Mass of the Mitral Valve: A Case Report and Review of the Literature

Introduction: Benign intracardiac tumours are the most common of the 5% of primary tumours and account for 90% of intracardiac tumours. Myxoma, which is the main benign tumour, rarely localizes to the mitral valve, in the order of 1-5%, associated with severe symptoms and enormous complications. The objective is to report a rare and severe case of mitral valve myxoma resulting in severe obstruction of the valve orifice. Presentation of Case: A 65-year-old Moroccan woman, without profession, the diabetic patient presented with progressive dyspnoea, in whom transthoracic echocardiography (TTE) completed by transesophageal echocardiography (TEE), a cardiac magnetic resonance imaging (MRI), a cerebro-throracoabdominopelvic Positron emission tomography-scan (PET-scan) showed a cauliflower-shaped mass embedded in the small mitral valve, evoking the diagnosis of myxoma, confirmed by the anatomopathological examination. A lumpectomy with mitral valve plasty was performed in association with coronary artery bypass surgery for a tri truncal lesion. The evolution was marked by an improvement in the clinical and echographic state. Discussion: Myxoma is the first benign tumour encountered in women between the 3rd and 6th decade, whose diagnosis is evoked by a TTE, better by a TEE or more, by a computed tomography (CT scan) or even a cardiac MRI which specifies the visualization of the soft parts with all the internal details of the myxoma, whose confirmation is carried out on the histopathological analysis of the operating room. Conclusion: The management was based on complete resection of the tumor associated with mitral valve plasty.

Medição automática de valva mitral a partir de ecocardiograma utilizando processamento digital de imagens / Automatic measurement of the mitral valve based on echocardiography using digital image processing

Fundamento: A avaliação da área valvar mitral por meio da reconstrução multiplano na ecocardiografia tridimensional é restrita a softwares específicos e à experiência dos ecocardiografistas. Eles precisam selecionar manualmente o frame do vídeo que contenha a área de abertura máxima da valva mitral, dimensão fundamental para a identificação de estenose mitral. Objetivo: Automatizar o processo de determinação da área de abertura máxima da valva mitral, por meio da aplicação de Processamento Digital de Imagens (PDI) em exames de ecocardiograma, desenvolvendo um algoritmo aberto com leitura de vídeo no formato avi. Método: Este estudo piloto observacional transversal foi realizado com vinte e cinco exames diferentes de ecocardiograma, sendo quinze com abertura normal e dez com estenose mitral reumática. Todos os exames foram realizados e disponibilizados por dois especialistas, com autorização do Comitê de Ética em Pesquisa, que utilizaram dois modelos de aparelhos ecocardiográficos: Vivid E95 (GE Healthcare) e Epiq 7 (Philips), com sondas multiplanares transesofágicas. Todos os vídeos em formato avi foram submetidos ao PDI através da técnica de segmentação de imagens. Resultados: As medidas obtidas manualmente por ecocardiografistas experientes e os valores calculados pelo sistema desenvolvido foram comparados utilizando o diagrama de Bland-Altman. Observou-se maior concordância entre valores no intervalo de 0,4 a 2,7 cm². Conclusão: Foi possível determinar automaticamente a área de máxima abertura das valvas mitrais, tanto para os casos advindos da GE quanto da Philips, utilizando apenas um vídeo como dado de entrada. O algoritmo demonstrou economizar tempo nas medições quando comparado com a mensuração habitual. (AU)

Background: The evaluation of mitral valve area through multiplanar reconstruction in 3-dimensional echocardiography is restricted to specific software and to the experience of echocardiographers. They need to manually select the video frame that contains the maximum mitral valve opening area, as this dimension is fundamental to identification of mitral stenosis. Objective: To automate the process of determining the maximum mitral valve opening area, through the application of digital image processing (DIP) in echocardiography tests, developing an open algorithm with video reading in avi format. Method: This cross-sectional observational pilot study was conducted with 25 different echocardiography exams, 15 with normal aperture and 10 with rheumatic mitral stenosis. With the authorization of the Research Ethics Committee, all exams were performed and made available by 2 specialists who used 2 models of echocardiographic devices: Vivid E95 (GE Healthcare) and Epiq 7 (Philips), with multiplanar transesophageal probes. All videos in avi format were submitted to DIP using the image segmentation technique. Results: The measurements obtained manually by experienced echocardiographers and the values calculated by the developed system were compared using a Bland-Altman diagram. There was greater agreement between values in the range from 0.4 to 2.7 cm². Conclusion: It was possible to automatically determine the maximum mitral valve opening area, for cases from both GE and Philips, using only 1 video as input data. The algorithm has been demonstrated to save time on measurements when compared to the usual method. (AU)

