Management of Patients With Severe Mitral Annular Calcification: JACC State-of-the-Art Review.

Mitral annular calcification (MAC) is a common and challenging pathologic condition, especially in the context of an aging society. Surgical mitral valve intervention in patients with MAC is difficult, with varying approaches to the calcified annular anatomy, and the advent of transcatheter valve interventions has provided additional treatment options. Advanced imaging provides the foundation for heart team discussions and management decisions concerning individual patients. This review focuses on the prognosis of, preoperative planning for, and management strategies for patients with MAC.

Right Sinus of Valsalva Aneurysm Mimicking Right Coronary Artery Ischemia.

An aneurysm of a single sinus of Valsalva is rare. It is usually asymptomatic and rarely discovered, unless it compresses the adjacent cardiac structures, or it presents in association with other pathology. We herein describe a case of a male, with known ischemic heart disease, collapsing after sudden back pain. A computed tomography scan demonstrated an aneurysm of the right sinus of Valsalva. The surgical repair aimed to exclude the aneurysm, preserving and reconstructing the aortic root.

Echocardiographically based treatment of chronic ischemic mitral regurgitation.

OBJECTIVES: We evaluated results of an echocardiographically based strategy combining mitral annuloplasty with other procedures to treat chronic ischemic mitral regurgitation. METHODS: From March 2006 to February 2009, 147 patients underwent mitral valve surgery for chronic ischemic mitral regurgitation. Mean effective regurgitant orifice was 36 ± 11 mm(2), and ejection fraction was 35% ± 9%. On the basis of echocardiographic findings, in 10 cases a prosthesis was inserted and mitral annuloplasty was performed in 137 cases, isolated in 83, associated with chordal cutting in 12 cases (in 5 anterior leaflet was augmented with pericardial patch), and with exclusion of anteroseptal (n = 35) or inferior (n = 7) scars in 42. RESULTS: Thirty-day mortality was 4.8%; 3-year survival was 86% ± 3%. None of the 126 survivors were in New York Heart Association functional class III or IV. Among 117 survivors of mitral valve repair, after 18 ± 6 months mean effective regurgitant orifice reduced from 34.1 ± 10.2 mm(2) to 2.3 ± 0.4 mm(2) (P < .001). Nine patients showed residual effective regurgitant orifice 10 to 19 mm(2). Reverse remodeling was present in 69 patients (59.0%), no remodeling in 40 (34.1%), and continuous remodeling in 8 (6.9%). Ejection fraction changed from 37% ± 10% to 43% ± 10% (P < .001), improving in 47, remaining unchanged in 63, and worsening in 7. CONCLUSIONS: Echocardiographically based strategy contributed to reduced postoperative mitral regurgitation persistence (effective regurgitant orifice ≥ 10 mm(2) in 7.7% of cases, with no patients showing effective regurgitant orifice ≥ 20 mm(2)). All patients remained in New York Heart Association functional class I or II, but more than mitral annuloplasty was performed in close to 40%.

Left ventricular surgical restoration for anteroseptal scars: volume versus shape.

OBJECTIVE: We report the long-term results of left ventricular surgical restoration in which 2 different strategies were used, which had restoration of ventricular volume or ventricular shape as their target. METHODS: From 1988 to 2008, 308 patients with anterior scars underwent elective left ventricular surgical restoration. Before 2002, a Dor procedure was performed in 107 cases to reduce left ventricular volume (group V); from 1998 to 2001, a Guilmet procedure was performed in 32 patients to rebuild a left ventricular conical shape (group S). From 2002, 169 patients (group S) underwent left ventricular surgical restoration to reshape a conical left ventricle by means of the Dor procedure (n = 29, septoapical scars) or septal reshaping (n = 140, when the septum was more involved than the anterior wall). The 2 groups were similar for all features but age, mitral regurgitation grade, mitral valve surgery rate (higher in group S), and ejection fraction (higher in group V). RESULTS: Early mortality was 7.8% (11.2% in group V vs 6.0% in group S, P = .102). Logistic regression showed that volume reduction was significantly related to higher early mortality. Five-year cardiac survival, cardiac event-free survival, and event-free survival were higher in group S. Cox analysis showed that the choice of volume reduction provided lower survival (hazard ratio, 2.1), cardiac survival (hazard ratio, 3.0), cardiac event-free survival (hazard ratio, 2.7), and event-free survival (hazard ratio, 2.2). When 30-day events were excluded, volume reduction was still a risk factor for cardiac event-free survival (hazard ratio, 2.2). CONCLUSIONS: When the main target of left ventricular surgical restoration is left ventricular reshaping rather than left ventricular volume reduction, early and late outcomes seem to improve.

