Mitral valve repair or replacement for ischemic mitral regurgitation? The Italian Study on the Treatment of Ischemic Mitral Regurgitation (ISTIMIR).

OBJECTIVE: It is uncertain whether mitral valve replacement is really inferior to mitral valve repair for the treatment of chronic ischemic mitral regurgitation. This multicenter study aimed at providing a contribution to this issue. METHODS: Of 1006 patients with chronic ischemic mitral regurgitation and impaired left ventricular function (ejection fraction < 40%) operated on at 13 Italian institutions between 1996 and 2011, 298 (29.6%) underwent mitral valve replacement whereas 708 (70.4%) received mitral valve repair. Propensity scores were calculated by a nonparsimonious multivariable logistic regression, and 244 pairs of patients were matched successfully using calipers of width 0.2 standard deviation of the logit of the propensity scores. The postmatching median standardized difference was 0.024 (range, 0-0.037) and in none of the covariates did it exceed 10%. RESULTS: Early deaths were 3.3% (n = 8) in mitral valve repair versus 5.3% (n = 13) in mitral valve replacement (P = .32). Eight-year survival was 81.6% ± 2.8% and 79.6% ± 4.8% (P = .42), respectively. Actual freedom from all-cause reoperation and valve-related reoperation were 64.3% ± 4.3% versus 80% ± 4.1%, and 71.3% ± 3.5% versus 85.5% ± 3.9 in mitral valve repair and mitral valve replacement, respectively (P < .001). Actual freedom from all valve-related complications was 68.3% ± 3.1% versus 69.9% ± 3.3% in mitral valve repair and mitral valve replacement, respectively (P = .78). Left ventricular function did not improved significantly, and it was comparable in the 2 groups postoperatively (36.9% vs 38.5%, P = .66). At competing regression analysis, mitral valve repair was a strong predictor of reoperation (hazard ratio, 2.84; P < .001). CONCLUSIONS: Mitral valve replacement is a suitable option for patients with chronic ischemic mitral regurgitation and impaired left ventricular function. It provides better results in terms of freedom from reoperation with comparable valve-related complication rates.

Aortic valve re-implantation technique with Gelweave Valsalva prosthesis: safety, reproducibility and pitfalls of a geometric reconstruction.

BACKGROUND: To evaluate the safety, reproducibility and pitfalls of an aortic valve re-implantation (AVRei) technique. METHODS: From June 2005 to December 2008, 30 patients underwent aortic valve-sparing re-implantation with Gelweave Valsalva prosthesis. Mean age was 66 +/- 7 years (range 47-81). Mean aortic root diameter was 49 +/- 6 mm (range 37-70) and 12 patients had an aortic insufficiency more than 2+. All the patients were elective, except three who underwent surgery for type A aortic dissection. Two patients had Marfan syndrome and one had a bicuspid aortic valve. Isolated aortic root replacement was performed in 26 patients, whereas hemiarch extension was required in four. All the survivors underwent serial echocardiographic assessment for functional results and multi-detector computed tomography (MDCT) for aortic root morphology evaluation. RESULTS: There was one early death and one re-exploration for bleeding. Two patients suffered from a perioperative stroke and four required a pacemaker implantation because of a complete atrio-ventricular block. Mean follow-up was 12 +/- 10 months (range 1-42) with no late deaths, whereas freedom from reoperation was 100% and freedom from aortic insufficiency 2+ or more was 96.5%. MDCT aortic root reconstruction showed a pseudo-normalization of the neo-sinuses of Valsalva mimicking the human normal aortic root morphology. CONCLUSION: AVRei with Valsalva conduit is a well-tolerated procedure both in elective and emergency situations. In well-selected patients, good functional and clinical results can be achieved, regardless of the cause of the aortic root disease. Application of simple surgical manoeuvres allows durable clinical efficacy to be obtained without the risk of major complications.

[Mitral regurgitation and left ventricular dysfunction: pathophysiology and surgical therapy]. / L'insufficienza mitralica nella disfunzione ventricolare sinistra: aspetti fisiopatologici e terapia chirurgica.

