Late Outcomes of Porcine and Pericardial Bioprostheses After Mitral Valve Replacement in 1162 Patients.

BACKGROUND: Debate continues regarding the superiority of porcine vs pericardial bioprostheses, and data relevant to this comparison are scant. This study compared late survival and structural valve deterioration of porcine and pericardial mitral valve prostheses. METHODS: Adults undergoing mitral valve replacement with 1 first-generation porcine valve model and 1 pericardial valve line were reviewed from a prospectively maintained institutional database between 1976 and 2020. Multivariable regression and Cox proportional hazards analysis were used to compare late outcomes. RESULTS: Of 1162 consecutive patients, 612 (53%) received porcine valves and 550 (47%) received pericardial valves. At 10 years, patient survival (porcine, 36% ± 2%; pericardial, 38% ± 3%; P = .5) and cumulative incidence of mitral valve structural deterioration (porcine, 18% ± 2%; pericardial, 19% ± 3%; P = .3) were similar. The structural failure mode was more likely severe mitral stenosis in pericardial valves (35 of 50 [70%] vs 38 of 106 [36%]; P < .001), and it was more likely severe mitral regurgitation in porcine valves (80 of 106 [75%] vs 19 of 50 [38%]; P < .0001). After adjustment, structural deterioration was associated with younger patient age (P < .001) but not valve type. At 10 years, porcine valves demonstrated a higher cumulative incidence of mitral reoperation (19% ± 2% vs 9% ± 2%; P < .001) and reoperation for structural deterioration (15% ± 1% vs 6% ± 2%; P = .007). CONCLUSIONS: This study demonstrated similar rates of 10-year survival and structural deterioration with porcine and pericardial bioprostheses in mitral valve replacement. The study suggests a lack of major improvement in durability of mitral bioprosthetic valves over time. The failure mode may have a greater influence on surgeon decision making regarding valve choice.

Late Survival After Redo Mitral Operation With Minithoracotomy Compared With Sternotomy.

BACKGROUND: The long-term effectiveness of minithoracotomy over redo median sternotomy for reoperative mitral operation is not well described. Here we present long-term survival after reoperative mitral operation based on operative approach. METHODS: Adults undergoing mitral valve operation with previous sternotomy by redo sternotomy and minithoracotomy were reviewed from our prospectively maintained institutional database from 1997 to 2022. Propensity score matching was performed to compare short- and long-term outcomes. RESULTS: Of 750 consecutive patients, thoracotomy was performed in 503 (67%). Median follow-up was 5.0 years (interquartile range, 0-23 years). Intraoperatively, sternotomy patients were more likely to have central aortic cannulation (205 of 223 [93%] vs 265 of 481 [56%]), cardioplegic arrest (220 of 223 [99%] vs 124 of 481 [26%]), and mitral valve replacement (190 of 223 [85%] vs 358 of 481 [74%]). Thoracotomy patients were older (63 ± 13 vs 58 ± 14 years) with elective presentation (387 of 503 [77%] vs 128 of 247 [52%]). Sternotomy patients were more likely to have endocarditis (52 of 247 [21%] vs 45 of 503 [9%], P < .001). At 10 years, thoracotomy patients experienced improved survival (52% ± 3% vs 46% ± 4%, P = .004). After propensity matching, 10-year survival was significantly higher for thoracotomy patients compared with sternotomy patients (60% ± 5% vs 42% ± 5%, P = .0006). The greatest difference in survival was at the first 6 months after operation (96% ± 1% vs 81% ± 3%, P < .001). CONCLUSIONS: For patients undergoing reoperative mitral valve operation, minimally invasive right anterior thoracotomy can significantly decrease risk of death in the first 6 months, with durable survival benefit out to 10 years. We present a large single-center series to suggest an important opportunity to durably improve outcomes after reoperative mitral operation through wider use of right minithoracotomy.

Infarct exclusion repair of postmyocardial infarction ventricular septal rupture with a hybrid patch and septal occluder device compared with patch only.

