Current status of the treatment of degenerative mitral valve regurgitation.

Degenerative mitral valve disease (myxomatous degeneration or fibroelastic deficiency) is the most common indication for surgical referral to treat mitral regurgitation. Mitral valve repair is the procedure of choice whenever feasible and when the results are expected to be durable. Posterior leaflet prolapse is the commonest lesion, found in up to two-thirds of patients. It is the easiest to repair, particularly when limited to one segment. In these cases, rates of repairability and procedural success approach 100%, and there is now ample evidence that the immediate and long-term results are better than those of valve replacement. Notably, minimally invasive valvular procedures, surgical or interventional, have attracted increasing interest in the last decade. When performed by experienced groups, mitral valve repair is unrivaled irrespective of the severity of lesions, from simple to complex, which leaflets are involved, and the type of degenerative involvement (myxomatous or fibroelastic). Its results should be viewed as the benchmark for other present and future technologies. By contrast, percutaneous mitral valve repair is still in its infancy and its results so far fall short of those of surgical repair. Nevertheless, continued investment in transcatheter procedures is of great importance to enable development and improved accessibility, particularly for patients who are considered unsuitable for surgery. In this review, we analyze the current status of management of degenerative mitral valve disease, discussing mitral valve anatomy and pathology, indications for intervention, and current surgical and transcatheter mitral valve procedures and results.

Quadricuspid aortic valve with a hidden left ostium: Case report and literature review.

Quadricuspid aortic valve (QAV) is a rare congenital condition that frequently progresses to aortic regurgitation with clinical impact in adulthood. Surgical treatment is required in the fifth to sixth decade of life in about one fifth of patients. We describe the case of a 64-year-old woman with regular cardiological follow-up for severe aortic valve regurgitation who had suffered recent clinical and echocardiographic deterioration. Conventional open surgery was indicated. During the procedure, a QAV with leaflet retraction and central orifice was observed. The aortic valve was successfully replaced.

Long-term results after concomitant mitral and aortic valve surgery: repair or replacement?

OBJECTIVES: The reported superiority of mitral valve (MV) repair for isolated MV regurgitation has not been confirmed in mitroaortic valve surgery. Our goals were to evaluate the feasibility of repair in patients undergoing mitral and aortic valve surgery and to identify factors predisposing to MV replacement, to compare long-term outcomes (survival and MV reoperation) of repair and replacement and to perform a subgroup analysis in patients with rheumatic MV disease. METHODS: From January 1992 through December 2016, 1122 consecutive patients were submitted to concomitant aortic and MV surgery in 2 different centres (Coimbra and Santiago). Of these, 837 patients underwent MV repair (74.6%) and 285 patients had MV replacement (25.4%). Rheumatic aetiology was predominant (666 patients; 59.4%). Cumulative follow-up was 9522.6 patient-years (25th-75th percentile 2.6-13.2 years) and was complete for 95.6% of patients. Propensity score matching (1:1) was performed in 232 patients for comparing each treatment option (MV repair and MV replacement). RESULTS: Previous MV intervention, rheumatic aetiology, chronic obstructive pulmonary disease, higher degrees of tricuspid and mitral regurgitation and pulmonary hypertension were independently correlated with MV replacement. The 30-day mortality rate was higher in patients with MV replacement (4.2% vs 1.8%, P = 0.021) and was confirmed in the propensity score matching (4.7% vs 1.7%, P = 0.06). Late survival was lower in the MV replacement group (53.3 ± 4.5% vs 61.7 ± 2.0% at 12 years; P = 0.026) and was confirmed in the propensity score matching (54.6 ± 4.9% vs 63.2 ± 3.8%, P = 0.062) and rheumatic subgroup (57.9 ± 4.8% vs 68.0 ± 2.5%, P = 0.018). Freedom from MV reoperation at 12 years was higher in the MV repair group (94.7 ± 1.1% vs 89.0 ± 3.1%, P = 0.004) but similar in patients with rheumatic MV disease. CONCLUSIONS: MV repair can be performed in most patients undergoing aortic valve replacement. It should be the procedure of choice whenever feasible, because it is associated with lower early and late mortality rates and with freedom from reoperation in non-rheumatic patients.

Mitral valve repair for degenerative mitral valve disease: surgical approach, patient selection and long-term outcomes.

