Echocardiographic characteristics of non-resectional ring-only valve repair in mitral valve prolapse.

BACKGROUND: Simple mitral valve repair (MVR) using a ring-only approach (ROA) was recently proposed for some complex forms of bileaflet myxomatous mitral valve prolapse (MVP). Nevertheless, few data are available concerning the characteristics of MVP patients that may benefit from this simple repair technique. METHODS: Based on 39 consecutive patients (28 men; mean age 57 ± 15) with severe primary Mitral regurgitation (MR) caused by bileaflet MVP referred for MVR, we sought to identify the preoperative echocardiographic parameters associated with successful ROA repair. RESULTS: Twenty-three patients (59%) underwent standard resectional MVR (SMVR) while 16 (41%) underwent ROA. Cardiopulmonary bypass and cross clamp times were lower in ROA than in SMVR (74 ± 27 min vs 99 ± 42 min and 49 ± 19 min vs 70 ± 25 min, respectively, p = 0.03 and p = 0.005). ROA patients were more frequently women (50% vs 13%, p = 0.027). Echocardiographic characteristics of successful ROA were mid-late systolic MR, a paradoxical systolic papillary muscle displacement, and paradoxical systolic annulus expansion (PAE). A prolapsing depth <10 mm, the absence of flail leaflet and ruptured chordae, the presence of multiple jets, more often in the central part of the valve were also associated with ROA. Non hemodynamic systolic anterior motion and residual trivial MR tended to be more frequent in ROA than in SMVR. CONCLUSION: Simple and fast MVR using a ROA is feasible in 4/10 patients with complex forms of bileaflet MVP. Successful ROA patients were more frequently women, with mid-late systolic central multiple jet, low prolapse depth, absence of chordal rupture or flail leaflet and PAE.

"Respect when you can, resect when you should": A realistic approach to posterior leaflet mitral valve repair.

OBJECTIVE: Avoiding resection to treat posterior leaflet prolapse has become popular to repair degenerative mitral regurgitation. We never subscribed to such simplification but advocated an alternative approach based on the "respect when you can, resect when you should" concept. The present study reviewed posterior leaflet prolapse in degenerative disease with the aim to expose the 10-year experience with this surgical policy, in particular long-term outcomes such as survival, recurrent/severe mitral regurgitation, and reoperation. METHODS: From January 2005 to December 2015, 701 consecutive patients with severe mitral regurgitation underwent mitral valve repair in 2 distinct institutions. Mitral regurgitation was degenerative in 441 patients, of whom the 376 with posterior leaflet prolapse constituted the study population. Patients were followed up by echocardiograms until December 2017. Longitudinal data stratified by institution were analyzed by mixed-effects models. Outcome measures were analyzed by Kaplan-Meier test. RESULTS: Patients with posterior leaflet prolapse (24.7% isolated P2 and 75.3% P2 associated with other segments) were aged 65.8 ± 13 years, and 70.5% were male. Median follow-up was 61.1 months. There were 3 hospital deaths (0.8%). Reoperation was necessary in 7 patients (1.9%). After 1, 5, and 10 years, overall survival was 97.8%, 93.6%, and 86.7%, respectively; the overall survival of the proportion of patients with recurrent/residual >2+ mitral regurgitation was estimated at 0.7%, 1.9%, and 5.9% and that of patients with New York Heart Association III/IV at 0.8%, 1.9%, and 5.3%. CONCLUSIONS: The "resect with respect" approach yields low operative mortality, no systolic anterior motion, good surface of coaptation, and low incidence of residual/recurrent mitral regurgitation and of reoperation, thus supporting resection when required concept.

Recurrent Aortic Prosthetic Valve Endocarditis: A Radical Additional Anatomical Solution.

Recurrent prosthetic valve endocarditis, especially when characterized by annular abscess and aortic root destruction, remains a surgical challenge. A radical and aggressive surgical treatment is required preventing recurrent infection. Homograft implants are still thought to be the best surgical option, but they are not always available and their use in younger patient remains controversial. We propose an additional anatomical surgical technique, which consists in the implantation of a composite graft in the left ventricular outflow tract, well below the native aortic annulus, and then the direct reimplantation of coronary ostia.

Hypertrophic obstructive cardiomyopathy: the mitral valve could be the key.

OBJECTIVES: As we strongly believe that treating the mitral valve abnormalities is a key feature of hypertrophic obstructive cardiomyopathy (HOCM), we have systematically corrected both the anterior and posterior leaflet (PL) size and geometry. We have analysed our immediate results and at mid-term follow-up. METHODS: From March 2010 until June 2015, 16 patients with HOCM underwent surgical correction of obstruction. The mean age was 51 years old (range, 32-72 years). All were symptomatic being New York Heart Association (NYHA) class 3 (n = 4) or 4 (n = 12). All had systolic anterior motion at echocardiogram with severe mitral regurgitation (MR). Intraventricular gradient preoperatively was 73.5 mmHg (range, 50-120 mmHg). All patients underwent a double-stage procedure: first septal resection through (i) the aortic valve and (ii) the detached anterior leaflet (AL) of the mitral valve and at second, mitral valve repair by (i) reducing PL height (leaflet resection or artificial neochordae) (ii) increasing AL height with pericardial patch. RESULTS: There was no in-hospital or late death. All patients were Class 1 NYHA at latest follow-up. Control echocardiography showed no MR, mean rest intraventricular gradient was 15 mmHg (range, 9-18 mmHg). CONCLUSIONS: Our good mid-term results support the concept that HOCM is not only a septal disease and that the mitral valve pathology is a key component that should be addressed. For most patients, the ideal surgical treatment should consist in a two-step procedure. It is even necessary to be studied whether treating the mitral valve alone could not suffice.