Decreasing mortality for aortic and mitral valve surgery in Northern New England. Northern New England Cardiovascular Disease Study Group

BACKGROUND: Although numerous reports have documented declining mortality rates associated with coronary artery bypass surgery in recent years, it is unknown whether similar trends have occurred with valve surgery during this time. METHODS: We conducted a regional, prospective study to assess trends in patient casemix and in-hospital mortality rates over time with aortic valve replacement (AVR), mitral valve replacement (MVR), and mitral valve repair. Data were collected from all patients undergoing AVR (n = 2,596), MVR (n = 759), or mitral valve repair (n = 522) in Northern New England between January 1992 and December 1997. Logistic regression was used to identify significant predictors of in-hospital mortality and to calculate risk-adjusted mortality rates. RESULTS: For AVR, the trend in patient casemix was toward increased risk with increases in patient age and in the proportion of patients with: body surface area less than 1.7, diabetes, coronary artery disease, and prior valve surgery. A decrease was noted in the proportion of patients undergoing additional surgical procedures. For MVR, patient risk improved over the time period with fewer female patients and fewer patients with coronary artery disease. For mitral valve repair patient risk increased over the time period with increases in the proportion of patients with coronary artery disease, diabetes, and whose surgical priority was classified as urgent. In addition, there was a borderline significant increase in the proportion of mitral valve repair patients in New York Heart Association class IV preoperatively. Risk-adjusted mortality decreased 44% from 9.3% in 1992 through 1993 to 5.3% in 1996 through 1997 for patients undergoing AVR (p = 0.01) and decreased 53% from 13.6% in 1992 through 1993 to 8.2% in 1996 through 1997 for patients undergoing MVR (p = 0.01). We observed a statistically insignificant increase in risk-adjusted mortality over the time period for patients undergoing mitral valve repair (from 3.6% in 1992 through 1993 to 5.0% in 1996 through 1997; p = 0.34). CONCLUSIONS: Significant improvement in mortality rates with valve replacement was observed in northern New England during this time period. This improvement persisted following adjustment for changes in patient casemix over this time. These trends mirror improvements in mortality with other cardiac surgical interventions that have been observed in recent years in our region and nationally.     

Mitral valve replacement with mechanical prostheses in children: improved operative risk and survival.

OBJECTIVE: The purpose of this study was to assess the early and late outcome following mitral valve replacement (MVR) with mechanical prostheses in children. PATIENTS AND METHODS: Between 1981 and 2000, 44 consecutive children (mean age 6.8+/-4.7 years, 2 months--16 years) underwent mechanical MVR in Southampton. Twenty-three children were less than 5-years-old and nine were infants. Disease aetiology was congenital in 37, rheumatic in four, infective in two and Marfan's syndrome in one. Mitral regurgitation was present in 36 and mitral stenosis in eight. Concomitant procedures were performed in 13, including aortic valve replacement (AVR) in seven. Follow-up was complete (mean 6.4+/-4.8 years, 1 month--18.1 years). RESULTS: The overall operative mortality was 14% (six patients). Before and after 1990 operative mortality was 31 vs 3.6% (P=0.02). From 1990, operative mortality for infants was zero out of six, for children less than 5-years-old was one out of 16 (one death after emergency AVR and MVR) and for older children it was 0/12. Seven children experienced valve or anticoagulation treatment-related events and eight had a mitral valve re-operation. Ten-year freedom from thromboembolism, prosthetic valve infection, bleeding, paravalvular leak and a mitral valve re-operation was 92.8+/-5.2, 97.3+/-2.7, 97.7+/-2.3, 97.2+/-2.7 and 75+/-9.7%, respectively. Overall 10-year survival was 78+/-7% (four late deaths); for children under vs over 5 years it was 61+/-11 vs 95.2+/-4.6% (P=0.02), for atrio-ventricular septal defect (AVSD) vs other pathology 55+/-15 vs 89+/-6.1% (P=0.05) and for those operated before 1990 vs after 1990 it was 63+/-8.1 vs 86+/-8.2% (P=0.04). CONCLUSIONS: Mechanical MVR, in the current era, carries a low operative risk across the spectrum of paediatric age. Late survival is better for older children and those having no-AVSD pathology but it has improved substantially during the 1990s irrespective of age and disease aetiology.     

The effect of preoperative atrial fibrillation on survival following mitral valve repair for degenerative mitral regurgitation.