Bilateral internal thoracic artery on the left side: a propensity score-matched study of impact of the third conduit on the right side.

OBJECTIVE: This study was undertaken to evaluate long-term results of bilateral internal thoracic artery grafting with saphenous vein or another arterial conduit as the third conduit. METHODS: From September 1991 to December 2002, a total of 1015 patients underwent first isolated coronary artery bypass grafting for triple-vessel disease, with bilateral internal thoracic artery plus saphenous vein in 643 cases and bilateral internal thoracic artery plus arterial conduit in 372. A nonparsimonious regression model was built to determine propensity score, then sample matching (saphenous vein vs arterial conduit) was performed to select 885 patients (590 with saphenous vein, 295 with arterial conduit). Groups had similar preoperative and operative characteristics. RESULTS: Eight-year freedoms from cardiac death were significantly higher when saphenous vein was used (98.6% +/- 0.5% with saphenous vein vs 95.3% +/- 1.3% with arterial conduit, P = .009), but this difference was related exclusively to right gastroepiploic artery grafting (94.5% +/- 1.6% vs saphenous vein, P = .004). This difference disappeared for radial artery grafting (97.6% +/- 1.6% vs saphenous vein, P = .492). Cox analysis confirmed that supplementary gastroepiploic artery was an independent variable for lower freedoms from all-cause mortality and from cardiac death. Presence of high-degree stenosis (80%) appeared to influence this result. CONCLUSIONS: In patients with triple-vessel disease undergoing first isolated coronary artery bypass grafting, supplementary venous grafts seem to provide more stability than gastroepiploic artery, which may even impair long-term outcome.

Mitral valve surgery for functional mitral regurgitation: prognostic role of tricuspid regurgitation.

BACKGROUND: The purpose of this study was to evaluate the impact of untreated moderate-or-more functional tricuspid regurgitation (FTR) on mid-term outcome of patients with functional mitral regurgitation (FMR) undergoing mitral valve surgery (MVS). METHODS: From January 1988 to April 2003, 165 patients having FMR underwent MVS with untreated FTR. Patients with organic mitral or tricuspid valve disease were excluded. The entire population was divided into two groups, group A: 102 patients (FTR 0/1+), group B: 63 patients (FTR 2+/3+). No statistical difference was found between two groups concerning preoperative and operative variables. MV was repaired in 137 and replaced in 28 cases; the impact of untreated moderate-or-more FTR was estimated by Cox analysis. RESULTS: Thirty-day mortality was 6.7 (5.9% group A vs 7.9% group B, p=0.607). Five-year actuarial survival was 73.5% (66.6-80.4%); 88.2% (83.0-93.4%) group A versus 46.0% (33.7-58.3%) group B, p<0.001; the possibility to be alive in NYHA class I-II was 65.8% (58.4-73.2%); 78.4% (72.3-84.5%) group A versus 41.2% (29.1-53.3%) group B, p<0.001. Cox analysis confirmed the impact of untreated moderate-or-more FTR on 5-year survival (HR=3.1, 95% CI=1.8-5.1, p<0.001) and possibility to be alive in NYHA class I-II (HR=3.0, 95% CI=1.8-4.9, p<0.001). After a median interval time of 28 months (IQR=11-60), TR grade was echocardiographically assessed in 122 (79.2%) of 154 patients surviving the first month. In group A (87 patients), TR grade decreased significantly from 0.7+/-0.5 to 0.3+/-0.5 (p<0.001) in the early postoperative period. Then, it increased again to 0.6+/-0.7 at follow-up (p<0.001); no difference was found between preoperative and follow-up time (p=ns). In group B (35 cases), TR grade decreased significantly from 2.2+/-0.4 to 1.3+/-0.7 in the early postoperative period (p<0.001), but then increased again to 2.2+/-0.9 (p<0.001 vs postoperative value; p=0.838 vs preoperative value). Cox analysis confirmed that the progression of TR grade at follow-up is a risk factor for lower survival and possibility to be alive in NYHA class I-II. CONCLUSIONS: Patients with untreated moderate-or-more FTR had survival and survival in NYHA class I-II lower than patients with untreated less-than-moderate FTR at 5-year follow-up.

