Risk of Surgical Mitral Valve Repair for Primary Mitral Regurgitation

BackgroundRisk estimation for surgical intervention is an essential component of heart team shared decision-making. However, current mitral valve (MV) surgery risk models used in practice lack etiologic or procedural specificity. The purpose of this study was to establish a comprehensive method for assessment of operative risk of MV repair of primary mitral regurgitation (MR).MethodsA novel etiology and procedure-specific algorithm identified 53,462 consecutive (July 2014 to June 2020) intention-to-treat MV repair patients with primary MR from The Society of Thoracic Surgeons Adult Cardiac Surgery Database. Risk models were fit for 30-day operative mortality, mortality and/or major morbidity, and conversion-to-replacement (CONV). As-treated mortality and morbidity models were derived separately.ResultsEvent rates for mortality (n = 619; 1.16%), mortality plus morbidity (n = 4746; 8.88%), and CONV (n = 3399; 6.36%) were low. Mortality was higher in CONV patients vs repair (3.18% vs 1.02%). All event rates were lower with increasing program volumes. The mortality risk model had excellent discrimination (AUC: 0.807) and calibration and confirmed very low mortality risk for isolated MV repair for primary MR, with mean mortality risk of 1.16% and median of 0.55% (interquartile range: 0.30%-1.17%) with 90th and 95th percentiles 2.48% and 3.99%, respectively. The mortality risk was <0.5% in patients <65 years of age, with 97% of the total population across age groups having a risk of <3%. Only 1 in 4 patients age 75 or older had >3% estimated risk of mortality.ConclusionsThis etiologic and procedure-specific risk model establishes that the contemporary mortality risk of MV repair for primary MR is <1% for the vast majority of patients.     

Mitral Valve Reconstruction and Mitral Valve Replacement for Ischemic Mitral Insufficiency

Abstract Background: Patients with ischemic mitral incompetence have a high operative risk whether the valve is repaired or replaced. The advantage of repair over replacement is unclear in this group of patients. Methods: Between April 1986 and December 1994, 232 patients underwent surgery for ischemic mitral valve insufficiency; mitral valve replacement was performed in 98 of them. Operative mortality was 13.3%. The actuarial survival rate after 5 years was 73.3%. The surgical risk in patients whose left ventricular ejection fraction (LVEF) was 10%-30% (operative mortality 50.0%) was higher than in those whose LVEF was greater than 30%. Valve reconstruction was performed in 102 patients. Operative mortality in this patient group was 14.7%. The surgical risk in patients whose LVEF was 30% was higher (operative mortality 42.9%). Results: The total actuarial survival rate of all patients was 64.4% after 5 years. Mortality during follow-up was higher in patients with residual mitral valve insufficiency greater than grade I after mitral valve reconstruction. Twenty-four patients with severly impaired left ventricular function underwent heart transplantation. Operative mortality in this group was 12.5%. Eight patients received left ventricular aneurysmectomy in addition to valve surgery, three of them died early. Conclusions: We conclude that patients with highly impaired left ventricular function and ischemic mitral insufficiency are at too great a risk for either valve reconstruction or replacement. Cardiac transplantation should be considered for this patient group. However, patients with ischemic mitral insufficiency and moderately impaired left ventricular function can undergo valve reconstruction or replacement with an acceptable prognosis. The goal of mitral valve reconstruction should be reducing mitral valve insufficiency to at least grade I. If this is not achieved, the prognosis after repair is worse than after valve replacement, therefore, the surgeon should replace the valve without delay.     

Mitral valve pericardioplasty—a long-term follow-up study

Posterior (17) and anterior (3) mitral cusp pericardioplasties were performed in 20 patients between 6 December 1961 and 10 July 1963. A long-term follow-up study was done in nine patients. In six of these, mitral valvectomy with Starr-Edwards ball valve replacement was required after intervals varying between two years and three months and seven years and three months. In only one of the six cases did the pericardium macroscopically appear normal. In four it was obviously thickened and in two of the four there was also evidence of calcification in the pericardium only. In one of these, calcification was gross, causing complete immobility of the whole 2 × 0·6 in (5 × 1·7 cm) pericardial inlay. In only one of the six cases had the pericardium become larger and thinner and this also was in the only patient with a dilated mitral ring. Only three patients remain with the pericardium as inserted into the posterior mitral cusp between eight years and eight years and eleven months previously, but in all three there is clinical evidence of progressive pathology in the mitral valve. The progressive mitral valve involvement in this series could well have been caused by progression of the pre-existing pathology in the cusps and chordae tendineae but the involvement of the pericardial inlay was much more extensive than that of the rest of the cusp.     

保留二尖瓣装置的二尖瓣替换术

本文报道保留二尖瓣装置的二尖瓣替换术１９例。结果表明：术后病人血波动力学稳定、心功能恢复快，手术并发症少。对手术适应证的迭择、手术方法和术中注意事项进行了讨论。     

二尖瓣成形术治疗二尖瓣关闭不全

二尖瓣成形术与二尖瓣置换术相比有较多优点，因此，近年来二尖瓣成形术治疗二尖瓣关闭不全越来越受到临床医生的重视。针对二尖瓣关闭不全的不同病理改变，可以采用瓣环成形、三角形切除、四边形切除以及腱索转移、置换等方法。随着微创外科的发展，小切口二尖瓣成形和机器人辅助的二尖瓣成形技术也逐渐发展起来；另外，对二尖瓣关闭不全进行介入治疗也开始起步。相信随着手术技术的不断成熟，将会有更多二尖瓣关闭不全患者接受二尖瓣成形术的治疗。     

Mitral valve disease in young; Review of surgical treatment

In India rheumatic mitral valve disease in younger age group continues unabated. The present study consists of 170 cases of mitral valve disease in young, operated upon at Military Hospital (Cardiothoracic Centre), Pune, during the last 10 years. The clinical electro-cardiographic and roentgenographic findings are presented. Echocardiographic and haemodynamic studies were performed in a few cases. 136 cases underwent closed mitral valvotomy and in 34 cases open heart surgery was performed. Closed mitral valvotomy achieved satisfying results in majority of the cases of mitral stenosis. Open heart surgery was considered when there was gross mitral regurgitation, multivalvular disease or left atrial thrombus. Closed mitral valvotomy continues to be the treatment of choice in the majority of the cases in this age group.