Transapical Transcatheter Valve-in-Valve Implantation for Failed Mitral Valve Bioprosthesis.

UNLABELLED: Background: The rate of mitral bioprosthesis implantation in clinical practice is increasing. Transcatheter valve-in- valve implantation has been described for high risk patients requiring redo valve surgery. OBJECTIVES: To report our experience with transapical valve-in-valve implantation for failed mitral bioprosthesis. METHODS: Since 2010, 10 patients have undergone transapical valve-in-valve implantation for failed bioprosthesis in our center. Aortic valve-in-valve implantation was performed in one of them and mitral valve-in-valve implantation in nine. Mean age was 82 ± 4 years and 6 were female (67%). Mean time from original mitral valve (MV) replacement to valve-in-valve procedure was 10.5 ± 3.7 years. Follow-up was completed by all patients with a mean duration of 13 ± 12 months. RESULTS: Preoperatively, all patients presented with significant mitral regurgitation, two with mitral stenosis due to structural valve failure. All nine patients underwent successful transapical valve-in-valve implantation with an Edwards Sapien balloon expandable valve. There was no in-hospital mortality. Mean and median hospital duration was 15 ± 18 and 7 days respectively. Valve implantation was successful in all patients and there were no major complications, except for major femoral access bleeding in one patient. At last follow-up, all patients were alive and in NYHA functional class I or II. Echocardiography follow-up demonstrated that mitral regurgitation was absent or trivial in seven patients and mild in two. At follow-up, peak and mean gradients changed from 26 ± 4 and 8 ± 2 at baseline to 16.7 ± 3 and 7.3 ± 1.5, respectively. CONCLUSIONS: Transcatheter transapical mitral valve-in-valve implantation for failed bioprosthesis is feasible in selected high risk patients. Our early experience with this strategy is encouraging. Larger randomized trials with long-term clinical and echocardiographic follow-up are recommended.

Sutureless Aortic Valve: Early and Mid-Term Results at a Single Center.

UNLABELLED: Background: Prolonged life expectancy has increased the number of elderly high risk patients referred for surgical aortic valve replacement (AVR). These referred high risk patients may benefit from sutureless bioprosthesis procedures which reduce mortality and morbidity. OBJECTIVES: To present our initial experience with sutureless aortic bioprotheses, including clinical and echocardiographic results, in elderly high risk patients referred for AVR. METHODS: Forty patients (15 males, mean age 78 ± 7 years) with symptomatic severe aortic stenosis underwent AVR with the 3F Enable or Perceval sutureless bioprosthesis during the period December 2012 to May 2014. Mean logistic EuroScore was 10 ± 3%. Echocardiography was performed preoperatively, intraoperatively, at discharge and at follow-up. RESULTS: There was no in-hospital mortality. Nine patients (22%) underwent minimally invasive AVR via a right anterior mini-thoracotomy and one patient via a J-incision. Four patients underwent concomitant coronary aortic bypass graft, two needed intraoperative repositioning of the valve, one underwent valve exchange due to inappropriate sizing, three (7.5%) had a perioperative stroke with complete resolution of neurologic symptoms, and one patient (2.5%) required permanent pacemaker implantation due to complete atrioventricular block. Mean preoperative and postoperative gradients were 44 ± 14 and 13 ± 5 mmHg, respectively. At follow-up, 82% of patients were in New York Heart Association functional class I and II. CONCLUSIONS: Sutureless AVR can be used safely in elderly high risk patients with relatively low morbidity and mortality. The device can be safely implanted via a minimally invasive incision. Mid-term hemodynamic results are satisfactory, demonstrating significant clinical improvement.

Mitral valve repair: isolated posterior compared to anterior or bileaflet pathology.