OBJECTIVE: There is conflicting evidence with regard to the impact of preoperative atrial fibrillation (AF) on the post mitral valve (MV) repair on the early and late outcome. METHODS: A total of 349 patients undergoing various MV repair procedures for degenerative mitral regurgitation (MR) between 1997 and 2003 were studied. Preoperatively, 152 (44%) of these patients were in AF and 197 (56%) patients were in sinus rhythm (SR). The clinical features and the outcome in these two cohorts of patients were compared. RESULTS: The patients in the AF group were older than their counterparts in the SR group (66+/-7 vs 62+/-9 years) (p=0.01), had a higher mean NYHA class score (2.4+/-0.6 vs 2.2+/-0.7) (p=0.04) and were more likely to have impaired left ventricular function (60% vs 36%) (p<0.0001). A similar proportion of patients in the AF (38%) and SR (30%) groups had additional cardiac surgical procedures (p=0.12). Operative mortality was 3.9% in AF group versus 0.5% in SR group (p=0.04), and operative morbidity was 27% versus 17%, respectively (p=0.03). At latest follow up, 4% of patients that were in SR preoperatively developed AF; conversely, 2% of the patients in the AF group converted to SR. The rates of recurrent grade II or III MR (4% vs 5%) (p=0.8) and MV re-operation (2.6% vs 2.5%) (p=1.0) were similar in the AF and SR groups. Kaplan-Meier survival at 7 years was 75+/-6% versus 90+/-3% (p=0.005). On Cox proportional hazards regression model, impaired LV function [(p=0.02), hazard ratio 0.25 (95% confidence intervals (C.I.) 0.078-0.84)] and AF [(p=0.03), hazard ratio 2.70 (95% C.I. 1.09-6.68)] were significant adverse predictors of survival. CONCLUSIONS: This study shows that in patients undergoing MV repair for degenerative MR, preoperative AF has a major negative impact on the early and late survival.     

Mitral repair is superior to replacement when associated with coronary artery disease

OBJECTIVE: To compare the outcomes of mitral repair and replacement in revascularized patients with ischemic mitral regurgitation. SUMMARY BACKGROUND DATA: Combined coronary bypass (CABG) and mitral procedures have been associated with the highest mortality (>10%) in cardiac surgery. Recent studies have suggested that mitral valve replacement (MVR) with sparing of the subvalvular apparatus had comparable results to mitral repair when associated with CABG. METHODS: Over the past 7 years, 54 patients had CABG/mitral repair versus 56 who had CABG/MVR with preservation of the subvalvular apparatus. The groups were similar in age at 69.2 years in the replacement group versus 67.0 in the repair group. We compared these 2 groups based on hospital mortality, incidence of complications including nosocomial infection, neurologic decompensation (stroke), pulmonary complication (pneumonia, atelectasis, and prolonged ventilation), and renal complications (acute renal failure or insufficiency). RESULTS: The mitral repair group had a hospital mortality of 1.9% versus 10.7% in the replacement group (P = 0.05). Infection occurred in 9% of repairs compared with 13% of replacements (P = 0.59). The incidence of stroke was no different between groups (2 of 54 repairs vs. 2 of 56 replacements, P = 1.00). Pulmonary complication rate was 39% in repairs versus 32% in replacements (P = 0.59). Worsening renal function occurred in 15% of repairs versus 18% of replacements (P = 0.67). CONCLUSIONS: Mitral repair is superior to mitral replacement when associated with coronary artery disease in terms of perioperative morbidity and hospital mortality. Although preservation of the subvalvular apparatus with MVR has a theoretical advantage in terms of ventricular function, mitral repair clearly adds a survival benefit in patients with concomitant ischemic cardiac disease.     

Does Metabolic Syndrome Influence Bioprosthetic Mitral Valve Degeneration and Reoperation Rate?

