Rheumatic mitral valve repair or replacement in the valve-in-valve era.

OBJECTIVE: For degenerative mitral disease, repair is superior to replacement; however, the best operative strategy for rheumatic mitral disease remains unclear. We evaluated the association between decision-making in choosing repair versus replacement and outcomes across 2 decades of rheumatic mitral surgery. METHODS: Patients undergoing isolated, first-time rheumatic mitral surgery were identified. Era 1 (1997-2008) and Era 2 (2009-2018) were distinguished by intraoperative assessment of anterior leaflet mobility/calcification (Era 2) in deciding between mitral repair versus replacement. Primary outcome was a composite of death, reoperation, and severe valve dysfunction. RESULTS: Among 180 patients, age was 59 ± 14 years, and ejection fraction was 58% ± 10%. A higher proportion in Era 1 (n = 56) compared with Era 2 (n = 124) had preoperative atrial fibrillation (68% vs 46%; P = .006); the groups were otherwise similar. Primary indication was mitral stenosis in 69% (124 out of 180; pure = 35, mixed = 89) and did not differ by era (P = .67). During Era 1, 70% (39 out of 56) underwent repair, compared with 33% (41 out of 124) during Era 2 (P < .001). Freedom from death, reoperation, or severe valve dysfunction at 5 years was higher in Era 2 (72% ± 9%) than Era 1 (54% ± 13%; P = .04). Five-year survival was higher in Era 2 than Era 1, but did not differ between repair versus replacement. Five-year cumulative incidence of reoperation with death as a competing risk did not differ by era, but was higher after repair than replacement. CONCLUSIONS: Careful assessment of anterior leaflet mobility/calcification to determine mitral repair or replacement was associated with improved outcomes. This decision-making strategy may alter the threshold for rheumatic mitral replacement in the current valve-in-valve era.

Early percutaneous mitral commissurotomy or conventional management for asymptomatic mitral stenosis: a randomised clinical trial.

OBJECTIVE: The decision to perform percutaneous mitral commissurotomy (PMC) on asymptomatic patients requires careful weighing of the potential benefits against the risks of PMC, and we conducted a multicentre, randomised trial to compare long-term outcomes of early PMC and conventional treatment in asymptomatic, severe mitral stenosis (MS). METHODS: We randomly assigned asymptomatic patients with severe MS (defined as mitral valve area between 1.0 and 1.5 cm2) to early PMC (84 patients) or to conventional treatment (83 patients). The primary endpoint was a composite of major cardiovascular events, including PMC-related complications, cardiovascular mortality, cerebral infarction and systemic thromboembolic events. The secondary endpoints were death from any cause and mitral valve (MV) replacement during follow-up. RESULTS: In the early PMC group, there were no PMC-related complications. During the median follow-up of 6.4 years, the composite primary endpoint occurred in seven patients in the early PMC group (8.3%) and in nine patients in the conventional treatment group (10.8%) (HR 0.77; 95% CI 0.29 to 2.07; p=0.61). Death from any cause occurred in four patients in the early PMC group (4.8%) and three patients in the conventional treatment group (3.6%) (HR 1.30; 95% CI 0.29 to 5.77). Ten patients (11.9%) in the early PMC group and 17 patients (20.5%) in the conventional treatment group underwent MV replacement (HR 0.59; 95% CI 0.27 to 1.29). CONCLUSIONS: Compared with conventional treatment, early PMC did not significantly reduce the incidence of cardiovascular events among asymptomatic patients with severe MS during the median follow-up of 6 years. TRIAL REGISTRATION NUMBER: NCT01406353.

Rheumatic heart disease in pregnancy and neonatal outcomes: A systematic review and meta-analysis.

PURPOSE: Associations between rheumatic heart disease (RHD) in pregnancy and fetal outcomes are relatively unknown. This study aimed to review rates and predictors of major adverse fetal outcomes of RHD in pregnancy. METHODS: Medline (Ovid), Pubmed, EMcare, Scopus, CINAHL, Informit, and WHOICTRP databases were searched for studies that reported rates of adverse perinatal events in women with RHD during pregnancy. Outcomes included preterm birth, intra-uterine growth restriction (IUGR), low-birth weight (LBW), perinatal death and percutaneous balloon mitral valvuloplasty intervention. Meta-analysis of fetal events by the New-York Heart Association (NYHA) heart failure classification, and the Mitral-valve Area (MVA) severity score was performed with unadjusted random effects models and heterogeneity of risk ratios (RR) was assessed with the I2 statistic. Quality of evidence was evaluated using the GRADE approach. The study was registered in PROSPERO (CRD42020161529). FINDINGS: The search identified 5949 non-duplicate records of which 136 full-text articles were assessed for eligibility and 22 studies included, 11 studies were eligible for meta-analyses. In 3928 pregnancies, high rates of preterm birth (9.35%-42.97%), LBW (12.98%-39.70%), IUGR (6.76%-22.40%) and perinatal death (0.00%-9.41%) were reported. NYHA III/IV pre-pregnancy was associated with higher rates of preterm birth (5 studies, RR 2.86, 95%CI 1.54-5.33), and perinatal death (6 studies, RR 3.23, 1.92-5.44). Moderate /severe mitral stenosis (MS) was associated with higher rates of preterm birth (3 studies, RR 2.05, 95%CI 1.02-4.11) and IUGR (3 studies, RR 2.46, 95%CI 1.02-5.95). INTERPRETATION: RHD during pregnancy is associated with adverse fetal outcomes. Maternal NYHA III/IV and moderate/severe MS in particular may predict poor prognosis.