Functional mitral regurgitation (FMR) is a distinctive valve disease in which the left ventricle is the "culprit" and the mitral valve is the "victim". It differentiates from organic regurgitation because the structure of the valve and subvalvar apparatus are not affected, hence abnormalities of the left ventricle are not the consequence but the cause of valve disease. It is at present well known that FMR conveys adverse prognosis in patients with left ventricular dysfunction, with a graded relationship between severity and reduced survival. Recent important advances in the understanding of pathophysiology of this complex valve disease have recognized that FMR results from changes in the geometry of the left ventricle, the mitral annulus and papillary muscles. Assessment of the degree of FMR, by Doppler echocardiography, has allowed to identify patients with adverse prognosis and predictors of death, drawing guidelines for therapy. Standard surgical restrictive annuloplasty represents the treatment of choice, although improvement in long-term survival had not been clearly demonstrated yet. New surgical and interventional therapies are currently under development. In this paper we reviewed the most important published literature, trying to define the mechanisms of regurgitation, diagnosis and therapeutic options, making an update of future perspectives for the treatment of FMR.

Importance of surgical timing on postoperative outcome in patients with native valve acute endocarditis.

BACKGROUND: The present study was undertaken to establish whether surgical outcome could be influenced by surgical timing in patients affected by native valve endocarditis (NVE). METHODS: From March 2002 to December 2004, 19 patients underwent surgical operation for NVE. Aortic valve replacement (AVR) was performed in ten patients (53%), mitral valve repair (MVRep) was performed in five patients (26%) and multivalvular procedures were performed in the remaining four patients (21%). In three patients (15.5%), emergency surgery was required for refractory congestive heart failure, urgent surgery was necessary in ten patients [in six patients (31%) for paravalvular abscess, in three patients (15.5%) for macrovegetations and in one patient (6%) for systemic embolism, respectively], five patients (26.3%) with isolated valve incompetence underwent elective surgery, whereas delayed surgery was reserved for one patient (6%) because of pre-operative embolic stroke. RESULTS: There were no surgical procedure, cardiac or infectious related deaths at 30 days in the entire group. One patient died from an intravenous overdose. Follow-up was 100% complete in the 18 hospital survivors and ranged from 4 to 37 months (mean 14.2 +/- 10 months). There were no late death, recurrence of endocarditis, or re-operation at follow-up. CONCLUSIONS: The surgical results for NVE are excellent if surgical timing criteria are correctly applied during the acute phase of the infectious process. Immediate surgical correction is required when rapid hemodynamic deterioration occurs whereas a more aggressive surgical approach appears to be advisable in the case of paravalvular abscess, macrovegetations or systemic embolism. Delayed surgery is recommended when pre-operative stroke develops.

Laparoscopic omental flap for the treatment of major sternal wound infection after cardiac surgery.

BACKGROUND: The ideal reconstructive procedure after sternal debridement is still a matter of debate. The omentum might be theoretically preferable for its favorable properties, but it is seldom used because it entails the added trauma of a laparotomy. METHODS: Three female patients with severe osteomyelitis after myocardial revascularization underwent sternal debridement and filling of the defect with a laparoscopically prepared omental flap. Sternal wound closure was achieved as a single-stage procedure in 2 patients. The third patient had a poststernotomy septicemia and required a 2-stage procedure. The abdominal procedures were conducted through 3 operating 5-mm ports. Omental flaps were developed by complete separation from the transverse colon and lengthening by division of some anastomosing arteries between gastroepiploic vessels and Barkow's arcade. Thoracic transposition of the omentum was achieved through a 5-cm diaphragmatic incision. The flaps were able to reach the base of the neck and fill the sternal defect in all patients. RESULTS: A smooth postoperative course was observed. Oral intake was started from day 2; sole oral nutrition was maintained from day 3 or 4. Optimal wound healing was observed with minimal or absent local discomfort. Minor transient paradoxical movements of the anterior chest wall disappeared within 1 month. Postoperative hospital stay was 9, 14, and 14 days, respectively. CONCLUSIONS: Laparoscopic omentoplasty, compared with the open procedure, entails several advantages for the treatment of sternal osteomyelitis. The introduction of minimally invasive techniques may widen the indications for the use of the omentum in the treatment of major sternal wound infections.