Effects of Surgical Techniques on Long-Term Results in Patients with Degenerative Mitral Valve Bileaflet Prolapse.

BACKGROUND AND AIM OF THE STUDY: The study aim was to evaluate the long-term results in patients with degenerative mitral valve bileaflet prolapse (DMVBLP) undergoing mitral valve repair (MVr) or mitral valve replacement (MVR), and to compare the consequences of survival related to each technique. METHODS: Between 2001 and 2012, a total of 421 patients underwent isolated primary surgery for DMVBLP. MVr was performed in 146 patients (34.7%), and MVR in 275 (65.3%). MVR patients were allocated to two subgroups. Subgroup A were operated on in routine fashion, preserving the posterior subvalvular apparatus, and in selected cases the anterior or both apparatus (n = 119; 43.3%). In subgroup B, surgery was performed without preservation of the subvalvular apparatus (n = 156; 56.7%). RESULTS: There were no intraoperative deaths in all patient groups. The median length of follow up was 5.96 ± 3.28 years. Five patients (3.4%) in the MVr group died, while 11 in MVR subgroup A (9.2%) died, and 29 in MVR subgroup B (18.6%). Patients in the MVr group demonstrated significant and persistent postoperative decreases in left ventricular end-diastolic diameter (LVEDD) and left ventricular end-systolic diameter (LVESD) during the follow up, while the left ventricular ejection fraction (LVEF) showed a trend to improve. In MVR subgroup A, preservation of the mitral subvalvular structures resulted in a decrease in LVEDD; this resulted in a lesser worsening of the LVEF, as occurs when subvalvular structures are resected. In MVR subgroup B, the LVEDD and LVESD were each increased constantly, which resulted in a statistically significant worsening of the LVEF. CONCLUSIONS: MVr in DMVBLP patients achieved a better preservation of left ventricular systolic indices than MVR, and guaranteed better shortand long-term survivals. When MVr is not feasible, it is recommended that subvalvular preservation be performed during MVR, in order to reduce the risk of early and late mortality and to improve left ventricular function.

Anatomic reconstruction in degenerative mitral valve bileaflet prolapse: long-term results.

BACKGROUND: Degenerative mitral valve (MV) bileaflet prolapse (DMVBP) is recognized as one of the most complex lesions to be treated by reconstructive surgery. In the present study, we report our long-term results with reconstructive surgery for DMVBP. METHODS: From 2000 to 2011, 140 patients with MV regurgitation due to DMVBP were treated at our institution. Mean age was 56.4±14.5 years (range 16 to 84). Of the 140 study patients, 24 (17%) were in functional class I, 48 (34%) in class II, 60 (43%) in III, and 8 (6%) in class IV of the New York Heart Association. The MV leaflets were reconstructed without using prosthetic material, maintaining the normal shape and dimension of the valve ring and inter-papillary distance. The standard surgical procedure included the excision of the most elongated or ruptured chordae area of the posterior leaflet, with subsequent transposition of second-order chordae from the posterior leaflet to the most elongated or ruptured chordae area of the anterior leaflet. This procedure was performed in 123 patients. A para-commissural edge-to-edge was performed in 16 patients and a triangular resection of the anterior MV leaflet in 1 patient. The posterior leaflet was reconstructed with different techniques: a longitudinal suture of the annulus and residual scallops in 86 patients, a Z-plasty suture in 51 and a sliding suture of the residual posterior scallops in 3 patients. A posterior trygon-to-trygon annuloplasty was performed with an autologous pericardium strip in all patients. During follow-up, serial echocardiograms were obtained once a year. RESULTS: There were no hospital deaths. Mean follow-up was 6.42±3.1 years. Of the 140 study patients, 7 developed severe (3+), 10 moderate (2+) and 18 mild (1+) MV regurgitation. Two patients were reoperated within 6 months; 1 after 8 years and 1 after 10 years for recurrence of severe MV regurgitation. At 12 years after the initial surgical procedure, overall survival was 95.8%, freedom from MV re-intervention was 91.8% and freedom from late recurrence of 2+ or greater MV regurgitation was 78.7%. All patients had a satisfactory residual MV area, leaflets motion, and inter-papillary muscle distance. No patient developed left ventricular outflow tract obstruction. CONCLUSIONS: Our results confirm the effectiveness of anatomic reconstruction in the DMVBP. Survival rate after mitral valve repair is identical to that of the general population when surgery is performed in asymptomatic or pauci-symptomatic patients; the identification of this kind of patient is required followed by a therapeutic strategy for early surgery. This management approach in patients with DMVBP leads to optimal long-term results of MV repair.

Primary cardiac angiosarcoma in a 25-year-old man: excision, adjuvant chemotherapy, and multikinase inhibitor therapy.

Primary cardiac tumors do not occur frequently, and only one quarter of them, chiefly sarcomas, are malignant. Patients with angiosarcoma typically have a shorter survival time than do patients with other sarcomas, and the prognosis for survival depends strictly on the stage of the disease at the time of diagnosis and the possibility of complete surgical excision. Chemotherapy and radiotherapy have well-established postoperative roles because of the high probability of metastasis. We report the case of a 25-year-old man who presented with pericardial effusion and echocardiographic evidence of an intracavitary right atrial mass but without the bulky, infiltrative growth typical of this location of the disease. Malignancy was suggested by the clinical presentation, the location of the mass in the right side of the heart, and the absence of conditions favoring thrombus formation. After complete surgical excision, the mass was confirmed to be an angiosarcoma. Conventional adjuvant chemotherapy and maintenance therapy with inhibitors of CD117 (c-kit) and vascular endothelial growth factor relieved the patient's clinical symptoms and enabled his long-term, disease-free survival. In addition to reporting this case, we discuss aspects of the diagnosis and treatment of angiosarcoma.

"Z-plasty suture": a new procedure for complex reconstructions of posterior mitral leaflet.

In recent years the conservative techniques to treat degenerative mitral valve insufficiency have developed to such an extent mainly due to a better understanding of the physiology and pathology of the mitral valve and to the possibility to get predictable and satisfactory results. Still a challenge persists for the cardiac surgeon when he has to deal with complex reconstructions. The technique described seems to offer an even better surgical option for patients with complex lesions involving the posterior mitral leaflet, especially as far as the hemodynamic performance is concerned.