Mitral valve repair for broad, asymmetrical prolapse in the posterior mitral leaflet

We designed a mitral valve repair and successfully performed this repair for a case of broad, asymmetrical prolapse in the middle scallop of the posterior mitral leaflet. The repair procedure consists of making a fan-shaped leaflet by resecting the prolapsed portion in a trapezoid shape with detachment of the leaflet along the annulus and leaflet reapproximation by rotating this fan-shaped leaflet. This technique can utilize more leaflet tissue for filling the gap made by leaflet resection than the quadrangular resection and suture technique. As a result, it helps reduce tension on the suture lines, avoids the need for extensive annular plication, and also avoids leaflet distortion while making it easier to adjust the height of the leaflets that should be reapproximated. The essence of this mitral valve repair exists in the “resecting line of the leaflet,” which has not yet been reported.     

Patient-reported outcome measures after mitral valve repair: a comparison between minimally invasive and sternotomy

OBJECTIVESTo compare patient-reported outcome measures of minimally invasive (MI) to sternotomy (ST) mitral valve repair.Open in a separate windowMETHODSWe included all patients undergoing isolated mitral valve surgery via either a right mini-thoracotomy (MI) or ST over a 36-month period. Patients were asked to complete a modified Composite Physical Function questionnaire. Intraoperative and postoperative outcomes, and patient-reported outcome measures were compared between 2 propensity-matched groups (n = 47/group), assessing 3 domains: ‘Recovery Time’, ‘Postoperative Pain’ (at day 2 and 1, 3, 6 and 12 weeks) and ‘Treatment Satisfaction’. Composite scores for each domain were subsequently constructed and multivariable analysis was used to determine whether surgical approach was associated with domain scores.RESULTSThe response rate was 79%. There was no mortality in either group. In the matched groups, operative times were longer in the MI group (P < 0.001), but postoperative outcomes were similar. Composite scores for Recovery Time [ST 51.7 (31.8–62.1) vs MI 61.7 (43.1–73.9), P = 0.03] and Pain [ST 65.7 (40.1–83.1) vs MI 79.1 (65.5–89.5), P = 0.02] significantly favoured the MI group. Scores in the Treatment Satisfaction domain were high for both surgical approaches [ST 100 (82.5–100) vs MI 100 (95.0–100), P = 0.15]. The strongest independent predictor of both faster recovery parameter estimate 12.0 [95% confidence interval (CI) 5.7–18.3, P < 0.001] and less pain parameter estimate 7.6 (95% CI 0.7–14.5, P = 0.03) was MI surgery.CONCLUSIONSMI surgery was associated with faster recovery and less pain; treatment satisfaction and safety profiles were similar.     

Benefits of robotically-assisted surgery for complex mitral valve repair

OBJECTIVESTo determine whether robotic mitral valve repair can be applied to more complex lesions compared with minimally invasive direct mitral valve repair through a right thoracotomy. Open in a separate windowMETHODSWe enrolled 335 patients over a 9-year period; 95% of the robotic surgeries were performed after experience performing direct mitral valve repair.RESULTSThe mean age in the robotic versus thoracotomy repair groups was 61 ± 14 vs 55 ± 11 years, respectively (P < 0.001); 97% vs 100% of the patients, respectively, had degenerative aetiologies. Repair complexity was simple in 106 (63%) vs 140 (84%), complex in 34 (20%) vs 20 (12%) and most complex in 29 (17%) vs 6 (4%) patients undergoing robotic versus thoracotomy repair, respectively. The average complexity score with robotic repair was significantly higher versus thoracotomy repair (P < 0.001). The robotic group underwent more chordal replacement using polytetrafluoroethylene and less resections. All patients underwent ring annuloplasty. Cross-clamp time did not differ between the groups, and no strokes or deaths occurred. More patients undergoing robotic repair underwent concomitant procedures versus the thoracotomy group (30% vs 14%, respectively; P < 0.001). The overall repair rate was 100%, with no early mortality or strokes in either group. Postoperative mean residual mitral regurgitation was 0.3 in both groups, and the mean pressure gradient through the mitral valve was 2.4 vs 2.7 mmHg (robotic versus thoracotomy repair, respectively; P = 0.031).CONCLUSIONSRobotic surgery can be applied to repair more complex mitral lesions, with excellent early outcomes.     