Mitral valve repair (MVRepair) has become the procedure of choice to correct severe degenerative mitral regurgitation (MR), due to its documented superiority to valve replacement regarding long-term survival, freedom from valve-related adverse events and preservation of left ventricular (LV) function. The refinement of MVRepair techniques has rendered almost all valves (more than 95%) amenable to repair with a 15-year freedom from reoperation of 90%. The concept of 'centres of excellence for MVRepair' has emerged, encouraging referring doctors to select the most experienced institutions or individual surgeons to deal with the most complex cases, based on repair volume, appropriate peri-procedural imaging and data regarding expected outcomes (repair, mortality and durability of repair). Based on the good results, operating on asymptomatic patients with severe MR is now widely accepted, prophylactically avoiding the dire consequences of chronic MR, such as LV function deterioration/enlargement, and development of atrial fibrillation and pulmonary hypertension. In reference centres, where the repair rate is over 95% for all types of disease with <1% mortality, it has become standard practice in nearly 50%-60% of all patients submitted to MVRepair. Finally, recent advances in the surgical treatment with the purpose of reducing invasiveness and surgical trauma, through partial sternotomy or mini-thoracotomy (video-assisted with or without robotics), are now being increasingly performed in 20%-30% of centres, claiming comparable results to conventional surgery. In addition, transcatheter technology, particularly the MitraClip, is evolving and treading its way in the treatment of high-risk patients with severe MR, but the results are still short of ideal.

Long-term follow-up of patients undergoing aortic root enlargement for insertion of a larger prosthesis.

OBJECTIVES: To evaluate the long-term survival of patients undergoing aortic root enlargement (ARE) compared with those with small aortic root (SAR), exploring risk factors for late mortality as well as the influence of patient-prosthesis mismatch (PPM). METHODS: From January 1999 through December 2010, a total of 3724 patients underwent isolated or combined aortic valve replacement at our institution. From these, 239 (6.4%) had transannular ARE with a pericardial patch, to permit implantation of a larger prosthesis. This study population was compared with a control group of 767 patients (20.6%) who were considered to have SAR, as a prosthesis of size 21 or less was implanted. Mean age was comparable: 70.4 ± 12.5 vs 69.9 ± 9.6 years for ARE and SAR groups, respectively (P = 0.552). Female sex predominated in the control group (81.6 vs 88.0%; P = 0.011). Patients of the ARE group tended to have higher mean body surface area (1.59 ± 0.15 vs 1.57 ± 0.13 m(2); P = 0.061) and were less symptomatic (NYHA III-IV: 49.4 vs 57.9%; P = 0.021). RESULTS: Implantation of bioprostheses was more frequent in the ARE group (76.2 vs 52.3%; P < 0.001), while concomitant procedures were more frequent in the SAR group (25.5 vs 32.2%; P = 0.050). Patients in the SAR group had higher moderate PPM (29.7 vs 50.1%; P < 0.001), but no patient was left with severe PPM. Hospital mortality was not statistically different between ARE and SAR groups (0.8 vs 0.5%; P = 0.632). The overall survival rate for ARE group patients at 5, 10 and 15 years was 82.7 ± 2.5, 64.8 ± 3.8 and 36.0 ± 7.5%, respectively, in comparison with 86.2 ± 1.3, 62.9 ± 2.3 and 38.4 ± 4.3% for the SAR group (P = 0.741). There was no significant difference in long-term survival of ARE patients compared with the age- and gender-matched general population (P = 0.794). Long-term survival was not affected by the presence of PPM. Increasing age, male sex, atrial fibrillation, LV end-systolic dimension, preoperative creatinine and NYHA class III-IV were significant predictors of late mortality. CONCLUSIONS: ARE can be done safely, effectively reducing PPM. Although no difference was found in early and late mortality compared with the SAR group, long-term survival rates of ARE patients was comparable with that of the general population, unlike those of the SAR group.

Long-term results of mitral valve surgery for degenerative anterior leaflet or bileaflet prolapse: analysis of negative factors for repair, early and late failures, and survival.