TAVI in Patients with Mitral Annular Calcification and/or Mitral Stenosis.

BACKGROUND: We herein aimed for analysis of influence of mitral annular calcification (MAC) and mitral stenosis (MS) on outcomes in transcatheter aortic valve implantation (TAVI). METHODS: Between 11/2009 and 06/2017, 1,058 patients underwent TAVI in the presence of concomitant MAC or MS at our center. Subgroups were built and multivariate logistic regression, COX regression, Kaplan-Meier survival analyses, and receiver operating characteristics method were performed. RESULTS: Thirty-day mortality was 7.5% (79/1,058) with highest mortality in patients severe MS (MAC: 3.4% vs. mild MS: 5.9% vs. moderate MS: 15.0% vs. severe MS: 72.7%; p < 0.001). Moderate-to-severe MS (odds ratio [OR]: 7.75, confidence interval [CI]: 3.94-16.26, p < 0.001), impaired left ventricular ejection fraction (OR: 1.38, CI: 1.10-1.72, p < 0.01), and coronary artery disease (OR: 1.36, CI: 1.11-1.67, p < 0.01) were predictive of 30-day survival. Left ventricular systolic/end-diastolic pressure drop of <59.5 mm Hg / <19.5 mm Hg was associated with increased mortality. CONCLUSIONS: TAVI in the presence of MAC and mild MS is associated with acceptable acute outcomes but should be considered high-risk procedures in patients with moderate and especially those with severe MS. Our results suggest adverse hemodynamics after TAVI with concomitant MS, which may be caused by underfilling of the left ventricle leading to low-cardiac output.

Long-term outcomes of rheumatic mitral valve repair: Is it worthwhile to do it?

AIM: This retrospective study was undertaken to evaluate the long-term outcomes of mitral valve repair in rheumatic patients. METHODS: From 2003 to 2019, 151 patients (mean age 26.5 ± 14.9 years; 68.9% female) underwent mitral valve repair. Fifty-three (35.1%) had atrial fibrillation, and 79 (52.3%) were in New York Heart Association class III/IV. Pure mitral regurgitation was present in 109 (72.2%) patients, pure stenosis in 9 (6%), and mixed regurgitation and stenosis in 33. RESULTS: Three (2%) patients died postoperatively and 4 (2.6%) were lost during follow-up. Mean follow-up was 90.5 ± 55.6 months. There were 22 (14.8%) late deaths. Actuarial survival at 5, 10, and 15 years was 90.7% ± 2.5%, 83.5% ± 3.6%, and 76.5 ± 6.1%, respectively. Twelve (8.5%) patients underwent reoperation. Freedom from reoperation at 5, 10, and 15 years was 96.1% ± 1.7%, 89.8% ± 3.2%, and 82.3% ± 6.1%, respectively. Forty-two (29.2%) patients developed recurrent mitral regurgitation. Freedom from recurrence of mitral regurgitation at 5, 10, and 15 years was 70.9% ± 4.3%, 56% ± 5.9%, and 53.3% ± 6.4%, respectively. Eighty-one (56.6%) patients were and free from all events during follow-up. Freedom from all events at 5, 10, and 15 years was 64.8% ± 4.1%, 48.6% ± 5.3%, and 43.7% ± 5.8%, respectively. CONCLUSIONS: Although rheumatic mitral valve repair is associated with late recurrence of mitral regurgitation, it has benefits in selected patients, especially children and young patients who want to avoid the lifelong risks of anticoagulation. Long-term follow-up is essential in these patients.

Contemporary trends in mitral valve surgery in East China: a 10-year experience.