Abstract Background: Evidence suggests that metabolic syndrome (MbS) is associated with early senescence of bioprosthetic aortic valve prostheses. The purpose of this study was to determine whether MbS is also associated with accelerated failure of bioprosthetic valves prostheses in the mitral position. Methods: Records of all patients undergoing bioprosthetic mitral valve replacement (MVR) from 1993 to 2000 were reviewed. Results: Of 114 patients undergoing bioprosthetic MVR, 48 (42%) had MbS. Mean age was 73 years (vs. 74 years for no MbS). Patients underwent MVR for regurgitation (n = 97; 85%), stenosis (n = 12; 11%), or mixed lesions (n = 4; 4%). Etiology was degenerative (n = 35; 32%), rheumatic (n = 26; 24%), ischemic (n = 30; 28%), calcific (n = 9; 8%), and endocarditis (n = 8; 8%). Mean follow‐up was 4.5 years. Overall survival at 5 and 10 years was 56% and 26%, respectively. Survival was similar between groups (p = 0.15). Five patients (2 MbS; 4% vs. 3 no MbS; 5%) required mitral reoperation at a mean of 3.8 years after initial MVR. The risk of prosthetic valve failure was not different between groups (p = 0.66). Despite no initial difference in transmitral gradients, gradients beyond five‐year follow‐up were greater for those with MbS (6.8 mmHg MbS vs. 4.7 mmHg no MbS, p = 0.007). Independent predictors of gradient progression beyond two years were MbS (p = 0.027) and female gender (p = 0.012). There were no significant differences in valve area, regurgitation, or ejection fraction. Conclusions: Although overall survival following bioprosthetic MVR is challenging, MbS did not predict diminished survival or excess reoperative risk compared to non‐MbS patients. The trend toward more rapid progression of transprosthetic gradients in MbS patients warrants further investigation.     

Economic impact of mitral valve plasty versus replacement for mitral valve insufficiency

AIM: The principal techniques for surgical correction of mitral valve regurgitation (MR) were compared, with emphasis on the economic impact. METHODS: In a prospective non-randomized study 225 patients undergoing mitral valve repair were analyzed, 75 had mitral valve plasty (MVP) and 150 had mitral valve replacement (MVR). Patient demographics showed no group differences. RESULTS: Cardiopulmonary bypass time and ischemia time were shorter in the MVP-group, p<0.0001. Hospital mortality was lower after MVP, 2.0% (3/150) compared to MVR, 6.7% (5/75). ICU-stay was shorter in the MVP-group and so was length of postoperative hospital stay, p=0.014. Urgent operation was the only significant risk factor for mortality after MVP. Re-operation, endocarditis, grade IV MR, and NYHA class IV were additional risk factors in the MVR-group. Postoperative improvements of NYHA and mitral valve function were similar in both groups. MVP was more cost effective than MVR (18,050 USD or 20,430 Euro versus 24,824 USD or 28,097 Euro, p<0.001). CONCLUSION: Mitral valve plasty for MR is efficient and associated with shorter CPB and ischemia times as well as length of stay in ICU, together with a lower device cost, which makes MVP more cost effective than MVR.     

Mitral valve repair in children with rheumatic heart disease

OBJECTIVE: The purpose of this study was to assess the long-term results of mitral valve repair in children with chronic rheumatic heart disease. METHODS: From January 1988 through December 2003, 278 children (153 male children) underwent mitral valve repair. Mean age was 11.7 +/- 2.9 years (range, 2-15 years). One hundred seventy-three children (62%) were in the New York Heart Association functional class III or IV. Congestive heart failure was present in 24 (8.6%). Reparative procedures included posterior collar annuloplasty (n = 242), commissurotomy (n = 187), cusp-level chordal shortening (n = 94), cusp thinning (n = 71), cleft suture (n = 65), and cusp excision or plication (n = 10). Associated procedures included atrial septal defect closure (n = 22), aortic valve repair/replacement (n = 13), and tricuspid valve repair (n = 3). RESULTS: Early mortality was 2.2% (6 patients). Preoperative left ventricular dysfunction was associated with greater mortality. Median follow-up was 56.5 months (mean, 58.9. +/- 32.3 months; range, 5 to 180 months). One hundred seventy-seven survivors (65%) had no or trivial mitral regurgitation. Sixteen patients (6%) required reoperation for valve dysfunction. There were 7 late deaths (2.6%). Actuarial, reoperation-free, and event-free survivals at a median follow-up of 56.5 months were 95.2% +/- 1.5%, 91.6% +/- 2.2%, and 55.9% +/- 3.5%, respectively; at 15 years, they were 95.2% +/- 1.5%, 85.9% +/- 5.9%, and 46.7% +/- 4.7%, respectively. CONCLUSION: Mitral valve repair in children with chronic rheumatic heart disease is feasible and provides acceptable long-term results.     