Objective: We developed a hybrid technique for repairing post-myocardial infarction (MI) ventricular septal defect (VSD) that combines infarct exclusion with patch and a nitinol-mesh septal occluder device (SOD) to provide a scaffold to support the damaged septal wall. Here, we compare outcomes of patients with post-MI VSD repaired using patch only or hybrid patch/SOD. Methods: Patients undergoing post-MI VSD repair at our institution from 2013 to 2022 who received patch alone or patch/SOD repair were analyzed. Primary outcome was survival to hospital discharge. Clinical outcomes and echocardiograms were also analyzed. Results: Over a 9-year period, 24 patients had post-MI VSD repair at our institution with either hybrid patch/SOD (n = 10) or patch only repair (n = 14). VSD size was 18 ± 5.8 mm for patch/SOD and 17 ± 4.6 mm for patch only. In the patch/SOD repair cohort, average size of SOD implant was 23.6 ± 5.6 mm. Mild left ventricular dysfunction was present prerepair and was unchanged postrepair in both groups; however, moderate-to-severe right ventricular (RV) dysfunction was common in both groups before repair. RV function worsened or persisted as severe in 10% of hybrid versus 54% of patch-only patients postrepair. Tricuspid annular systolic excursion and RV:left ventricle diameter ratio, quantitative metrics of RV function, improved after patch/SOD repair. No intraoperative mortality occurred in either group. Postoperative renal, hepatic, and respiratory failure requiring tracheostomy was common in both groups. Survival to hospital discharge in both cohorts was 70%. Conclusions: Post-MI VSD repair with patch/SOD has comparable short-term outcomes with patch alone. Addition of a SOD to patch repair provides a scaffold that may enhance the repair of post-MI VSD with patch exclusion.

Long-term outcomes of phenoclusters in severe tricuspid regurgitation.

AIMS: Severe tricuspid regurgitation (TR) exhibits high 1-year morbidity and mortality, yet long-term cardiovascular risk overall and by subgroups remains unknown. This study characterizes 5-year outcomes and identifies distinct clinical risk profiles of severe TR. METHODS AND RESULTS: Patients were included from a large US tertiary referral center with new severe TR by echocardiography based on four-category American Society of Echocardiography grading scale between 2007 and 2018. Patients were categorized by TR etiology (with lead present, primary, and secondary) and by supervised recursive partitioning (survival trees) for outcomes of death and the composite of death or heart failure hospitalization. The Kaplan-Meier estimates and Cox regression models were used to evaluate any association by (i) TR etiology and (ii) groups identified by survival trees and outcomes over 5 years. Among 2379 consecutive patients with new severe TR, median age was 70 years, 61% were female, and 40% were black. Event rates (95% confidence interval) were 30.9 (29.0-32.8) events/100 patient-years for death and 49.0 (45.9-52.2) events/100 patient-years for the composite endpoint, with no significant difference by TR etiology. After applying supervised survival tree modeling, two separate groups of four phenoclusters with distinct clinical prognoses were separately identified for death and the composite endpoint. Variables discriminating both outcomes were age, albumin, blood urea nitrogen, right ventricular function, and systolic blood pressure (all P < 0.05). CONCLUSION: Patients with newly identified severe TR have high 5-year risk for death and death or heart failure hospitalization. Partitioning patients using supervised survival tree models, but not TR etiology, discriminated clinical risk. These data aid in identifying relevant subgroups in clinical trials of TR and clinical risk/benefit analysis for TR therapies.

Impact of Transcatheter Mitral Valve Repair Availability on Volume and Outcomes of Surgical Repair.