OBJECTIVES: The results of mitral valve (MV) repair for anterior leaflet pathology (ALP) are considered less favorable than those for posterior leaflet pathology (PLP). We compared clinical and echocardiography outcomes of PLP repair with ALP and/or bileaflet pathology (BLP) repair. METHODS: Between 2004 and 2011, 407 patients underwent MV repair due to degenerative MV: 276 patients (68%) had PLP and 131 (32%) had ALP/BLP. Mean age was 59 ± 12 and 56 ± 15 years in PLP and ALP/BLP groups, respectively (p = 0.03). Patient characteristics and co-morbidities were similar between groups. Valve repair techniques included leaflet resection (61% and 24%), annuloplasty (99% and 97%), and artificial chordea (46% and 67%), in the PLP and ALP/BLP groups, respectively. RESULTS: There was one (0.4%) in-hospital death in the PLP group, and none in the ALP/BLP group. Early complication rate was similar between groups. Completed clinical and late echocardiography follow-up was 95% (29 ± 22 months, 1 to 87). Freedom from reoperation was 98% (270/276) and 98% (129/131), and there were three (1%) and three (2%) late deaths, in the PLP and ALP/BLP groups, respectively (NS). Late echocardiography revealed that 89% and 94% of patients (PLP and ALP/BLP groups, respectively) were free from moderate or severe mitral regurgitation (MR) (p = 0.13). All other late valve-related complications were similar between groups. CONCLUSIONS: Anterior and bileaflet MV disease can be repaired with early and mid-term results similar to those of posterior MV disease. All patients with severe MR due to anterior or posterior pathology should be considered equally for early valve repair.

Quality of mitral valve repair: median sternotomy versus port-access approach.

OBJECTIVES: We sought to compare early and late clinical and echocardiographic outcomes of patients undergoing minimally invasive mitral valve repair by means of the port-access and median sternotomy approaches. METHODS: Between 2000 and 2009, 503 patients had mitral valve repair, of whom 143 underwent surgical intervention for isolated posterior leaflet pathology: 61 through port access and 82 through median sternotomy. The port-access group had better preoperative New York Heart Association functional class (P = .007) and a higher rate of elective cases (97% vs 87%, P = .037). Other preoperative characteristics were similar between the groups, including mitral valve pathology and repair techniques. RESULTS: Operative, bypass, and clamp times were significantly longer in the port-access group. Mean hospital stay was 5.3 +/- 2.5 days in the port-access group versus 5.7 +/- 2.5 days in the median sternotomy group (P = .4). Early postoperative echocardiographic analysis showed that most patients in both groups had none or trivial mitral regurgitation and none of the patients had greater than grade 2 mitral regurgitation. Follow-up extended for up to 100 months (mean, 34 +/- 24 months). New York Heart Association class improved in both groups (P = .394). Freedom from reoperation was 97% and 95% in the port-access and median sternotomy groups, respectively. Late echocardiographic analysis revealed that 82% (49/60) in the port-access group and 91% (73/80) in the median sternotomy group were free from moderate or severe mitral regurgitation (P = .11). CONCLUSIONS: In isolated posterior mitral valve pathology, quality of mitral valve repair with the port-access approach can compare with that with the conventional median sternotomy approach.

Current strategies of mitral valve repair.

BACKGROUND: During the last decade new surgical techniques for mitral valve repair were developed. We have been using those techniques in order to widen the spectrum of patients eligible for MV repair. OBJECTIVES: To assess the operative and mid-term results a wide variety of surgical techniques. METHODS: From January 2004 through December 2006, 213 patients underwent MV repair in our institution. Valve pathology was degenerative in 123 patients (58%), ischemic in 37 (17%), showed annular dilatation in 25 (12%), endocarditis in 16 (8%), was rheumatic in 13 (6%), and due to other causes in 14 (7%). Preoperative New York Heart Association score was 2.35 +/- 0.85 and ejection fraction 53 +/- 12%. Isolated MV repair was performed in 90 patients (42%) and 158 concomitant procedures were done in 123 patients (58%). A wide variety of surgical techniques was used in order to increase the number of repairs compared to valve replacement. RESULTS: There were 7 in-hospital deaths (3.3%). NYHA class improved from 2.19 +/- 0.85 to 1.4 +/- 0.6, and freedom from reoperation was 100%. Echocardiography follow-up of patients with degenerative MV revealed that 93% of the patients (115/123) were free of mitral regurgitation greater than 2+ grade. In patients operated by a minimal invasive approach there were no conversions to stemotomy, no late deaths, none required reoperation, and 96% were free of MR greater than 2+ grade. The use of multiple surgical techniques enabled the repair of more than 80% of pure MR cases. CONCLUSIONS: MV repair provides good perioperative and mid-term results, and supports the preference for MV repair over replacement, when feasible. Multiple valve repair techniques tailored to different pathologies increases the feasibility of mitral repair.