Incidence, associated factors and evolution of non-severe functional mitral regurgitation in patients with severe aortic stenosis undergoing aortic valve replacement.

INTRODUCTION: In order to improve the prognosis, repair of severe mitral regurgitation should be undertaken at the same time as aortic valve replacement in patients with severe aortic valve stenosis. However, mitral regurgitation may be secondary to pressure overload or ventricular dysfunction and improve after surgery. AIM: To assess the incidence of non-severe functional mitral regurgitation before and after isolated aortic valve replacement and determine its influence on the postoperative course. METHODS: The clinical and surgical characteristics were compared in a cohort of 577 consecutive patients who underwent isolated aortic valve replacement. RESULTS: The mean age was 68.4+/-9.2 years (44% women). Non-severe functional mitral valve regurgitation was detected prior to surgery in 26.5% of the patients. These patients were older (p=0.009), more often had ventricular dysfunction (p=0.005) and pulmonary hypertension (0.002), and had been admitted more frequently for heart failure (0.002), with fewer of them conserving sinus rhythm (p<0.001). Additionally, the pre-surgery existence of mitral regurgitation was associated with greater morbidity and mortality (10.5% vs 5.6%; p=0.025). The mitral regurgitation disappeared or improved prior to hospital discharge in 56.2% and 15.6%, respectively. Independent factors predicting this improvement were the presence of coronary lesions (OR 3.7, p=0.038), and the absence of diabetes (OR 0.28, p=0.011) and pulmonary hypertension (0.33, p=0.046). CONCLUSIONS: The presence of intermediate degree mitral regurgitation in patients undergoing isolated aortic valve replacement increases morbidity and mortality. However, a high percentage of those who do survive experience disappearance or improvement of the mitral regurgitation.     

Late Echocardiographic and Clinical Outcomes after Mitral Valve Repair for Degenerative Disease

Abstract   Background and aim of the study: Mitral valve repair is the procedure of choice for severe degenerative mitral regurgitation (MR). The objective of this study was to review prospectively gathered echocardiographic and clinical results with mitral valve repair for degenerative disease. Methods: Between May 1995 and July 2004, 403 patients underwent mitral valve repair for degenerative disease (mean age 63 ± 12 years, 72% males). Concomitant procedures included CABG (29%), radiofrequency left-sided maze procedure (8%), aortic valve replacement (6%), and tricuspid valve repair (4%). Results: Thirty-day mortality was 0.4% for patients with isolated mitral valve repair and 5.1% for patients with mitral valve repair and concomitant procedure (p = 0.003). Five-year survival was higher for isolated mitral valve repair compared to mitral valve repair with a combined procedure (92 ± 2% vs. 76 ± 5%; p < 0.001). Pulmonary artery pressure and left atrial and left ventricular end-diastolic diameters were significantly improved following mitral valve repair (all p ≤ 0.005) and this was sustained afterward. The freedom from severe (3+ or 4+) and moderate-severe (2+, 3+, or 4+) MR was 95% and 77% at 5 years, respectively, whereas the freedom from reoperation was 96 ± 1% at 5 years. Significant predictors of moderate-severe MR recurrence were cardiac dilatation, anterior leaflet prolapse, and concomitant procedure, whereas mitral valve disease amenable to posterior leaflet resection had a lower risk of MR recurrence. Conclusions: Excellent clinical outcomes can be obtained using standard techniques of mitral valve repair of the degenerative valve. MR recurrence is low but nonnegligible, emphasizing the necessity for long-term postoperative echocardiographic follow-up in these patients. (J Card Surg 2010;25:9-15)     

Anatomic repair of anomalous left coronary artery from the pulmonary artery by aortic reimplantation: early survival,patterns of ventricular recovery and late outcome