BACKGROUND: The impact of transcatheter edge-to-edge repair (TEER) on national surgical mitral valve repair (MVr) volume and outcomes is unknown. OBJECTIVES: This study aims to assess the impact of TEER availability on MVr volumes and outcomes for degenerative mitral regurgitation. METHODS: MVr volume, 30-day and 5-year outcomes, including mortality, heart failure rehospitalization and mitral valve reintervention, were obtained from the Society of Thoracic Surgeons database linked with Medicare administrative claims and were compared within TEER centers before and after the first institutional TEER procedure. A difference-in-difference approach comparing parallel trends in coronary artery bypass grafting outcomes was used to account for temporal improvements in perioperative care. RESULTS: From July 2011 through December 2018, 13,959 patients underwent MVr at 278 institutions, which became TEER-capable during the study period. There was no significant change in median annualized institutional MVr volume before (32 [IQR: 17-54]) vs after (29 [IQR: 16-54]) the first TEER (P = 0.06). However, higher-risk (Society of Thoracic Surgeons predicted risk of mortality ≥2%) MVr procedures declined over the study period (P < 0.001 for trend). The introduction of TEER was associated with reduced risk-adjusted odds of mortality after MVr at 30 days (adjusted OR: 0.73; 95% CI: 0.54-0.99) and over 5 years (adjusted HR: 0.75; 95% CI: 0.66-0.86). These improvements in 30-day and 5-year mortality were significantly greater than equivalent trends in coronary artery bypass grafting. CONCLUSIONS: The introduction of TEER has not significantly changed overall MVr case volumes for degenerative mitral regurgitation but is associated with a decrease in higher-risk surgical operations and improved 30-day and 5-year outcomes within institutions adopting the technology.

Imaging Considerations and Clinical Implications of Mitral Annular Disjunction.

Mitral annular disjunction is increasingly recognized as an important anatomic feature of mitral valve disease. The presence of mitral annular disjunction, defined as separation between the left atrial wall at the point of mitral valve insertion and the left ventricular free wall, has been associated with increased degeneration of the mitral valve and increased incidence of sudden cardiac death. The clinical importance of this entity necessitates standard reporting on cardiovascular imaging reports if patients are to receive adequate risk stratification and management. We provide a narrative review of the literature pertaining to mitral annular disjunction, its clinical implications, and areas needing further research.

Sustained results of robotic mitral repair in a lower volume center with extensive minimally invasive mitral repair experience.

The literature for robotic mitral repair is dominated by a small number of large volume institutions, and intermediate-term outcomes out to 5 years are rare. Whether and under what circumstances a lower volume institution could obtain durable outcomes is not known. A retrospective review was performed on all 133 patients undergoing robotically assisted mitral repair from 2011 to 2019 at a single institution. Mean volume of robotic mitral repair was 16 ± 7 cases per year, while mean institutional total volume of mitral repair was 116 ± 16 cases per year. Mean age was 58 ± 12 years, 77% were men, and mitral etiology was prolapse in 90%. Comorbidity was infrequent with atrial fibrillation in 20% and moderate tricuspid regurgitation in 14%. Central aortic cannulation was used in 97% with concurrent tricuspid operation in 5% and concurrent maze in 14%. Median clamp time, pump time, and length of stay were 146 min, 265 min, and 5 days, respectively, but none improved with experience. There were no deaths or stroke. At 5 years, the cumulative incidence of moderate mitral regurgitation was 18 ± 6% (prolapse patients 11 ± 5%), severe regurgitation 4 ± 3%, and mitral replacement 9 ± 5% (prolapse patients 5 ± 3%). 5-year survival was 96 ± 3%. At centers with significant mitral repair volume, a volume of 16 robotic mitral cases/year can yield good clinical outcomes durable out to 5 years. A case volume of 16 cases per year was not sufficient to improve pump time or length of stay over time.

The outcome of mitral repair for degenerative versus ischemic mitral regurgitation using a single complete ring.

BACKGROUND: The durability of surgical repair for degenerative versus ischemic mitral regurgitation (MR) is thought to be markedly different. We, therefore, examined late outcomes and durability for mitral repair in a large cohort of patients receiving a single annuloplasty device. METHODS: A total of 749 consecutive patients receiving mitral repair for degenerative mitral regurgitation (DMR) or ischemic mitral regurgitation (IMR) were evaluated from a prospective database. Patients with tricuspid or maze surgery were included. Papillary muscle rupture and mixed valve etiologies were excluded. Outcomes were compared for IMR versus DMR. RESULTS: Patients with DMR were younger and less urgent. Patients with IMR had mean end-systolic diameter 4.5 ± 1.1 cm. All patients received the same complete semirigid annuloplasty device with median ring size 32 mm for DMR and 24 mm for IMR. New York Heart Association failure class improved from 2.8 to 1.5 (p < .001). Patients with DMR had lower operative mortality (1/384 [0.3%] vs. 26/365 [7%], p < .0001) and shorter length of stay. A 15-year survival was better with DMR (63% ± 3% vs. 13% ± 2%, p < .001). At 10 years, the incidence of recurrent ≥2+ MR (10% ± 2% vs. 16% ± 2%, p = .16) was not significantly different. Predictors of recurrent ≥2+ MR were female gender (odds ratio [OR]: 3.0 (1.9-4.8, p < .0001), and prior operation (OR: 2.4 [1.3-4.5], p = .02) but not IMR (OR: 1.4 [0.9-2.3], p = .15). CONCLUSIONS: In this series, where patients with IMR had relatively preserved ventricular dimensions, the primary determinants of late recurrent MR were female gender and prior operation but not IMR versus DMR. Selected patients with IMR can obtain relatively durable mitral repair despite higher operative risk and lower survival compared to DMR.