Mitral valve surgery for functional mitral regurgitation: should moderate-or-more tricuspid regurgitation be treated? a propensity score analysis.

BACKGROUND: The aim of this retrospective study was to evaluate the clinical outcome of treating or not treating moderate-or-more functional tricuspid regurgitation in patients with functional mitral regurgitation undergoing mitral valve surgery. METHODS: From January 1988 to March 2003, 110 patients with functional mitral regurgitation undergoing mitral valve surgery showed moderate-or-more functional tricuspid regurgitation, which was treated (group T) in 51 and untreated in 59 (group UT) patients. Propensity score was used to adjust midterm results. The tricuspid valve was always repaired using the DeVega technique. The mitral valve was repaired in 84 and replaced in 26 patients; no residual moderate-or-more functional mitral regurgitation was assessed at hospital discharge. RESULTS: Thirty-day mortality was 5.5% (8.5% for group UT versus 2% for group T; p= 0.245). Adjusted 5-year survival was 45.0% +/- 6.1% in group UT and 74.5% +/- 5.1% in group T (p= 0.004), whereas the possibility to be alive in New York Heart Association class I or II was 39.8% +/- 6.0% in group UT versus 60.0% +/- 6.5% in group T (p= 0.044). Proportional Cox analysis, forcing propensity score into the model, demonstrated that untreated moderate-or-more tricuspid regurgitation was a risk factor for lower midterm survival (hazard ratio, 2.7; 95% confidence interval, 1.3 to 5.4) and survival in New York Heart Association class I or II (hazard ratio, 1.9; 95% confidence interval, 1.1 to 3.4). Follow-up functional tricuspid regurgitation progression rate (3+/4+) was 5% in group T versus 40% in group UT (p < 0.001). The progression of functional tricuspid regurgitation grade at follow-up was a risk factor for worse survival and the possibility to be alive in New York Heart Association class I or II. CONCLUSIONS: Tricuspid annuloplasty is an easy and safe procedure, mandatory in case of at least moderate functional tricuspid regurgitation to achieve better mid-term outcome in patients with functional mitral regurgitation undergoing mitral valve surgery.

Mitral valve repair for ischemic mitral regurgitation.

Our aim was to evaluate midterm results in patients who underwent mitral valve repair (MVR) for ischemic mitral regurgitation (IMR) in our most recent experience. From March 2006 to March 2008, 105 patients underwent MVR for IMR. Mean IMR grade was 2.6 +/- 1.1, with 46 patients having or=3/4. Five patients (4.8%) died within first month; Two-year freedom from death any cause was 85.5% +/- 3.8, freedom from cardiac death was 88.7% +/- 3.4. NYHA Class of the survivors was 1.3 +/- 0.6, with 3 patients in NYHA Class III. Freedom from death any cause and NYHA Class III-IV was 78.6% +/- 4.6. IMR grade decreased from 2.6 +/- 1.1 to 0.1 +/- 0.3 at the discharge and to 0.5 +/- 0.3 after a mean of 7 +/- 4 months, with no patient with IMR grade 3/4 or 4/4. MVR for IMR should be performed in patients with moderate-or-more IMR grade or when the MV is excessively dilated, to achieve good midterm results.

Impact of ischemic mitral regurgitation on long-term outcome of patients with ejection fraction above 0.30 undergoing first isolated myocardial revascularization.