BACKGROUND: To determine the early and late outcomes of patients presenting with anomalous left coronary artery from the pulmonary artery who had repair by aortic reimplantation. METHODS: From January 1952 to July 2000, 67 patients presented with anomalous coronary artery from the pulmonary artery. Forty-seven patients who had repairs performed by aortic reimplantation are the subject of this study. The median age at repair was 7.7 months. Before repair, 10 infants (21%) presented in extremis requiring ventilatory and inotropic support, and 38 infants (80%) presented in heart failure. Autologous pericardial hood coronary arterioplasty was used in 4 patients, and concomitant mitral valve repair was used in 1 patient. RESULTS: Hospital survival was 92%. Five children required postoperative extracorporeal membrane oxygenation for a median of 4 days (range, 2 to 8 days). Patients who had extracorporeal membrane oxygenation were significantly more likely to have presented in critical condition (40% vs 3% if no extracorporeal membrane oxygenation; p = 0.006) or with ventricular arrhythmias (67% vs 7%; p = 0.027), to have presented with significantly lower preoperative repair median ejection fraction (10%, n = 5 vs 40%, n = 38; p = 0.01) or to have presented with more severe left ventricular dilatation (p = 0.03). Within a 15-year or less follow-up (mean, 4.7 years) there were no late deaths. Kaplan-Meier survival was 91% at 5 years, and freedom from reoperation was 93% at 10 years. At late follow-up, echocardiography demonstrated significant improvements in mean ejection fraction (64% +/- 9% vs 33% +/- 21% preoperatively, p < 0.0001); moderate mitral regurgitation (9% vs 38% preoperatively, p < 0.02); and wall motion abnormalities (15% vs 81% preoperatively, p < 0.002). The ratio of measured left ventricular end-diastolic dimension to the 95th percentile of normal declined from 1.4 +/- 0.3 to 1.0 +/- 0.1 (p < 0.0006). Children who had extracorporeal membrane oxygenation had normal ejection fractions and ventricular dimensions at follow-up (n = 3). Repeated measures of mixed linear regression analysis demonstrated that normalization of ejection fraction and left ventricular function occurred within 1 year of repair. Improvements in mitral regurgitation lagged behind normalization of ejection fraction and left ventricular dilatation. CONCLUSIONS: Anatomic repair of anomalous left coronary artery from the pulmonary artery by aortic reimplantation yields excellent early survival and late functional outcomes even in critically ill infants.     

Factors affecting mitral valve reoperation in 317 survivors after mitral valve reconstruction.

From a very heterogeneous group of 340 patients undergoing mitral valve reconstruction from 1969 through 1988, 313 hospital survivors were analyzed for factors affecting the occurrence of reoperative mitral valve procedures related to native mitral valve dysfunction. Follow-up was 100% and extended from 1 year to 20 years (mean follow-up, 7.2 years). Sixty-three patients (18.5% of the 340) required mitral valve reoperation at a mean postoperative interval of 6 years (range, 1 to 15 years). Incremental risk factors analyzed for the event late mitral valve failure included age, sex, preoperative New York Heart Association class, cause of valvular disease, pathophysiology of the mitral valve, previous mitral valve operation, mitral valve pathology, and estimation of mitral valve function at operation after repair. Mitral valve pathophysiology affected the actuarial freedom from mitral valve replacement (p = 0.023 [log-rank]). Actuarial freedom from mitral valve reoperation was 90% at 5 years and 80% at 8 years in patients who had either pure mitral regurgitation or isolated mitral stenosis compared with 80% and 72% at 5 and 10 years, respectively, in patients who had mixed mitral stenosis and regurgitation (p = 0.023). Patients undergoing late reoperation were younger (51.7 +/- 1.56 years [+/- the standard error of the mean]) than those not having reoperation (p less than 0.0003). Durability of the repair was less in patients with rheumatic heart disease (p less than 0.025) and greater in patients with ischemic heart disease (p less than 0.004). Seventy-three percent of patients undergoing reoperation had concomitant operations compared with 68% of those not having reoperation (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)     

Evolving techniques for mitral valve reconstruction

OBJECTIVE: To analyze the effectiveness of new techniques of mitral valve reconstruction (MVR) that have evolved over the last decade, such as aggressive anterior leaflet repair and minimally invasive surgery using an endoaortic balloon occluder. SUMMARY BACKGROUND DATA: MVR via conventional sternotomy has been an established treatment for mitral insufficiency for over 20 years, primarily for the treatment of patients with posterior leaflet prolapse. METHODS: Between June 1980 and June 2001, 1,195 consecutive patients had MVR with ring annuloplasty. Conventional sternotomy was used in 843 patients, minimally invasive surgery in 352 (since June 1996). Anterior leaflet repair was performed in 374 patients, with increasing use over the last 10 years. Follow-up was 100% complete (mean 4.6 years, range 0.5-20.5). RESULTS: Hospital mortality was 4.7% overall and 1.4% for isolated MVR (1.1% for minimally invasive surgery vs. 1.6% for conventional sternotomy; =.4). Multivariate analysis showed the factors predictive of increased operative risk to be age, NYHA functional class, concomitant procedures, and previous cardiac surgery. The 5-year results for freedom from cardiac death, reoperation, and valve-related complications among the 782 patients with degenerative etiology are, respectively, as follows ( >.05 for all end points): for anterior leaflet repair, 93%, 94%, 90%; for no anterior leaflet repair, 91%, 92%, 91%; for minimally invasive surgery, 97%, 89%, 93%; and for conventional sternotomy, 93%, 94%, 90%. CONCLUSIONS: These findings indicate that late results of MVR after minimally invasive surgery and after anterior leaflet repair are equivalent to those achievable with conventional sternotomy and posterior leaflet repair. These options significantly expand the range of patients suitable for mitral valve repair surgery and give further evidence to support wider use of minimally invasive techniques.     