BACKGROUND: Contemporary nationwide data from mainland China on trends in mitral valve surgery are scarce. The purpose of the present study was to review a single-center experience with mitral valve surgery over a 10-year period in East China. METHODS: Between July 2009 and June 2019, 3238 consecutive patients who underwent mitral valve surgery in our center were retrospectively reviewed. The patients were evenly divided into three periods: July 2009 to October 2012 (period I), November 2012 to February 2016 (period II), March 2016 to June 2019 (period III). RESULTS: The 3238 patients included 536 (16.6%) who had mitral valve repair and 2702 (83.4%) who had mitral valve replacement. Early mortalities for mitral valve repair and mitral valve replacement were 0.2% and 0.9%, respectively. There were trends towards a higher proportion of degenerative valve lesions (24.6%, 35.8%, 54.7% in periods I, II, and III, respectively) and a lower proportion of rheumatic valve lesions (71.0%, 62.6%, 38.0%) in more recent years. The proportions of minimally invasive surgery (0.7%, 2.1%, 30.2%), mitral valve repair (8.3%, 15.4%, 27.5%), use of a bioprosthesis (10.1%, 17.0%, 23.1%), and concomitant tricuspid valve procedures (13.2%, 28.5%, 46.0%) increased dramatically, while early mortality remained constant during the 10-year period (1.0%, 0.3%, 0.9%). CONCLUSIONS: In the past 10 years, the spectrum of mitral valve disease experienced a trend towards more degenerative valve lesions and less rheumatic valve lesions in East China. Mitral valve repair, bioprostheses, tricuspid valve repair, and minimally invasive surgery have been more often applied in recent years.

The Natural History of Severe Calcific Mitral Stenosis.

BACKGROUND: Prevalence of calcific mitral stenosis (MS) increases with age; however, its natural history and relation to cardiac symptoms or comorbidities are not well defined. OBJECTIVES: This study assessed the prevalence of symptoms, comorbidities, and determinants of all-cause mortality in patients with severe calcific MS. METHODS: The authors retrospectively investigated adults with isolated severe calcific MS and mitral valve area ≤1.5 cm2 from July 2003 to December 2017. Inactivity was defined as requirement for assistance with activities of daily living. RESULTS: Of 491 patients with isolated severe MS, calcific MS was present in 200 (41%; age 78 ± 11 years, 18% men, 32% with atrial fibrillation). Charlson Comorbidity Index was 5.1 ± 1.7 and 14 (7%) were inactive. Mitral valve area and transmitral gradient (TMG) were 1.26 ± 0.19 cm2 and 8.1 ± 3.8 mm Hg, respectively. Symptoms were present at baseline in 120 (60%); 20 (10%) developed symptoms during follow-up of 2.8 ± 3.0 years. Kaplan-Meier survival at 1 year was 72% without intervention. Inactivity (hazard ratio [HR]: 6.59; 95% confidence interval [CI]: 3.54 to 12.3; p < 0.01), Charlson Comorbidity Index >5 (HR: 1.53; 95% CI: 1.04 to 2.26; p < 0.01), TMG ≥8 mm Hg (HR: 1.68; 95% CI: 1.12 to 2.51; p = 0.012), and right ventricular systolic pressure ≥50 mm Hg (HR: 2.27; 95% CI: 1.50 to 3.43; p < 0.01) were independently associated with mortality. Symptoms were not associated with mortality. CONCLUSION: Patients with isolated severe calcific MS had a high burden of comorbidities, resulting in high mortality without intervention. Symptoms were reported in 60%, but not associated with mortality. TMG ≥8 mm Hg and right ventricular systolic pressure ≥50 mm Hg were independently associated with mortality.

Severe Mitral Annular Calcification and Mitral Valve Surgery: An Algorithmic Approach to Management.

The management of mitral valve dysfunction in the setting of substantial mitral annular calcification (MAC) remains controversial and is one of the most challenging problems in mitral valve surgery. The physiopathology of severe MAC is related to a combination of progressive, degenerative and active calcium deposition in the annulus that is often multifactorial, but largely attributable to aging and chronic disease conditions. Given the fact that overall life expectancy in the elderly population are increasing, it is imperative to understand contemporary and future therapeutic options since this MAC is likely going to be a frequent problem faced by the next generation of cardiac surgeons. This review provides a relevant synthesis of existing literature and aims to assess the efficacy of existing therapeutic choices for patients with mitral valve dysfunction and 'big' MAC with a goal of minimizing postoperative complications (e.g. left ventricular outflow tract obstruction, prosthetic paravalvular leak, valve embolization, and stroke) that can be achieved via a multidisciplinary heart team approach.

Impact of Valvular Heart Disease on Mortality, Thromboembolic and Cardiac Events in Japanese Patients With Atrial Fibrillation　- The Fushimi AF Registry.