Late Durability of Mitral Repair for Ischemic Versus Nonischemic Functional Mitral Regurgitation.

BACKGROUND: Concerns regarding long-term durability of surgical repair for functional mitral regurgitation are based on short-term data, with few comparisons of ischemic mitral regurgitation (IMR) versus nonischemic functional mitral regurgitation (NIFMR) etiology. METHODS: Consecutive patients (N = 788) receiving mitral repair for functional mitral regurgitation were evaluated from a prospectively maintained database. Patients with other surgical procedures were included. Propensity score matching was used to compare outcomes in IMR versus NIFMR. RESULTS: Unmatched IMR patients tended to be older men with greater comorbidities. One hundred ninety-eight matched pairs of IMR versus NIFMR patients had similar demographics with a relatively preserved ejection fraction of 40% ± 13% and an end-systolic diameter of 4.3 ± 1.1 cm. Concomitant coronary revascularization occurred in 70% of matched IMR patients. All patients received an annuloplasty ring, usually 24 to 26 mm. Heart failure class improved from 2.8 preoperatively to 1.5 at 5 years (P < .0001). Survival at 15 years was worse with IMR (12% ± 3% vs 43% ± 5%, P < .0001). At 10 years the cumulative incidence of moderate or more (≥2+) mitral regurgitation (27% ± 4% vs 26% ± 4%, P = .4), severe regurgitation (10% ± 3% vs 8% ± 2%, P = .5), and mitral reoperation (3% ± 1% vs 3% ± 1%, P = .4) was not different between IMR versus NIFMR. Recurrent moderate regurgitation was associated with heart failure readmission but not with mortality. CONCLUSIONS: In propensity-matched patients IMR versus NIFMR had worse survival but similar repair durability, with moderate regurgitation in 27% at 10 years and rare severe regurgitation or mitral reoperation. In selected patients with relatively preserved function, mitral repair for IMR or NIFMR can improve symptoms with durable mild regurgitation in most patients out to 10 years.

Bicuspid aortic valve repair: An ongoing struggle in material science.

BACKGROUND: Techniques and results of aortic valve repair remain challenging. AIMS: Safari et al. seek to improve aortic valve repair by either aortic patching or valve sparing root replacement. MATERIALS AND METHODS: The results of bicuspid aortic valve (BAV) repair in 142 patients were examined withor without valve sparing root replacement. RESULTS: Isolated BAV repair with or without valve sparing root replacement provided goodclinical outcomes with relatively low reoperation rate and durable valve function. DISCUSSION: While clinical outcome from BAV repair was generally good, the authors have stopped pericardial patch augmentation of BAV leaflets due to suboptimal durability. CONCLUSION: Thelack of a durable valve patch material and the modest durability of BAV repairin general point out that aortic valve repair remains an ongoing struggle inmaterial science.

Is redo mitral mortality getting better or getting worse?

Zubarevich et al. present the 30 day and 1-year outcomes of redo mitral valve replacement in 58 high-risk patients. The authors conclude that careful patient selection and risk stratification provides acceptable surgical results in this cohort. This series reminds us that increased use of bioprostheses, increased use of mitral replacement instead of repair, and an aging population drive the volume of high-risk redo mitral replacement. It remains to be seen whether redo mitral mortality is getting better or worse, but the risk and the patients will be with us for some time.