Reoperations for valve surgery: perioperative mortality and determinants of risk for 1,000 patients, 1958-1984

One thousand consecutive cardiac reoperations for valve surgery in 897 patients were reviewed to determine in-hospital mortality and indicators of risk. Subgroups based on the number of previous cardiac procedures and the valve or valves replaced or repaired at reoperation (aortic valve, mitral valve, tricuspid valve, or multiple valves and mortality [deaths/number of procedures (% mortality)]) for those subgroups are as follows: (Table: see text) Predictors of increased risk for a first aortic valve reoperation were advanced age (p = .0002), endocarditis (p = .0018), female sex (p = .014), impaired left ventricular function (p = .039), and number of coronary vessels obstructed by 70% or more (p = .055). For a first mitral valve reoperation, the predictors were advanced age (p less than .0001), preoperative shock or cardiac arrest (p = .01), previous aortic or tricuspid valve operations (p = .02), type of mitral valve procedure (risk for repair of periprosthetic leak was greater than mitral valve replacement which was greater than mitral valve-conserving operation [p = .05]), and impaired left ventricular function (p = .059). For a first multiple valve reoperation, the predictors were diabetes (p = .04) and ascites (p = .02), whereas patients undergoing mitral valve replacement and tricuspid valve operations were at decreased risk (p = .01). Comparison of second reoperations with first reoperations indicates risk increases for multiple operations (p = .01) but not for aortic or mitral valve procedures. Rereplacement of a prosthesis (p = .007), coronary bypass grafting at reoperation (p = .006), and advanced age (p = .06) increased the risk for second reoperations. Age is the most consistent predictor of risk for patients undergoing valve reoperations.     

Predictors of outcome in a multicenter port-access valve registry

BACKGROUND: The aim of this study was to examine the predictors of outcome in patients undergoing isolated valve operation using port-access techniques. METHODS: Logistic regression analysis was performed in a prospective, multi-institutional registry of patients undergoing isolated aortic valve replacement (AVR, n = 252), mitral repair (MVP, n = 491), or mitral replacement (MVR, n = 568) using port-access techniques from 1997 to 1999. RESULTS: Endoaortic balloon occlusion was used in 2% (AVR), 93% (MVP), and 90% (MVR) of cases. Conversion to full sternotomy occurred in 3.8% of all cases. For all patients, early mortality was 50 of 1,311 (3.8%) and onset of new atrial fibrillation occurred in 140 of 1,311 (11%) patients. The determinants of 30-day mortality were redo, age, and MVR or AVR. The determinants of reoperation for bleeding were age, reoperation, and MVR. Age was a predictor for stroke, and age and low or medium volume center were predictors of new atrial fibrillation. CONCLUSIONS: Excellent short-term results can be obtained using port-access techniques in isolated mitral or aortic valve operations. Patient outcome is not related to institutional case volume, and the primary determinants of outcome after port-access valve procedures are generally patient-related factors.     