Comparative Morphological and Morphometrical Analysis of Atrio-Ventricular Valves of Human and Porcine

There is increased incidence of valvular heart diseases in recent years due to life style modifications. The mortality rates in valvular diseases are kept in pace using various modalities of treatments. One such lifesaving treatment is valve replacement surgeries. These are done by using mechanical valve prosthesis or tissue grafts. The tissue valves prosthesis, harvested from porcine heart are called as xenograft and are increasingly used in valve repair and replacement surgeries. In the present scenario, there is a smaller number of systematically analysed literatures available on the comparative anatomy of human and porcine heart valves. Hence this study was carried out to acquire knowledge and to put forth some points to future research works on heart valves. In this study, 20 formalin fixed porcine and human hearts were procured from slaughter house and cadavers respectively. The morphology and morphometry of tricuspid valve and mitral valve was observed and analysed using spss software 20 version. All the dependent variables were compared using student t test and independent sample test. The results were tabulated and compared. It was observed that the tricuspid and the mitral valve of the porcine resembles the corresponding human heart valves in morphology and morphometry and their values were coinciding to their maximum. The porcine valve resembles human heart valves in morphology and it can be used in designing valve substitutes in replacement surgeries. Porcine valve can also be used as bio-prosthesis by matching the morphometry and by reducing the geometrical difference to their minimum by using any interventional radiology.

The effect of levosimendan on the right ventricular function in patients with right ventricular dysfunction undergoing mitral valve surgery

Background: Right ventricular (RV) dysfunction is an important predictor of both immediate and long-term outcomes in valve surgeries. Levosimendan has proven beneficial in improving RV function. Aims: The objective was to study the effect of the addition of levosimendan to the conventional treatment on RV function in patients with RV dysfunction undergoing mitral valve (MV) surgeries. Setting and Design: Prospective randomized double-blinded controlled study at a tertiary care institution. Materials and Methods: Sixty adult patients aged 15� years, with preoperative transthoracic echocardiography (TTE) findings of RV dysfunction posted for elective MV surgery, were randomized into levosimendan (L) group and placebo (P) group. Patients in the L group were administered levosimendan at a rate of 0.1 mcg/kg/min after induction for 24 hrs, whereas patients in the P group were given multivitamin infusion at the same rate. Both the groups received standard inotropic therapy. The hemodynamic and echocardiographic parameters of RV function (RV size, Inferior vena cava (IVC) diameter, RV fractional area change (RVFAC) Tricuspid annular plane systolic excursion (TAPSE), and Systolic Pulmonary Artery Pressure (SPAP) were compared between the groups at 6 hrs, 24 hrs, and 7th day postoperatively. Results: All hemodynamic and echocardiographic parameters of RV function like RV size, IVC diameter, RVFAC, TAPSE, and SPAP improved from baseline to 24 hrs in both groups. Levosimendan caused a significant improvement in RV function compared to the P group at 24 hrs and 7th day postoperatively. Conclusions: The present study concludes that levosimendan is a promising option in patients with RV dysfunction undergoing MV surgeries.

Comparison of Outcomes After Transcatheter Versus Surgical Repeat Mitral Valve Replacement

ABSTRACT Introduction: Repeat transcatheter mitral valve replacement (rTMVR) has emerged as a new option for the management of high-risk patients unsuitable for repeat surgical mitral valve replacement (rSMVR). The aim of this study was to compare hospital outcomes, survival, and reoperations after rTMVR versus surgical mitral valve replacement. Methods: We compared patients who underwent rTMVR (n=22) from 2017 to 2019 (Group 1) to patients who underwent rSMVR (n=98) with or without tricuspid valve surgery from 2009 to 2019 (Group 2). We excluded patients who underwent a concomitant transcatheter aortic valve replacement or other concomitant surgery. Results: Patients in Group 1 were significantly older (72.5 [67-78] vs. 57 [52-64] years, P<0.001). There was no diference in EuroSCORE II between groups (6.56 [5.47-8.04] vs. 6.74 [4.28-11.84], P=0.86). Implanted valve size was 26 (26-29) mm in Group 1 and 25 (25-27) mm in Group 2 (P=0.106). There was no diference in operative mortality between groups (P=0.46). However, intensive care unit (ICU) and hospital stays were shorter in Group 1 (P=0.03 and <0.001, respectively). NYHA class improved significantly in both groups at one year (P<0.001 for both groups). There was no group effect on survival (P=0.84) or cardiac readmission (P=0.26). However, reoperations were more frequent in Group 1 (P=0.01). Conclusion: Transcatheter mitral valve-in-valve could shorten ICU and hospital stay compared to rSMVR with a comparable mortality rate. rTMVR is a safe procedure; however, it has a higher risk of reoperation. rTMVR can be an option in selected high-risk patients.