BACKGROUND: There is a growing burden of valvular heart disease (VHD) and atrial fibrillation (AF) due to population aging, but data regarding the characteristics and outcomes of patients with AF and concomitant VHD are lacking.Methods and Results:The Fushimi AF Registry is a community-based prospective survey of AF patients in Fushimi-ku, Kyoto. Among 3,566 patients with available echocardiographic data, 20% had VHD, consisting of 131 valvular AF (VAF: 3.7%) and 583 nonvalvular AF with VHD (NVAF-VHD: 16.3%). Here, VAF was defined as AF with mitral stenosis or a prosthetic heart valve. AF patients with VHD were older, had more comorbidities with a higher CHADS2 score, and were prescribed oral anticoagulants more frequently than those without VHD. After adjusting for confounders, VHD was not associated with stroke or systemic embolism, all-cause mortality, or cardiac death. NVAF-VHD was significantly associated with an increased risk of hospitalization for heart failure (adjusted hazard ratio [HR], 1.44; 95% confidence interval [CI], 1.16-1.78), whereas VAF was not (HR, 1.28; 95% CI, 0.86-1.92). Among all types of VHD, aortic valve diseases were associated with a higher risk of cardiac events, whereas mitral valve diseases were not. CONCLUSIONS: Although VHD did not significantly affect thromboembolism or mortality, it affected cardiac events depending on type, with aortic valve diseases having higher risk, in Japanese patients with AF.

The effect of patient-prosthesis mismatch on survival after aortic and mitral valve replacement: a 10 year, single institution experience.

BACKGROUND: The evidence on the impact of patient-prosthesis Mismatch (PPM) on survival thus far has been conflicting. The aim of this study was to 1) study the effect of PPM on survival after isolated aortic and mitral valve replacement and 2) Assess the interaction between left ventricular function and PPM on survival. METHODS: The study cohort was patients who underwent isolated Aortic valve replacement (AVR) and Mitral valve replacement (MVR) over a 10-year period from 2008 to 2018. PPM was defined using the projected indexed effective orifice area (EOAi). The cohort was divided into different groups based on the degree of PPM. The severity of PPM was classified using threshold values of EOAi used in the literature. The Kaplan- Meier method was used to compare survival by degree of PPM. Multivariate Cox proportional hazards models were used to generate adjusted hazard ratios (HR) with 95% confidence intervals. An interactive term for ejection fraction (EF) was added to test whether EF modifies the effect of the PPM grade on survival. In addition, sub-group analysis based on left ventricular function was performed. RESULTS: In the AVR cohort, there were a total of 1953 patients. The distribution of patients in the different PPM categories was as follows: no PPM 59.7%; moderate PPM 36.8%; severe PPM 3.5%. There was no significant difference in survival between the different groups. At 10 years, the adjusted HR between patients with severe PPM versus no PPM was 1.1(CI 0.5-2.4, p >  0.05) and the HR between those with moderate PPM versus no PPM was 0.97 (CI 0.74-1.23, p >  0.05). In the MVR cohort, there were a total of 298 patients. The distribution of PPM is as follows: no PPM 59.4%; and with PPM 40.6%. Again, there was no significant difference in survival between the groups. At 5 years, the adjusted HR between patients with PPM versus no PPM was 1.45 (CI 0.67-3.14, p >  0.05). In both groups, there was no significant interaction between left ventricular function (LVF) and degree of PPM on survival. CONCLUSIONS: In our study cohort, the degree of PPM was not an independent predictor of survival after AVR or MVR. There was also no significant interaction between LV function and degree of PPM on survival.

Hemodynamics and Prognostic Impact of Concomitant Mitral Stenosis in Patients Undergoing Surgical or Transcatheter Aortic Valve Replacement for Aortic Stenosis.