Ischemic mitral valve prolapse: mechanisms and implications for valve repair

Objective: The aim of this study was to assess the mechanisms of prolapse in ischemic mitral valve regurgitation (MR) and the techniques of valve repair. Methods: Out of 121 patients operated upon for ischemic MR, a prolapse was present in 44 patients (36.4%). The operation was performed emergently in four cases (9.1%) and electively in 40 patients (90.9%). Fifteen patients (34.1%) were operated upon within 60 days following acute myocardial infarction. Results: The diagnosis of prolapse had been overlooked by echography in five cases (11.4%). A commissural area was involved as the site of prolapse in 31 cases (70.4%). The mechanism of prolapse was a papillary muscle (PM) lesion in 38 cases (86.4%) (anterior PM: n=8, posterior PM n=36) or a chordal lesion in six cases (13.6%). PM injury was elongation (n=16), or rupture (total n=1, partial n=21, incomplete n=4). The operative technique was mitral valve repair with Carpentier's techniques in 42 cases (95.5%) or replacement in two cases (4.5%). Hospital mortality was 11.4% (n=4). The mean follow-up was to 44.7±29.6 months. Overall survival and freedom from reoperation were 68.3±9.0 and 89.9±5.7% at 5 years, respectively. Freedom from MR equal or > grade 2 was 69.7±9.5% at 5 years. Conclusions: The mechanisms of ischemic mitral valve prolapse were variable and tightly linked to the PM anatomy. A reliable mitral valve repair could be achieved in most cases with acceptable mid-term results.     

Limited right anterolateral thoracotomy for mitral valve surgery

Objective: There has been great enthusiasm in recent years to perform mitral valve surgery through small multiple incisions with the use of the Port Access technique. The procedure is costly, involves a relatively long training curve and leaves the patient with multiple scars in the chest and groin. We used a mini-thoracotomy technique for mitral valve patients and compared our results with the conventional technique. Methods: We randomized 100 consecutive patients presenting to our practice for mitral valve surgery between two groups. The first group (test group) consisted of 50 patients in which mitral valve surgery was performed via mini-right anterolateral thoracotomy approach. The control group (50 patients) underwent classical mitral valve surgery through median sternotomy. Standard aortic and bicaval cannulation with antegrade blood cardioplegia was adopted in both groups. Results: There was no statistical difference between the two groups preoperatively regarding their age, pathology, LV function and male/female ratio. Most of the patients had valve replacement except four in the test group and three in the control group. The incision in the test group was 12–15 cm long in the right submammary groove. Direct aortic cannulation, clamping and cardioplegia administration was achieved in all patients easily. The mean bypass time was slightly longer in the test group (64±12 min) when compared with the test group (59±11 min). The cross-clamp time was lower in the test group (27±8 min) when compared with the control group (31±9 min). There was no hospital mortality in both groups and there was one morbidity in the form of sternal infection in the control group. The mean hospital stay was similar for both groups (7±2 days). Conclusion: The cosmetic appearance in the test group was excellent and the patients’ wounds were scarcely apparent in the female patients. The study demonstrates the efficacy and safety of this older technique, with excellent cosmetic results and no additional cost or risk to the patients.     

微创手术治疗青少年腰椎间盘突出症的临床分析

目的探讨微创手术治疗青少年腰椎间盘突出症的临床疗效。方法回顾分析应用小切口微创手术治疗青少年腰椎间盘突出症21例。结果术后评分按照Nakai分级标准,优17例,良2例,可2例,差0例,手术优良率近90．5％。结论小切口微创手术治疗青少年腰椎间盘突出症具有组织创伤小、手术出血少、对脊椎稳定性破坏轻微、疗效确实等特点,是一种理想的临床手术方法。     

The upside-down technique.: A novel method to correct posterior leaflet prolapse

The upside-down technique is a method for ‘in situ’ secondary cordae transposition for posterior leaflet lesions. The segmental prolapse of the posterior leaflet is corrected by rotating the resected segment upside-down and reattaching it to the annulus and adjacent leaflet segments. As the procedure is completed, the original annular attachment becomes the new free edge. The secondary chords, originally positioned at the base of the segment, become primary chordae. It is indicated in all cases when quadrangular resection is not feasible such as in case of calcified annulus, posterior leaflet hypoplasia, or when the prolapsing portion is wide.     