Mitral valve repair in the elderly: operative risk for patients over 70 years of age is acceptable

AIM: Mitral valve repair for degenerative disease is widely accepted. Because of low risk and excellent late outcomes, surgical intervention is recommended increasingly early when repair appears possible. The place of repair vis a vis continued medical therapy in the elderly, however, is less well defined as there are scant data on their surgical risk. We reviewed our recent results with mitral valvuloplasty for degenerative disease with attention to the influence of age. METHODS: Thirty-day results of mitral valvuloplasty for degenerative disease between January 1996 and April 2000 were examined retrospectively. Patients with ischemic etiology were excluded. Results among those over age 70 years were compared with younger patients. RESULTS: Of 140 patients (78 men and 62 women) aged 27 to 91 (mean 62+/-13) years (44 gs;70 years of age), 61 underwent isolated mitral valvuloplasty, 71 mitral valvuloplasty and coronary artery bypass, and 8 mitral valvuloplasty with other procedures. By multivariate analysis preoperative cardiogenic shock (0.001), but not age, was as a risk factor for death. Among patients stratified by age gs; or <70, there were differences in atrial fibrillation (47.7% vs 29.2%, p=0.03), prolonged ventilation (31.8% vs 15.6%, p=0.03) and hospital stay (median 9.5, range 5-285 vs median 6.5, range 2-36, p=0.001), but not 30-day readmission (15.9% vs 22.9%) or death (5.2% vs 9.1%, p=0.49). CONCLUSION: Operative results for mitral valvuloplasty in the elderly are acceptable. Surgery should not be withheld on the basis of age alone.     

Impact of MitraClip™ therapy on secondary mitral valve surgery in patients at high surgical risk

Objective: Conventional or minimally invasive surgical mitral valve repair (MVR) is the gold-standard treatment for severe mitral regurgitation (MR) of any etiology. Given its good safety profile, trans-catheter MVR with the MitraClip™ device is used increasingly for high-risk or inoperable patients. We report our experience with failed MitraClip™ therapy and its impact on subsequent surgical strategies, such as the feasibility of MVR in high-risk patients. Methods: During a follow-up of 344 ± 227 days from the first 215 consecutive patients treated with the MitraClip™ device, six patients required surgical re-intervention due to failed repair (n = 3) or recurrent severe MR (n = 3) at 35.8 ± 47.7 (range 0–117) days after trans-catheter MVR. Feasibility of secondary surgical MVR was assessed with regard to prior clip therapy. Results: In three patients, secondary surgical MVR was successfully performed following the surgical strategy deemed optimal before trans-catheter treatment. Injury of the mitral leaflets caused by prior clip treatment was present in three other patients and influenced the surgical strategy toward more complex surgical techniques in one case and MV replacement in two others. One patient died 6 days after MV replacement. All other patients are alive with adequate valve function at the latest follow-up of 12.4 ± 7.4 months (range 4–22). Conclusions: Secondary surgical MVR was feasible in some patients after prior clip treatment, but led to valve replacement in others. At present, patient selection criteria for trans-catheter MVR should not be expanded toward more healthy patients, as primary trans-catheter MVR may complicate secondary surgery in certain cases and may even preclude reconstructive valve surgery.     

Outcome after mitral valve repair for acute and healed infective endocarditis.

OBJECTIVE: To evaluate the long-term clinical and echocardiographic outcomes after mitral valve surgery for acute and healed infective endocarditis. METHODS: Of 37 consecutive patients presenting with native mitral valve endocarditis, mitral valve repair (MVRep) was feasible in 34 (92%) patients. In 17 (50%) patients, surgery was indicated during antibiotic therapy (acute endocarditis), whereas 17 (50%) underwent surgery after antibiotic therapy was completed (healed endocarditis). Patients were evaluated for early and long-term clinical and echocardiographic outcome. RESULTS: In-hospital death occurred in two (6%) patients and two (6%) died during follow-up, with a 2-year survival of 100% in healed endocarditis as compared to 76% (p=0.03) in patients undergoing surgery in acute endocarditis. No patient with acute endocarditis needed repeat mitral valve surgery. Three (9%) patients underwent re-operation because of early mitral regurgitation (n=1) or late recurrent endocarditis (n=2). The average grade of mitral regurgitation was 3.8+/-0.4 (all grades 3 to 4+) before surgery and 0.6+/-0.8 during follow-up (p<0.001). Significant reductions in left atrial (from 52+/-8mm to 46+/-8mm, p=0.004), left ventricular end-diastolic (from 61+/-8mm to 54+/-8mm, p=0.001), and end-systolic dimensions (from 41+/-8mm to 36+/-9 mm, p=0.02) were observed during follow-up, compared to preoperative dimensions. Of note, significant reverse remodeling was only observed in patients undergoing surgery in healed endocarditis. CONCLUSION: MVRep for mitral valve endocarditis is feasible with good clinical results, maintained valve competency with significant reductions in left atrial and left ventricular dimensions after surgery.     