BACKGROUND: Mitral stenosis frequently coexists in patients with severe aortic stenosis. Mitral stenosis severity evaluation is challenging in the setting of combined aortic stenosis and mitral stenosis because of hemodynamic interactions between the 2 valve lesions. The impact of aortic valve replacement (AVR) for severe aortic stenosis on mitral stenosis is unknown. This study aimed to assess the effect of AVR on mitral stenosis hemodynamics and the clinical outcomes of patients with severe aortic stenosis with and without mitral stenosis. METHODS: We retrospectively investigated patients who underwent surgical AVR or transcatheter AVR for severe aortic stenosis from 2008 to 2015. Mean transmitral gradient by Doppler echocardiography ≥4 mm Hg was identified as mitral stenosis; patients were then stratified according to mitral valve area (MVA, by continuity equation) as >2.0 cm2 or ≤2.0 cm2. MVA before and after AVR in patients with mitral stenosis were evaluated. Clinical outcomes of patients with and without mitral stenosis were compared using 1:2 matching for age, sex, left ventricular ejection fraction, method of AVR (surgical AVR versus transcatheter AVR) and year of AVR. RESULTS: Of 190 patients with severe aortic stenosis and mitral stenosis (age 76±9 years, 42% men), 184 were matched with 362 with severe aortic stenosis without mitral stenosis. Among all mitral stenosis patients, the mean MVA increased after AVR by 0.26±0.59 cm2 (from 2.00±0.50 to 2.26±0.62 cm2, P<0.01). MVA increased in 105 (55%) and remained unchanged in 34 (18%). Indexed stroke volume ≤45 mL/m2 (odds ratio [OR] 2.40; 95% CI, 1.15-5.01; P=0.020) and transcatheter AVR (OR, 2.36; 95% CI, 1.17-4.77; P=0.017) were independently associated with increase in MVA. Of 107 with significant mitral stenosis (MVA ≤2.0 cm2), MVA increased to >2.0 cm2 after AVR in 52 (49%, pseudo mitral stenosis) and remained ≤2.0 cm2 in 55 (51%, true mitral stenosis). During follow-up of median 2.9 (0.7-4.9) years, true mitral stenosis was an independent predictor of all-cause mortality (adjusted hazard ratio, 1.88; 95% CI, 1.20-2.94; P<0.01). CONCLUSIONS: MVA improved after AVR in nearly half of patients with severe aortic stenosis and mitral stenosis. MVA remained ≤2.0 cm2 (true mitral stenosis) in nearly half of patients with severe aortic stenosis and significant mitral stenosis; this was associated with worse survival among patients undergoing AVR for severe aortic stenosis.

Heart valve operations associated with reduced risk of death from mitral valve disease but other operations associated with increased risk of death: a national population-based case-control study.

BACKGROUND: Mitral valve disease is the most common heart valve disease worldwide. Heart valve operation is the predominant treatment strategy for heart valve disease. This study analyzed the death risk from heart valve disease with respect to the frequency of heart valve operation and other operations in patients with mitral valve disease. MATERIALS AND METHODS: We conducted a retrospective nationwide population-based case-control study using a claims dataset from Taiwan's National Health Insurance Research Database. The case and control groups enrolled mitral valve disease patients from 2002 to 2013 who had either underwent an heart valve operation procedure or not, respectively. Conditional logistic regression was estimated the odds ratios (ORs) associated with various risk factors for heart valve operation-related death, including other operations and comorbidities. RESULTS: A total of 25,964 patients with mitral valve disease were recruited for the study and divided into heart valve operation (600 patients) and non-heart valve operation (25,364 patients) groups. After matching, a total of 1800 non-heart valve operation patients were selected for final analysis. Heart valve operation was associated with decreased risk of death (adjusted OR [aOR] 0.439), but operations related to other cardiovascular disease (CVD, aOR 3.691), respiratory conditions (aOR 3.210), and the urinary system (aOR 1.925) were associated with increased risk of death for patients with mitral valve disease. Patients with mitral valve disease and diabetes (aOR 1.505), chronic kidney disease (CKD, aOR 3.760), or emphysema (aOR 2.623) also had a higher risk of death. Patients who underwent more heart valve operations had a lower risk of death from mitral valve disease, but patients who underwent more other operations had a higher risk of death from mitral valve disease. CONCLUSIONS: The death risk for patients with mitral valve disease patients could be lowered by more frequently performing heart valve operations. However, the risk of death is increased for patients with mitral valve disease who more frequently undergo other operations, chiefly those for other CVD system, respiratory conditions, and urinary system, or have comorbidities such as diabetes, chronic kidney disease, and emphysema.

Impact of High Baseline Left Ventricular Filling Pressure on Transcatheter Aortic Valve Replacement Outcomes in Patients with Significant Mitral Annular Calcification.