BACKGROUND: We evaluated the impact of ischemic mitral regurgitation (IMR) on long-term outcome of patients with an ejection fraction (EF) exceeding 0.30 undergoing isolated coronary artery bypass grafting (CABG). METHODS: From November 1994 to December 2002, 4226 patients (EF > 0.30) underwent a first isolated CABG. Preoperative IMR was present in 1421 (33.6%, group IMR), of which 1254 had mild (1/4) and 167 had moderate (2/4). The remaining 2805 patients (66.4%, group no-IMR) showed no IMR. A nonparsimonious regression model was built to determine the propensity score. Ten-year freedom from death from any cause, cardiac death, and cardiac events was evaluated by the Kaplan-Meier method. Results of Cox analysis were adjusted by entering the propensity score as an independent variable. RESULTS: All patients had similar early mortality (2.1% no-IMR vs 2.5% IMR, p = 0.502) and morbidity (6.5% no-IMR vs 6.6% IMR, p = 0.840). In patients with EF of 0.31 to 0.40, but not in those ones with EF exceeding 0.40, IMR grade was an independent variable for worse long-term freedom from cardiac death (82.8 +/- 3.2 vs 91.4 +/- 2.4; Cox hazard ratio [HR], 2.1 [95% confidence interval (CI), 1.1 to 4.1]; p = 0.0324) and cardiac events (78.6 +/- 3.5 vs 88.5 +/- 2.7; Cox HR, 2.0 [95% CI, 1.1 to 3.7]; p = 0.0174). CONCLUSIONS: Mild or moderate IMR in patients with an EF exceeding 0.30 undergoing first isolated CABG influences long-term outcome when EF is 0.31 to 0.40, but not when it exceeds 0.40.

A simple method to obtain the correct length of the artificial chordae in complex chordal replacement.

BACKGROUND: Different techniques have been proposed to measure the correct length of artificial chordae. We herein describe a new simple method to measure the chordal length in complex chordal replacement. METHOD: Chordal replacement was used by us for two different purposes: (1) to maintain the correct chordal length for the anterior leaflet (AL) and (2) to eliminate any movement of the posterior leaflet (PL) to fix it. To reach this goal, the AL is pulled up to the maximum extent and the new chordae are tied 5 mm higher than the related border. On the contrary, in the PL the new chordae are tied at the level of the related border. RESULTS: From March 2006 to March 2007, at the University of Catania, this technique was used in 32 patients (16 for correction of PL prolapse, 6 patients for correction of AL prolapse, and in 10 patients for correction of both leaflets prolapse). The number of chordae per patients was 8.6 for the PL and 6.8 for the AL. No patient died or had major complications. After a mean follow-up of 5 +/- 2 months, two-dimensional echocardiography showed that all the patients had no or trivial mitral regurgitation (MR). The echocardiogram showed a correct movement of the new chordae. CONCLUSIONS: This technique allows to easily establish the length of the new chordae of the AL and, if necessary, of the PL in complex mitral valve repair.

Does off-pump coronary surgery reduce postoperative acute renal failure? The importance of preoperative renal function.

BACKGROUND: Off-pump was compared with on-pump coronary artery bypass graft surgery to evaluate the impact of cardiopulmonary bypass on the incidence of postoperative acute renal failure (ARF). METHODS: From November 1994 to December 2001, 2,943 patients having multivessel surgical disease underwent myocardial revascularization. Ninety patients were excluded because of incompleteness of data, intraoperative death, or preoperative chronic dialysis. The analysis was split: one analysis included 1,724 (862 each group) of 2,618 patients with normal preoperative creatinine (<1.5 mg/dL), and the second analysis included 160 (80 each group) of 215 patients with preoperative abnormal renal function; in both analyses matched groups were selected applying propensity score. RESULTS: In the group with normal preoperative creatinine, the incidence of 30-day ARF was 5.4% (2.9% off-pump versus 7.9% on-pump; p < 0.001). Stepwise logistic regression confirmed that cardiopulmonary bypass was an independent variable for increased postoperative ARF incidence (odds ratio, 3.3), as well as age and reduced left ventricular ejection fraction. Receiver operating characteristic curves showed that cardiopulmonary bypass duration was a predictor of higher ARF incidence (area under the curve, 0.79) with a cutoff value of 66 minutes. In the patients with abnormal renal function preoperatively, the incidence of ARF was similar between the groups (16.3% on-pump versus 12.5% off-pump; p = 0.499). Acute renal failure had an important impact on early (odds ratio, 3.6) and late mortality (hazard ratio, 4.1). CONCLUSIONS: Off-pump surgery plays an important renoprotective role and provides better early and late outcome in patients with normal preoperative creatinine. When the preoperative creatinine is abnormal, the surgical strategy does not seem to have any influence. The occurrence of ARF significantly impairs early and long-term mortality, and the surgical strategy does not improve outcomes.

Mitral valve repair for degenerative mitral regurgitation.