Influence of systemic lupus erythematosus on procedure selection and outcomes of patients undergoing isolated mitral valve surgery

Abstract Background: Cardiovascular disease is the main cause of morbidity and mortality in patients with systemic lupus erythematosus (SLE). SLE as a risk factor for adverse outcomes during mitral surgery has not been studied. The purpose of this investigation was to compare procedure selection and outcomes of patients with and without SLE. Methods: The 2005–2008 Nationwide Inpatient Sample database was searched to identify patients ≥18 years of age undergoing isolated mitral repair or replacement. Patients with and without SLE were compared on baseline characteristics and hospital outcomes. Within patients with SLE, those undergoing repair and replacement were compared. Results: SLE patients comprised 0.9% (620/70,969) of the isolated mitral valve surgery population. Patients with SLE were significantly younger, more likely to be female, less likely to be white, had higher Charlson comorbidity index, and less often presented electively. Patients with SLE had a higher incidence of prolonged hospitalization (LOS > 10 days; 44.4% vs. 34.7%, p = 0.0392). Mortality was similar for patients with and without SLE undergoing isolated mitral valve surgery (OR = 0.76, 95% CI 0.28–2.05, p = 0.5821). Patients with SLE were less likely to have mitral valve repair (27.1% vs. 45.6%, p = 0.0002). Baseline characteristics were similar between SLE repair and replacement subsets. Median LOS was higher for replacement (10 days vs. 7 days, p = 0.0014). Hospital mortality was 0% for SLE mitral repair patients and <4.0% for SLE replacement patients. Conclusions: Patients with SLE present for isolated mitral valve surgery at a much younger age and with worse preoperative profiles. Although mitral repair rates were lower in patients with SLE, hospital outcomes were excellent, and comparable to those of patients without SLE. (J Card Surg 2012;27:29–33)     

Mitral valve surgery for patients after undergoing percutaneous transvenous mitral commissurotomy (PTMC)--investigation on indication of PTMC based on the intraoperative findings]

Ten patients underwent open heart surgery for mitral valve after PTMC because of post PTMC MS (n = 4) and MR (n = 6) out of 150 patients undergoing PTMC in our hospital between June 1987 and October 1991. Intraoperative findings of 4 patients with residual mitral stenosis included severe thickening, stiffening and calcification on anterior and posterior leaflets, commissures and subvalvular apparatus. Mitral valve repair was possible in 2 and mitral valve replacement (MVR) was necessary in the other 2. In all 6 cases who massive mitral regurgitation after PTMC, in repairable tears in the mitral leaflets necessitated MVR. Since in these cases changes in the leaflets were less severe than those of the commissures or subvalvular apparatus, surgical repair could have been possible if open mitral commissurotomy (OMC) was done primarily. Patients selection for PTMC versus OMC based on precise morphological evaluation of mitral valve would reduce occurrence of massive MR resulting in surgical replacement.     

A Nationwide Survey of Surgical Treatment for Severe Ischemic Mitral Regurgitation

Objective: Mitral subvalvular procedures in addition to restrictive annuloplasty are promising for ischemic mitral regurgitation (IMR). However, the prevalence and efficacy of specific subvalvular repair in severe IMR have not been elucidated. This is the first nationwide survey regarding surgeons’ attitudes toward IMR in Japan.Methods: A questionnaire was sent to 543 institutions. From 2015 to 2019, numbers of elective first-time mitral valve replacement (MVR) with/without complete chordal preservation (CCP)/papillary muscle approximation (PMA) and mitral valvuloplasty (MVP) with/without papillary muscle relocation (PMR)/PMA in patients with severe IMR were collected. Concomitant procedures for coronary artery, tricuspid valve, and arrhythmia could be included but left ventricular reconstruction was excluded.Results: Completed questionnaires were received from 286 institutions (52.7%). The majority (90%) had less than 20 cases within 5 years. The number of MVP (1413, 61.5%) surpassed MVR (886, 38.5%). CCP was performed in half of MVR (50.0%), while PMA was included in only 1.9% of MVR. PMA and PMR were also performed infrequently, in only 7.7% and 10.9% of MVP, respectively.Conclusion: Japanese surgeons aggressively perform MVP for severe IMR. Subvalvular repair was also aggressively performed in addition to MVR, but not to MVP. A multicenter registry study is in progress.