BACKGROUND: Left ventricular filling pressure (LVFP) has been demonstrated to be a major predictor of poor cardiovascular outcomes. However, estimation of LVFP in patients with aortic stenosis is limited by the high prevalence of significant mitral annular calcification. The aim of this study was to investigate the effect of transcatheter aortic valve replacement on LVFP and the relationship of LVFP to mortality and hospitalization. METHODS: This was a single-center, retrospective study of 140 consecutive patients in sinus rhythm with significant mitral annular calcification who underwent transcatheter aortic valve replacement for severe aortic stenosis from May 2011 to June 2015. Mean follow-up duration was 3.06 ± 1.48 years (minimum, 2.4 years; maximum, 6.5 years). Diastolic function was assessed using recently proposed criteria for those with significant mitral annular calcification. High LVFP was defined as a mitral E/A ratio > 1.8 or a ratio of 0.8 to 1.8 and isovolumic relaxation time < 80 msec. RESULTS: At baseline, the proportion of patients with high LVFP was 40.7%, similar to 1 month (39.7%) (P = .86). However, the proportion of patients with high LVFP was significantly decreased at 1 year compared with those at baseline (26.9% vs 40.7%, P = .02). Multivariate analysis showed that high LVFP at baseline significantly increased risk for all-cause mortality compared with patients with normal LVFP (hazard ratio, 2.84; 95% confidence interval, 1.33-6.05; P = .007). CONCLUSIONS: High baseline LVFP was associated with a significantly increased all-cause mortality, and LVFP does not improve in the short term but only at 1 year after transcatheter aortic valve replacement.

Outcomes of Mitral Valve Replacement after Closed Mitral Valvotomy: A Retrospective Cohort Study.

BACKGROUND: The incidence of rheumatic fever and rheumatic heart disease still remains high in the developing countries. Mitral stenosis is predominantly due to rheumatic origin and affects females more than males. Historically, closed mitral valvotomy (CMV) was the first effective intervention for mitral stenosis. We studied the immediate and early surgical outcomes of MVR in patients with history of CMV to see whether their disease behaves differently, when compared with patients without prior CMV undergoing MVR. METHODS: This single center retrospective cohort study was conducted in Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram, Kerala, India. Patients who underwent MVR from January 2008 to December 2012 at our institute were studied. The hospital records of 90 patients were analyzed both in the CMV cohort and also in the non-CMV cohort. Preoperative details, intraoperative parameters, immediate postsurgery echocardiography parameters, and follow-up echocardiography details at 1 year and 5 years were studied. RESULTS: Both the cohorts were similar in age, height, weight, and BSA. In the CMV cohort, 67% were females and in the non-CMV cohort 48% were females. Most of the patients in both the cohorts presented with functional classes 2 and 3. The mean duration between onset of symptoms and MVR in the CMV cohort and the non-CMV cohort was 24.6 years and 6.25 years, respectively. Fifty-nine patients in the CMV cohort had preoperative atrial fibrillation, whereas 47 patients in the non-CMV cohort presented with atrial fibrillation. The mean left atrial (LA) size of patients with sinus rhythm and atrial fibrillation was 46.34 (SE, 0.852) and 55.21(SE, 0.808), respectively. Preoperative echocardiographic assessment revealed a mean ejection fraction of 62% and 63%, mean mitral stenosis gradient of 13 mm Hg and 14.7 mm Hg, mean LA size of 53.2 mm and 50.5 mm, and mean right ventricular systolic pressure of 47.5 mm Hg and 43.6 mm Hg in the post-CMV cohort and in the non-CMV cohort, respectively. The CMV cohort had a longer cardiopulmonary bypass time (111.5 minutes) in comparison with the non-CMV cohort (97 minutes). The aortic cross-clamp time remained similar in both the cohorts. Thirty-six percent of the post-CMV cohort patients had a valve size of 25, and 48% of patients belonging to the non-CMV cohort had a valve size of 27. The percent of moderate-to-severe subvalvar pathology was 88 in both the cohorts. Patients belonging to the post-CMV cohort had a median ventilation time of 16.35 hours, and the patients of the non-CMV cohort had a median ventilation time of 13.75 hours. The duration of ICU stay was 4.41 (SE, 0.188) days and 4.13 (SE, 0.153) days, and length of hospital stay was 8.93 (SE, 0.230) days and 9.13 (SE, 0.313) days in the CMV and the non-CMV cohorts, respectively. Inotropic requirement, measured by the vasoactive inotropic score, was higher in the post-CMV group (11.9), when compared to the other cohort (9.7). Right ventricular (RV) function and pulmonary arterial hypertension assessed in the immediate postoperative period, at 1 year, and at 5 years did not show any significant difference. CONCLUSION: The percentage of females in the CMV cohort is higher. Delaying the valve replacement by performing a surgical palliative procedure like CMV, is beneficial in female patients in the child-bearing age group so that they can complete the families. The disease process started earlier in the CMV cohort, and they had a longer duration of illness before undergoing MVR. Even with the longer duration of disease, the RV function, LA size, PA pressures, and mitral stenosis gradients were comparable. Therefore, CMV prevented progression of the disease in the CMV group. The mean LA size is significantly higher in patients with atrial fibrillation. The CMV cohort had a longer cardiopulmonary bypass time. The duration of ventilation, ICU stay, and hospital stay were similar in both cohorts. Inotrope requirement was higher in the post-CMV group. RV function and pulmonary arterial hypertension assessed in the immediate postoperative period, at 1 year, and at 5 years did not show any significant difference.