Mitral valve repair for degenerative mitral regurgitation is nowadays one of the most common valvular procedures. Different technical modifications were added to the original Carpentier's method, trying to maximise the stability of the results and to reduce the incidence of immediate complications and of late failure of the correction. Survival is good, even if recent reports showed that recurrence of mitral regurgitation can be higher than expected. Prolapse of the anterior leaflet remains challenging and is related to higher reintervention rates. Nevertheless, the overall success rate is high, and the increasing experience of the different surgical teams approaching this procedure will help maintain satisfactory and stable long-term results.

Impact of no-to-moderate mitral regurgitation on late results after isolated coronary artery bypass grafting in patients with ischemic cardiomyopathy.

BACKGROUND: This study analyzes retrospectively a cohort of patients with ischemic cardiomyopathy (ejection fraction < or = 0.30) who underwent isolated coronary artery bypass grafting to evaluate the impact of no-to-moderate mitral regurgitation (MR) on long-term results. METHODS: From January 1988 to December 2002, 6,108 patients had isolated coronary artery bypass grafting. Two hundred thirty-nine (3.9%) had ischemic cardiomyopathy; 60 patients had no, 102 had mild, and 77 had moderate MR. Using propensity score, a group of 70 patients with no or mild MR (group A) was case-matched with a group of 70 patients with moderate MR (group B) to obtain two groups with similar preoperative characteristics. RESULTS: Nine patients (6.4%) died within the first 30 days; all deaths were cardiac-related. There was no difference in the early results between groups. Patients in group B showed lower freedom from death, from cardiac death, from cardiac death and ischemic events, and from death and New York Heart Association class III and IV than patients in group A. Cox analysis confirmed that moderate MR was an independent variable for worse late outcome in this subgroup of patients. Functional and echocardiographic results, after a mean of 62 +/- 28 months in 87.8% of survivors, showed a significant impairment of New York Heart Association class (from 2.2 +/- 0.5 to 2.8 +/- 0.6; p < 0.001) and MR degree (from 2.0 to 2.7 +/- 1.0; p = 0.023) in patients with preoperative moderate MR. CONCLUSIONS: This study confirms that moderate ischemic MR has an important negative impact on survival and quality of life of patients with severely impaired left ventricular function, treated by coronary artery bypass grafting alone.

Mitral valve repair in ischemic mitral regurgitation.

Ischemic mitral regurgitation (IMR) is a common complication after acute myocardial infarction due to annulus dilatation and papillary muscles displacement. In our opinion 3/4 and 4/4 IMR have always to be indicated for MV surgery. In presence of low EF and dilated LV, moderate (2/4) IMR has to be corrected. The end-systolic distance between the coaptation point of mitral leaflets and the plane of mitral valve annulus is the key point to decide repair (≦10 mm) or replacement (≫10 mm). MV annuloplasty has always been addressed to the posterior annulus, whose size can be easily reduced. A specially designed 40 mm long ring has been used to achieve a posterior overreductive annuloplasty. For MV repair thirty-day mortality was 2.4%. Five-year survival and the possibility of being alive and in NYHA class I-II were 75.6±4.7 and 59.8±5.4, respectively. After a mean of 38±35 months, the NYHA class decreases from 3.2±0.5 to 2.1±0.6 (P≪0.001). Most patients (77.4%) have an improvement of its own functional class. MR decreases from 3.2±0.8 to 1.2±1.1 (P≪0.001). 97.5% of the survivors have MR equal to or less than moderate.

Late results of first myocardial revascularization in multiple vessel disease: single versus bilateral internal mammary artery with or without saphenous vein grafts.