Clinical study on morphology and dynamics of mitral valve device in patients with different types of functional mitral regurgitation by real-time three-dimensional echocardiography / 中华超声影像学杂志

Objective:To quantitatively evaluate and compare the morphology and dynamics parameters of mitral valve devices in patients with atrial functional mitral regurgitation (AFMR) and ventricular functional mitral regurgitation (VFMR) by real-time three-dimensional ultrasound, in order to provide theoretical basis for diagnosis and clinical treatments of the two types of regurgitation patients.Methods:A retrospective study was conducted on 20 AFMR patients (AFMR group) and 20 VFMR patients (VFMR group) who underwent transesophageal echocardiography at Wuhan University People′s Hospital from May to November 2022. Additionally, 20 patients who underwent transesophageal echocardiography at our hospital during the same period due to patent foramen ovale or non cardiac surgery monitoring were selected as the control group. All subjects were measured mitral annulus anteroposterior diameter (AP diameter), anterolateral posteromedial diameter (ALPM diameter), anteroposterior diameter/anterolateral posteromedial diameter (AP/ALPM), commissural width (CW), annular area (AA), annular circumference (AC), annular height (AH), coaptation depth (CD), tenting volume (TV), non-planar angle (NPA) and posterior leaflet angle at isovolumic relaxation time, early diastole, mid diastole, late diastole, isovolumic contraction time, early systole, mid systole, and late systole. The total change rate and systolic change rate of the above parameters were calculated, the differences in structure and dynamic changes of the mitral valve device among three groups were compared, and the correlations between the change rate of mitral annular parameters and left ventricular long axis strain (GLS) were analyzed.Results:①The GLS of three groups were as follows: control group>AFMR group>VFMR group, and the differences between the groups were statistically significant (all P<0.05). ②Static structure: The AP diameter, ALPM diameter, AA, AC, and total leaflet area (TLA) of the AFMR group and VFMR group were significantly larger than those of the control group (all P<0.05), but there was no statistically significant difference between the AFMR group and VFMR group (all P>0.05). Compared with the other two groups, the TV, CD, and posterior leaflet angle of the VFMR group were significantly increased, exhibiting the mitral valve tethering; the control group had the largest AH/CW and the deepest saddle shape; the AFMR group had the smallest TLA/AA and the least mitral valve remodeling; there was no statistically significant difference in the junction area among the three groups (all P>0.05). ③Dynamic changes: AP diameter, ALPM diameter, AA and AC in the control group showed regular changes throughout the cardiac cycle, gradually decreased from isovolumic relaxation time to late diastole, and gradually increased from isovolumic contraction time to late systole; The changes in the above parameters in the AFMR and VFMR groups appeared more disordered. In addition, compared with the control group, the total change rate and systolic change rate of AP diameter in the AFMR group were significantly reduced, but the total change rate of ALPM diameter was significantly increased (all P<0.05). ④The total change rate of AA, ALPM diameter and AP diameter were moderately correlated with GLS ( r=0.353, P=0.006; r=-0.304, P=0.018; r=0.300, P=0.020), while the systolic change rate of posterior leaflet angle was weakly correlated with GLS ( r=0.267, P=0.039). Conclusions:There are differences in the morphology and dynamics parameters of mitral valve device in patients with AFMR and VFMR.Different clinical strategies can be used for the two kinds of functional mitral regurgitation.

Preliminary application of transesophageal echocardiography in transapical mitral valve repair with Memoclip / 中华超声影像学杂志