Outcomes After Transcatheter Mitral Valve Repair in Patients With Renal Disease.

BACKGROUND: Renal disease is associated with poor prognosis despite guideline-directed cardiovascular therapy, and outcomes by sex in this population remain uncertain. METHODS AND RESULTS: Patients (n=5213) who underwent a MitraClip procedure in the National Cardiovascular Data Registry Transcatheter Valve Therapy registry were evaluated for the primary composite outcome of all-cause mortality, stroke, and new requirement for dialysis by creatinine clearance (CrCl). Centers for Medicare and Medicaid Services-linked data were available in 63% of patients (n=3300). CrCl was <60 mL/min in 77% (n=4010) and <30 mL/min in 23% (n=1183) of the cohort. Rates of primary outcome were higher with lower CrCl (>60 mL/min, 1.4%; 30-<60 mL/min, 2.7%; <30 mL/min, 5.2%; dialysis, 7.8%; P<0.001), and all low CrCl groups were independently associated with the primary outcome (30-<60 mL/min: adjusted odds ratio, 2.32; 95% CI, 1.38-3.91; <30 mL/min: adjusted odds ratio, 4.44; 95% CI, 2.63-7.49; dialysis: adjusted hazards ratio, 4.52; 95% CI, 2.08-9.82) when compared with CrCl >60 mL/min. Rates of 1-year mortality were higher with lower CrCl (>60 mL/min, 13.2%; 30-<60 mL/min, 18.8%; <30 mL/min, 29.9%; dialysis, 32.3%; P<0.001), and all low CrCl groups were independently associated with 1-year mortality (30-<60 mL/min: adjusted hazards ratio, 1.50; 95% CI, 1.13-1.99; <30 mL/min: adjusted hazards ratio, 2.38; 95% CI, 1.78-3.20; adjusted hazards ratio: dialysis, 2.44; 95% CI, 1.66-3.57) when compared with CrCl >60 mL/min. CONCLUSIONS: The majority of patients who undergo MitraClip have renal disease. Preprocedural renal disease is associated with poor outcomes, particularly in stage 4 or 5 renal disease where 1-year mortality is observed in nearly one-third. Studies to determine how to further optimize outcomes in this population are warranted.

Robotic mitral valve repair: 7-year surgical experience and mid-term follow-up results.

BACKGROUND: The feasibility and safety of robotic mitral valve repair has been proven in several studies but the mid-term to long-term outcomes are unclear. We aim to summarize our surgical experience with robotic mitral valve repair and demonstrate the follow-up results out to 7 years. METHODS: From 2007 to 2014, 110 consecutive patients underwent robotic mitral valve repair with da Vinci Surgical System (Intuitive Surgical, USA) in our center. The operative data were collected, and patients were echocardiographically followed regularly up to 7 years. RESULTS: The patients' average age was 45±13 (14 to 70) years with male to female ratio of 2.3:1. Mitral regurgitation (95.5%) or stenosis (4.5%) was diagnosed. The triangular or quadrangular resection was the most performed type of repair (63.3%). Nitinol U-clips (58.1%), running suture (31.1%), and Cor-Knot™ suture device (LSI Solutions, Victor, NY) (10.8%) were used to secure the annuloplasty ring. All cases were performed by the same surgeon. One case of conversion to sternotomy was noted. The mean CPB time was 121±34.3 (range, 70 to 152) minutes, and the mean cross-clamp time was 82.6±25.3 (range, 47 to 122) minutes. After surgery, one death (0.91%) and two cases of transient neurocognitive defect (1.82%) occurred. Three cases of early failure of repair that required reoperation (2.73%) were noticed. All patients were successfully followed for a median of 4.1 (range, 1 month to 7 years) years and 94.5% had freedom of re-operation. CONCLUSIONS: Robotic mitral valve repair is a safe and effective procedure with excellent mid-term outcomes.

Predictors of Left Ventricular Outflow Tract Obstruction After Transcatheter Mitral Valve Replacement.