OBJECTIVE(S): We evaluated our experience to investigate if the use of bilateral internal mammary artery (BIMA) grafting, with or without complementary saphenous vein grafts (SVGs), if compared to the use of single IMA and SVG(s), increases the quality of the results of coronary bypass grafting in patients younger than 75 years who undergo first myocardial revascularization. METHODS: From September 1986 to December 1999, 1602 patients younger than 75 years underwent first myocardial revascularization using left internal mammary (LIMA) to left anterior descending (LAD) and SVG(s) (n=576) or BIMA (one IMA on the LAD) with or without SVG(s) (n=1026). Propensity score analysis was used to select 1140 patients with the same preoperative and operative characteristics. Thirty day outcome was evaluated as well as 10-year freedom from death by any cause, cardiac death, acute myocardial infarction (AMI), AMI in a grafted area (GA), redo/PTCA, redo/PTCA in a GA, target cardiac events (death from cardiac cause, AMI in a GA, redo/PTCA in a GA), and any event. Follow-up ranged from 3.5 to 16.8 years (mean 7.3+/-4.8 years). RESULTS: Thirty day mortality was 2.8% in Group LIMA and 2.1% in Group BIMA, P n.s.; incidence of major complications was, respectively, 7.0 versus 5.4%, P n.s. Group BIMA showed better 10-year freedom from cardiac death (96.5+/-0.8 versus 91.3+/-1.4, P=0.0288), AMI (98.0+/-0.6 versus 94.3+/-1.2, P=0.0180), AMI in a GA (98.4+/-0.6 versus 94.7+/-1.1, P=0.0057) and target cardiac events (93.9+/-1.1 versus 86.3+/-1.8, P=0.0388). Cox analysis confirmed that LIMA+SV(s) was an independent risk factor from lower freedom from cardiac death, AMI, AMI in a GA and cardiac events. CONCLUSIONS: As freedom from cardiac events is a main target of any revascularization procedure, we think that, when a patient undergoes a first coronary surgery and is younger than 75 years, BIMA grafting should not be denied, especially if his life expectancy is higher than 10 years.

Partial clamping of the brachiocephalic trunk for total ascending aorta replacement without circulatory arrest: early and midterm results.

BACKGROUND: The aim of this study was to evaluate in elective patients the early and midterm results of partial clamping of the brachiocephalic trunk (BCT) for total ascending aorta replacement (TAAR) without circulatory arrest. Contraindications to the procedure were BCT/aortic arch calcifications and chronic aortic dissection. METHODS: The right radial artery was cannulated to monitor the systemic pressure after the BCT was partially clamped. A specially designed clamp was applied obliquely to occlude approximately 50% of the BCT and part of the aortic arch. The distal tip of the clamp was positioned in front of the left subclavian artery. From January 2002 to October 2003, 92 patients underwent TAAR. In 62 patients (67.4%), partial clamping of the BCT was used. Twenty of these patients underwent isolated TAAR, 27 underwent aortic valve replacement and TAAR, 11 had a Bentall operation, and 2 had a Cabrol operation. The aortic valve was spared in the remaining 2 patients. The mean (+/- SD) aortic cross-clamping and cardiopulmonary bypass times were 96 +/- 31 minutes and 116 +/- 43 minutes, respectively. RESULTS: Early mortality was 1.6% (1 patient). No cerebrovascular accidents occurred, demonstrating the safety of the technique. The major complications were acute respiratory insufficiency in 2 cases and acute renal failure in 5. The mean follow-up time was 9.0 +/- 6.5 months. The mean 18- month and event-free survival rate was 96.6% +/- 0.9%. CONCLUSION: Partial clamping of the BCT for TAAR without circulatory arrest provides good early and midterm clinical results. Aortic arch clamping is not associated with cerebrovascular accidents.

Septal reshaping for exclusion of anteroseptal dyskinetic or akinetic areas.

BACKGROUND: Our purpose is to describe a technique for exclusion of anteroseptal dyskinetic or akinetic areas. METHODS: From January to December 2002, 22 consecutive patients with myocardial infarction following left anterior descending artery occlusion underwent septal reshaping. All of them were admitted for dyspnea. Eight patients were referred for angina. After a 5 to 8 cm apical incision, 2 U stitches were passed from inside to join the anterior wall to the septum, as high as possible, following the border of the scars. An oval Dacron patch was then sutured from the septum (end of the direct suture through the border with the inferior septum) to the anterior wall (between the healthy and the scarred wall) up to the new apex. Purpose of the procedure is to maintain a longitudinal size as similar as possible to the normal. The incision was closed in a double layer. RESULTS: No patient died and only one had acute renal failure. No patients had restrictive syndrome. After a mean follow-up of 6.7 +/- 3.6 months (3 to 15), mean New York Heart Association Class improved from 2.7 +/- 1.1 to 1.2 +/- 0.3 (p < 0.001). Echocardiographic results showed reduction of left ventricle volumes and normalization of the stroke volume. In patients with low ejection fraction (