Objective:To explore the value of transapical catheter of mitral valve repair (MVR) with Memoclip device in the management of moderate to severe and severe mitral regurgitation (MR) guided by transesophageal echocardiography (TEE).Methods:Fifteen patients with moderate to severe and severe MR in Hefei High-tech Cardiovascular Hospital from December 2021 to October 2022 were prospectively selected. Mitral valve morphology and length, regurgitation severity, left ventricular ejection fraction and pulmonary venous Doppler spectra were carefully evaluated before MVR by TEE.Intraprocedural TEE was performed to guide the MVR including transseptal catheterization, alignment of the clip delivery system, assessment of leaflet capture, clip deployment, post-clip deployment assessment, and withdrawal of the clip delivery system. The position and coaptation length of the clips, the mitral orifice morphology, residual mitral valve regurgitation and pressure gradient were evaluated after MVR.Meanwhile, the complications were monitored throughout the procedure.Results:Among the 15 patients, 12 were implanted with 1 clip and 3 were implanted with 2 clips, respectively. No complications occurred. There were 13 patients with mild regurgitation and 2 showed to moderate mitral regurgitation 1 month later after MVR, and 13 remained mild and 2 maintained moderate regurgitation 3 months later. Significant differences were found in maximal MR area (MRA-max), maximal and mean mitral valve pressure gradient (MVPG-max, MVPG-mean) and mitral valve area (MVA) among the 5 observation time points (all P<0.05). MRA-max, MVA and MVPG-mean were significantly decreased immediately and 3 months after the procedure ( P<0.001). No significant stenosis was found in mitral valve after MVR. Conclusions:MVR with Memoclip is safe, effective, easy to operate in treating patients with moderate to severe and severe MR. TEE plays a key role in perioperative MVR with Memoclip through apical catheterization.

Short-term clinical and echocardiographic outcomes of the novel domestic transcatheter edge-to-edge repair Neonova? system in patients with mitral regurgitation / 中华超声影像学杂志

Objective:To investigate short-term safety, efficacy and the learning curve of this self-developed novel transcatheter valve repair system (Neonova?) in patients with mitral regurgitation, and explore the role of perioperative echocardiography.Methods:Ten patients who visited the Union Hospital of Tongji Medical College, Huazhong University of Science and Technology from June 2021 to March 2022 and met the inclusive criteria were prospectively enrolled. All the patients were at high risk of surgery with moderate to severe or severe mitral regurgitation (MR). Clamps of Neonova? were implanted under guidance of transesophageal echocardiography and digital subtraction angiography. Clinical outcomes, echocardiography indexes and learning curves of this technique were evaluated immediately after intervention, 7 d, 1 month and 3 months post-intervention.Results:The technical success rate was 100% with MR relieved in all patients immediately after intervention. The device and procedural success rates were both 90.0% with 1 patient received surgical replacement at 37 days post-intervention while the others′ reduced to mild (8/9) and moderate (1/9) MR. New York Heart Association class and the Kansas City Cardiomyopathy Questionnaire improved significantly (all P<0.001). Mean mitral valve pressure gradient didn′t increase significantly after intervention when compared with that before intervention( P=0.324), and no mitral stenosis was observed. Left ventricular end-diastolic diameter decreased significantly ( P=0.008) during follow up.Procedure duration ranged from 60 to 300 (175.8±75.2)minutes. The simple linear regression model between procedure volume and duration showed that procedure duration decreased significantly with the increase of procedure volume ( F=15.857, P=0.004). Conclusions:Neonova? implantation can improve MR severity and clinical symptoms safely and effectively. Transthoracic echocardiography and transesophageal echocardiography are essential for perioperative management of transcatheter mitral valve repair.

Application and development of totally thoracoscopic mitral valve plasty / 中国胸心血管外科临床杂志

@#Thoracoscopic minimally invasive technology has been used in mitral valve plasty since 1990s. Totally thoracoscopic mitral valve plasty has the advantages of small trauma, beautiful incision and rapid postoperative recovery. It is favored by more and more patients and cardiac surgeons. However, according to the reports, the proportion of totally thoracoscopic mitral valve surgery in China is still low. Mitral valve plasty via the totally thoracoscopic approach is still controversial in terms of population adaptation, perioperative complications and long-term prognosis. In addition, the technical difficulty and the long training cycle of surgeons also limit the popularization of this technology. By summarizing the existing literature, this paper analyzes the application and development of totally thoracoscopic approach in comparison with the traditional median thoracotomy mitral valve plasty.