OBJECTIVES: The aim of this study was to evaluate the predictors of left ventricular outflow tract (LVOT) obstruction after transcatheter mitral valve replacement (TMVR). BACKGROUND: LVOT obstruction is a major concern with TMVR, but limited data exist regarding its predictors and impact on outcomes. METHODS: Patients with pre-procedural multidetector row computed tomography (MDCT) undergoing TMVR for failed mitral bioprosthetic valves (valve-in-valve), annuloplasty rings (valve-in-ring), and mitral annular calcification (valve-in-MAC) were included in this study. Echocardiographic and procedural characteristics were recorded, and comprehensive assessment with MDCT was performed to identify the predictors of LVOT obstruction (defined as an increment of mean LVOT gradient ≥10 mm Hg from baseline). The new LVOT (neo-LVOT) area left after TMVR was estimated by embedding a virtual valve into the mitral annulus on MDCT, simulating the procedure. RESULTS: Among 194 patients with pre-procedural MDCT undergoing TMVR (valve-in-valve, 107 patients; valve-in-ring, 50 patients; valve-in-MAC, 37 patients), LVOT obstruction was observed in 26 patients (13.4%), with a higher rate after valve-in-MAC than valve-in-ring and valve-in-valve (54.1% vs. 8.0% vs. 1.9%; p < 0.001). Patients with LVOT obstruction had significantly higher procedural mortality compared with those without LVOT obstruction (34.6% vs. 2.4%; p < 0.001). Receiver-operating characteristic curve analysis showed that an estimated neo-LVOT area ≤1.7 cm2 predicted LVOT obstruction with sensitivity of 96.2% and specificity of 92.3%. CONCLUSIONS: LVOT obstruction after TMVR was associated with higher procedural mortality. A small estimated neo-LVOT area was significantly associated with LVOT obstruction after TMVR and may help identify patients at high risk for LVOT obstruction.

Transcatheter aortic valve replacement in patients with concomitant mitral stenosis.

AIMS: Multivalvular disease is of increasing concern in elderly patients undergoing transcatheter aortic valve replacement (TAVR). The objective of the present analysis was to investigate the impact of concomitant mitral stenosis (MS) on clinical outcomes in patients undergoing TAVR for severe, symptomatic aortic stenosis (AS). METHODS AND RESULTS: Among 1339 patients undergoing TAVR between August 2007 and December 2015, adequate echocardiographic data for the assessment of severity and aetiology of MS was available in 971 (72.5%) patients. Patients were stratified according to degree and aetiology of concomitant MS. Mitral stenosis was documented in 176 (18.1%) TAVR patients (mean mitral valve area 1.9 ± 0.4 cm2) and considered degenerative in 110 (62.5%) and rheumatic in 66 (37.5%) patients, respectively. Mitral stenosis was categorized as moderate/severe in 28 patients (2.9%). Baseline characteristics were comparable between patients with vs. without MS. At 1 year, patients with MS were at increased risk of cardiovascular death [36 (21.4%) vs. 66 (8.7%); adjusted hazard ratio (HRadj) 3.64, 95% confidence interval (CI) 2.38-5.56] and disabling stroke [12 (7.1%) vs. 23 (3.0%); HRadj 2.98, 95% CI 1.46-6.09] as compared to patients without MS. Differences in cardiovascular death and disabling stroke emerged within 30 days of the index procedure and were largely driven by a difference in patients with rheumatic MS [cardiovascular death: 7 (10.6%) vs. 24 (3.2%), HRadj 4.80, 95% CI 1.98-11.6; disabling stroke: 4 (6.1%) vs. 16 (2.0%), HRadj 4.18, 95% CI 1.34-13.0]. CONCLUSION: Concomitant MS was documented in approximately one-fifth of patients undergoing TAVR for severe, symptomatic AS and associated with a three-fold increased risk of cardiovascular adverse events at 1 year. The difference emerged early and was largely driven by patients with rheumatic MS.

Hazards of Mitral Valve Replacement for Mitral Stenosis Caused by Massive Mitral Annular Calcium With or Without Aortic Valve Replacement for Aortic Stenosis.

Mitral annular calcium (MAC) is common in older adults in the Western World and if extensive may cause mitral stenosis . The purpose of this report is to describe outcomes of 12 patients having mitral valve replacement for mitral stenosis secondary to massive MAC. Operatively excised deposits of calcium removed from the mitral annular area and the accompanying stenotic mitral valves were examined and then the patients' medical records were examined to confirm the diagnosis and the degree of valvular dysfunction. A total of 12 patients with massive MAC causing mitral stenosis and receiving mitral valve replacement with or without aortic valve replacement for aortic stenosis were observed in 2013 to 2015. Of the 12 patients, 7 died from 5 to 44 days (mean 19) after the valve operation and all had "stormy" postoperative courses; one survived 150 days and another, 600 days; the remaining 3 were improved by the operation and are alive 22, 27, and 59 months postoperatively. In conclusion, the high mortality in these patients suggests that mitral valve replacement in the setting of massive MAC be considered with caution.