OBJECTIVES: To evaluate the feasibility of mitral valve repair in patients with anterior leaflet (ALP) or bileaflet prolapse (BLP) and identify factors predisposing patients to replacement. To compare long-term survival of patients submitted to repair (Group Repair) against those submitted to replacement (Group Replacement), and investigate causes of early and late failures of repair. METHODS: From January 1992 through December 2012, 768 patients with ALP or BLP were submitted to mitral valve surgery, of whom 501 had degenerative involvement [Myxomatous (Myx)-336 (67.1%) or fibroelastic deficiency (Fed)-165 (32.9%)] and constituted the study population. Isolated ALP was present in 274 patients (54.7%) and BLP in 227 (45.3%). Associated procedures were admitted. RESULTS: Patients with Fed were significantly older (64.4 ± 12.1 vs 54.8 ± 15.5 years, P < 0.001), more symptomatic (63 vs 44.3%; P < 0.001) and with higher incidence of atrial fibrillation (43.6 vs 26.2%; P < 0.001). Repair was achieved in 94.8% of patients with an overall 30-day mortality rate of 1.2% (0.3% in the last decade) and no differences regarding aetiology. Age, moderate to severe left ventricular (LV) dysfunction, previous cardiac surgery, multiple segment prolapse, mitral calcification, leaflet retraction and the performing surgeon were independently associated with replacement. Group Repair patients had a greater adjusted 20-year survival by comparison with Group Replacement (43.4 ± 5.5 vs 13.6 ± 11.3%; P < 0.001) and similar to that of the age- and sex-adjusted general population (P = 0.10). Valve replacement, New York Heart Association (NYHA) class III-IV, pulmonary hypertension and LV dysfunction emerged as independent predictors of late mortality. Patients in NYHA class I-II experienced a higher repair rate (98.4%) and better survival than those in Class III-IV. Two repair patients were reoperated during the first year after surgery (early failure) and both were 'rerepaired'. Late failure was observed in 21 patients, mostly for progression of the disease. The 20-year rate of freedom from reoperation was 88 ± 2.7%, significantly worse in ALP patients (P = 0.040), and not different between Fed and Myx. CONCLUSIONS: Patients with ALP or BLP can be submitted to surgery with low mortality and great probability of repair in expert hands. Patients should be operated on at an early phase (asymptomatic or mildly symptomatic), because there is a higher probability of repair and greater benefit on long-term survival.

Coronary artery bypass surgery without cardioplegia: hospital results in 8515 patients†.

OBJECTIVES: Cardioplegic myocardial protection is used in most cardiac surgical procedures. However, other alternatives have proved useful. We analysed the perioperative results in a large series of patients undergoing coronary artery bypass (CABG) using cardiopulmonary bypass (CPB) and non-cardioplegic methods. METHODS: From January 1992 to October 2013, 8515 consecutive patients underwent isolated CABG with CPB without cardioplegia, under hypothermic ventricular fibrillation and/or an empty beating heart. The mean age was 61.9 ± 9.5 years, 12.4% were women, 26.3% diabetic, 64% hypertensive; and 9.6% had peripheral vascular disease, 7.8% cerebrovascular disease and 54.3% previous acute myocardial infarction (AMI). One-third of patients were in Canadian Cardiovascular Society Class III/IV. Three-vessel disease was present in 76.5% of the cases and 10.9% had moderate/severe left ventricle (LV) dysfunction (ejection fraction <40%). A multivariate analysis was made of risk factors associated to in-hospital mortality and three major morbidity complications [cerebrovascular accident, mediastinitis and acute kidney injury (AKI)], as well as for prolonged hospital stay. RESULTS: The mean CPB time was 58.2 ± 20.7 min. The mean number of grafts per patient was 2.7 ± 0.8 (arterial: 1.2 ± 0.5). The left internal thoracic artery (ITA) was used in 99.4% of patients and both ITAs in 23.1%. The in-hospital mortality rate was 0.7% (61 patients), inotropic support was required in 6.6% and mechanical support in 0.8, and 2.0% were re-explored for bleeding and 1.3% for sternal complications (mediastinitis, 0.8%). AKI, the majority transient, occurred in 1595 patients (18.9%). The incidence rates of stroke/transient ischemic attack (TIA) and acute myocardial infarction (AMI) were 2.6 and 2.5%, respectively, and atrial fibrillation/flutter occurred in 22.6% of cases. Age, LV dysfunction, non-elective surgery, previous cardiac surgery, peripheral vascular disease and CPB time were independent risk factors for mortality and major morbidity. The mean hospital stay was 7.2 ± 5.7 days. CONCLUSIONS: Isolated CABG with CPB using non-cardioplegic methods proved very safe, with low mortality and morbidity. These methods are simple and expeditious and remain as very useful alternative techniques of myocardial preservation.

Mitral valve surgery after percutaneous mitral commissurotomy: is repair still feasible?