Concomitant repair of moderate or less tricuspid regurgitation during mitral valve surgery improves early and mid-term prognosis of tricuspid valve and right heart function / 中国胸心血管外科临床杂志

@#Objective    To investigate the effect of concomitant tricuspid valve repair during mitral valve surgery on the early and mid-term prognosis of the tricuspid valve and right heart function in the patients with moderate or less tricuspid regurgitation. Methods    A retrospective study of 461 patients with mitral valve disease requiring cardiac surgery combined with moderate or less tricuspid regurgitation in our hospital from 2011 to 2014 was done. They were 309 males and 152 females with a median age of 53.00 (44.00, 60.00) years. According to whether they received tricuspid valve repair (Kay’s annuloplasty, DeVega’s annuloplasty or annular ring implantation), the patients were divided into a mitral valve surgery only group (a nTAP group, n=289) and a concomitant tricuspid valve repair group (a TAP group, n=172). At the same time, 43 patients whose tricuspid valve annulus diameter was less than 40 mm in the TAP group were analyzed in subgroups. Results    The median follow-up duration was 3.00 years (range from 0.10 to 9.30 years). There was no perioperative death. Three months after surgery, the anteroposterior diameter of the right ventricle in the TAP group was significantly improved compared with that in the nTAP group [–1.00 (–3.00, 1.00) mm vs. 0.00 (–0.20, 2.00) mm, P=0.048]. Three years after surgery, the improvement of right ventricular anteroposterior diameter in the TAP group was still significant compared with the nTAP group [–1.00 (–2.75, 2.00) mm vs. 2.00 (–0.75, 4.00) mm, P=0.014], and the patients in the TAP group were less likely to develop moderate or more tricuspid regurgitation (3.64% vs. 35.64%, P<0.001). Annuloplasty ring implantation was more effective in preventing regurgitation progression (P=0.044). For patients with a tricuspid annulus diameter less than 40 mm, concomitant tricuspid valve repair was still effective in improving the anteroposterior diameter of the right ventricle in the early follow-up (P=0.036). Conclusion     Concomitant tricuspid valve repair for patients with moderate or less tricuspid regurgitation during mitral valve surgery can effectively improve the tricuspid valve and right heart function in the early and mid-term after surgery. Annuloplasty ring implantation is more effective in preventing regurgitation progression. Patients whose tricuspid annulus diameter is less than 40 mm can also benefit from concomitant tricuspid repair.

Clinical pathway for transcatheter mitral valve edge-to-edge repair in China (abbreviated version 2022) / 中国胸心血管外科临床杂志

@#Transcatheter mitral valve edge-to-edge repair (TEER) has become an important treatment opinion for patients with severe mitral regurgitation (MR) at high risk for surgery. The devices and procedural techniques of TEER are complex and require excellent team cooperation. However, there is still a lack of standardized clinical pathways in China. Based on the latest evidence, the expert group wrote this clinical pathway to guide and optimize TEER therapy in clinical practice. It demonstrates the following key issues of clinical concern: (1) TEER team building; (2) preoperative clinical evaluation of TEER patients; (3) imaging assessment before TEER procedure; (4) standardized procedures for TEER; (5) TEER for complex MR; (6) the standard process of perioperative comprehensive management; and (7) full life-cycle rehabilitation and follow-up. This clinical pathway might be helpful to facilitate the standardized development of TEER therapy and application, and promote the improvement of management and life quality for patients with MR.

Mitral Surgery for Severe Mitral Annular Calcification: Calcium Resection or Exclusion Procedure / 日本心臓血管外科学会雑誌

Background: Extensive calcification of the mitral annulus (MAC) represents a problem for mitral surgery due to a technical difficulty for implanting prosthetic valves, because the calcium does not allow placing direct sutures through the annulus and para-prosthetic leakage or cardiac rupture may result. We describe our experience with mitral valve surgery with or without decalcification of the annulus. Methods: Since 2005, we performed mitral valve operations in 1,327 patients and among them, severe mitral annular calcification was present in 25 (1.9%). Results: The mean age was 75±9 years and there were 6 men and 19 women, with hemodialysis in 4. Mitral valve replacement (MVR) was performed in all patients. A concomitant operation was aortic valve replacement in 19 and coronary artery bypass grafting in 4 patients. The MAC was resected in 14 (Group-R) and was excluded in 11 (Group-E). In-hospital mortality was four patients in Group-R. The cause of death was congestive heart failure in two, cerebellar infarction in one, and respiratory failure in one. Postoperative morbidity included one patient with reexploration and one with prolonged respiratory failure The aortic cross clamp time was a mean of 180±44 min (range 108∼266 min) in Group-R and 139±32 min (range 61∼186 min) in Group-E (p=0.009). The size of the prosthetic mitral valve was 24.3±1.0 mm in Group-R and 24.6±0.8 mm in Group-E (p=0.618). The postoperative echocardiography showed no abnormal mean pressure gradient of mitral valve prosthesis nor para-valvular leak in any patients in either group. Conclusions: The mitral valve replacement without annular decalcification in a severely calcified mitral annulus is a safe and an effective approach in an elderly patient.