OBJECTIVES: Due to progression of rheumatic disease, percutaneous mitral commissurotomy (PMC) is a palliative procedure. We aimed at evaluating the outcomes of patients requiring surgery for failure of PMC, focusing on the fate of the mitral valve (MV) (repair versus replacement). METHODS: From January 1993 through December 2012, 61 patients with previous PMC were submitted to MV surgery. Detailed operative findings were collected from all patients and an intraoperative anatomical score was introduced to predict reparability. Time to surgery, overall survival and freedom from reoperation were analysed. RESULTS: The mean time to surgery after PMC was 6.9±5.9 years and indications were restenosis in 25 patients (41%) and mitral regurgitation or mixed lesion in 36 (59%). Nine patients (14.8%) had more than one previous intervention. Intraoperative inspection of the valve revealed leaflet laceration outside the commissural area in 27 patients (44.3%). Valve repair was accomplished in 38 patients (62.3%). Pulmonary hypertension, calcification and intraoperative anatomical score were independently associated with the probability of valve replacement (OR 1.12, OR 7.03 and OR 4.49, respectively, P<0.05). There was no hospital mortality. MV area increased on average 1.6 cm2 after surgery to 2.7 cm2; 5-, 10- and 20-year survival rates were 98.1±1.9, 91±5.2 and 82.7±9.2%, respectively. The rate of freedom from mitral reoperation (for repaired cases) at 5, 10 and 15 years was 100, 95.8±4.1 and 87.8±8.5%, respectively. There was no difference in survival between repaired or replaced MVs, but the former had less valve-related events during follow-up. CONCLUSION: The MV can be repaired after failed PMC, with very low complication rates and excellent long-term results. Hence, whenever possible, these patients should be sent to reference centres where repair can be successfully achieved.

Negative impact of atrial fibrillation and pulmonary hypertension after mitral valve surgery in asymptomatic patients with severe mitral regurgitation: a 20-year follow-up.

OBJECTIVES: The timing for mitral valve (MV) surgery in asymptomatic patients with severe mitral regurgitation (MR) and preserved left ventricular (LV) function remains controversial. We aimed at analysing the long-term outcome of asymptomatic patients with atrial fibrillation (AF) and/or pulmonary hypertension (PHT) after successful MV repair. METHODS: From January 1992 to December 2012, 382 patients with severe degenerative MR, with no or mild symptoms, preserved LV function (ejection fraction > 60%) and LV systolic dimensions <45 mm were submitted to surgery and followed up for up to 22 years (3209 patient-years). Patients with associated surgeries, other than tricuspid repair, were excluded. Patients with AF and/or PHT (Group A; n = 106, 24.4%) were compared with patients without these comorbidities (Group B; n = 276, 63.6%). Propensity-score matching (for preoperative variables) was performed obtaining 102 patients in each arm. Survival and event-free survival [major cardiac and cerebrovascular events (MACCEs); freedom from mitral reoperation and recurrent moderate and severe MR] were analysed. RESULTS: MV repair was performed in 98.2% of cases and tricuspid annuloplasty in 6.9%. Overall 30-day mortality was 0.8%, not different between groups, and absent in patients with isolated posterior leaflet prolapse (n = 211). Patients with AF/PHT had worse late survival by comparison with Group B patients (67.0 ± 7.4 vs 86.5 ± 3.9% at 15 years, P < 0.001), survival free from MACCE (52.7 ± 8.7 vs 74.5 ± 5.0%, P < 0.001), from recurrent moderate and severe MR (65.1 ± 10.3 vs 87.0 ± 3.8%, P = 0.002) and from mitral reoperation during the follow-up (87.3 ± 6.3 vs 94.2 ± 2.7%, P = 0.04). These differences were confirmed in the propensity score-matched population. Patients from Group A also displayed a lesser degree of reverse remodelling. There was a significant reduction in the systolic pulmonary artery pressure (SPAP) after surgery, more pronounced in Group A patients; nonetheless, the mean SPAP at late follow-up was higher in these patients (45 vs 30 mmHg). CONCLUSIONS: MV repair can be achieved in the great majority of patients with degenerative regurgitation, with low mortality (<1%). Asymptomatic or mildly symptomatic patients with severe MR, preserved LV function and AF/PHT had poorer long-term survival and event-free survival even after a successful surgery. The durability of MV repair was also compromised in these patients, which indicates that they should have been operated earlier.

Preservation of the subvalvular apparatus during mitral valve replacement of rheumatic valves does not affect long-term survival.

OBJECTIVES: The importance of preservation of the subvalvular apparatus (PSVA) during mitral valve replacement (MVR) in non-rheumatic mitral valves is well recognized. Our aim was to analyse the impact of PSVA in MVR for rheumatic valves on long-term survival. METHODS: From January 1992 to December 2012, 605 consecutive patients with rheumatic mitral valve disease were submitted to MVR. PSVA (limited to the posterior leaflet) was achieved in 224 (37.7%) patients. Follow-up was 4259 patient-years, and complete for 97% of the patients. Propensity score analysis was introduced to reduce selection bias. RESULTS: Patients with PSVA were slightly older (61.9 vs 59.8 years, P = 0.014), with lower incidence of calcification (54.9 vs 63.0%, P = 0.05), pure mitral stenosis (29.9 vs 38.9%, P = 0.014) and history of rheumatic fever (44.6 vs 53.9%, P = 0.028). Mechanical prostheses were more frequently implanted in the Non-PSVA group (75.1 vs 65.6%, P = 0.013). Thirty-day mortality was 1.1%. Late survival rates at 5, 10 and 18 years were 86.6 ± 2.0, 70.8 ± 3.2 and 48.0 ± 5.1%, respectively, with no difference between groups. Both groups had compromised late survival when compared with the general population (age and gender matched, P < 0.001). Only age, large left atrium, pulmonary hypertension and 'pure' MR appeared as independent predictors for late mortality. There was no difference regarding adverse valve-related events between groups. CONCLUSIONS: Patients submitted to MVR for rheumatic mitral valve disease have a poor prognosis, independently of having the subvalvular apparatus preserved. PSVA did not improve late survival in this setting.

Surgical Treatment of Posterior Mitral Valve Prolapse: Towards 100% Repair.

BACKGROUND: The study aim was to evaluate the immediate and long-term results of surgical treatment of isolated posterior mitral valve leaflet prolapse (PLP), focusing on survival and freedom from recurrent mitral regurgitation (MR). METHODS: Between January 1998 and December 2012, a total of 492 consecutive patients (375 males, 117 females; mean age 61.8 ± 12.1 years; range: 13-86 years) with isolated PLP [304 (61.8%) with myxomatous degeneration; 188 (38.2%) with fibroelastic deficiency] were treated at the authors' institution. Of these patients, 202 (41.1%) were in NYHA class III-IV, and atrial fibrillation was present in 104 (21.1%). Mitral valve repair was achieved in 484 patients (98.4%), resection was performed in 419 (85.2%), and prosthetic ring annuloplasty was used in 436 (88.6%). Concomitant procedures were performed in 153 patients (31.1%), including tricuspid valve repair in 50 (10.2%), aortic valve surgery in 34 (6.9%), and coronary artery bypass grafting (CABG) in 64 (13%). RESULTS: The hospital mortality rate was 0.2%, and the mean follow up was 7.1 ± 3.9 years. There were 71 late deaths (14.4%), and overall survival at five, 10 and 15 years was 91.7 ± 1.3%, 82.1 ± 2.3% and 64.7 ± 6.1%, respectively. There was no significant difference in long-term survival compared with the age- and gender-matched general population (p = 0.146). Multivariate Cox-proportional hazard analysis showed older age (HR 1.03 per annum), left ventricular dysfunction (HR 2.44), atrial fibrillation (HR 1.96), left ventricular end-diastolic dimension (HR 1.05 per mm) and non-use of prosthetic ring (HR 3.03) as significant predictors of late mortality. Recurrence of moderate or severe MR occurred in 31 patients, six of whom underwent mitral valve reoperation. Predictors of late recurrence of MR were fibroelastic deficiency (HR 2.38), mitral calcification (HR 5.26), posterior leaflet plication (HR 3.58), absence of complete ring annuloplasty (HR 3.84) and systolic pulmonary artery pressure at discharge (HR 1.10 per mmHg). Freedom from mitral valve reoperation at 15 years was 97.4 ± 1.1% CONCLUSIONS: Mitral valve repair in isolated PLP can be achieved in virtually all cases with a very low operative risk and a high durability of repair. Atrial fibrillation or large left ventricles are associated with a poor prognosis. Failure to use a complete ring annuloplasty carries a risk not only for the return of MR but also for survival.