Minimally invasive mitral valve surgery after failed transcatheter mitral valve repair in an intermediate-risk cohort

Open in a separate window OBJECTIVESAlthough clinical experience with transcatheter mitral valve interventions is rapidly increasing, there is still a lack of evidence regarding surgical treatment options for the management of recurrent mitral regurgitation (MR). This study provides guidance for a minimally invasive surgical approach following failed transcatheter mitral valve repair, which is based on the underlying mitral valve (MV) pathology and the type of intervention.METHODSA total of 46 patients who underwent minimally invasive MV surgery due to recurrent or residual MR after transcatheter edge-to-edge repair or direct interventional annuloplasty between October 2014 and March 2021 were included.RESULTSThe median age of the patients was 78 [interquartile range, 71–82] years and the EuroSCORE II was 4.41 [interquartile range, 2.66–6.55]. At the index procedure, edge-to-edge repair had been performed in 45 (97.8%) patients and direct annuloplasty in 1 patient. All patients with functional MR at the index procedure (n = 36) underwent MV replacement. Of the patients with degenerative MR (n = 10), 5 patients were eligible for MV repair after removal of the MitraClip. The 1-year survival following surgical treatment was 81.3% and 75.0% in patients with functional and degenerative MR, respectively. No residual MR greater than mild during follow-up was observed in patients who underwent MV repair.CONCLUSIONSMinimally invasive surgery following failed transcatheter mitral valve repair is feasible and safe, with promising midterm survival. The surgical management should be tailored to the underlying valve pathology at the index procedure, the extent of damage of the MV leaflets and the type of previous intervention.     

"缘对缘"二尖瓣成形术治疗二尖瓣前叶脱垂的早中期随访

目的 回顾性分析"缘对缘"二尖瓣成形术的早、中期效果.方法 1999年8月至2007年7月完成了128例"缘对缘"(edge to edge)二尖瓣成形术,分析其围术期及随访结果.结果 全组无手术死亡.平均随访46.8个月(1～97个月),无二次手术率96.9%,生存率98.4%.5例(3.9%)复发二尖瓣中、重度反流,其中4例(3.1%)行二尖瓣置换,1例早期缝线撕脱二次手术后死亡,1例拒绝二次手术而死亡.3例(2.3%)轻度二尖瓣狭窄,心功能Ⅰ级,仍在随访中.其余120例二尖瓣反流明显减轻(术前3.4对术后1.1,P＜0.05),心功能(NYHA)级别明显改善(术前2.4级对术后1.1级,P＜0.05).术后二尖瓣口面积平均为(2.45±0.70)cm2.左室舒张末径显著缩小[术前(57.9±9.0)mm对术后(48.6±7.6)mm,P＜0.05].术后左心室射血分数无明显改变(术前0.61±0.08对术后0.60±0.06,P=0.03).结论 "缘对缘"二尖瓣成形术是治疗二尖瓣前叶脱垂的安全、有效方法,早、中期效果良好.远期效果尚有待于进一步观察.     

Comparison of outcomes between minimally invasive and median sternotomy for double and triple valve surgery: A meta-analysis

Background

Limited data exists demonstrating the efficacy of minimally invasive surgery (MIS) compared to median sternotomy (MS) for multiple valvular disease (MVD). This systematic review and meta-analysis aims to compare operative and peri-operative outcomes of MIS vs MS in MVD.

Methods

PubMed, Ovid, and Embase were searched from inception until August 2019 for randomized and observational studies comparing MIS and MS in patients with MVD. Clinical outcomes of intra- and postoperative times, reoperation for bleeding and surgical site infection were evaluated.

Results

Five observational studies comparing 340 MIS vs 414 MS patients were eligible for qualitative and quantitative review. The quality of evidence assessed using the Newcastle-Ottawa scale was good for all included studies. Meta-analysis demonstrated increased cardiopulmonary bypass time for MIS patients (weighted mean difference [WMD], 0.487; 95% confidence interval [CI], 0.365-0.608; P < .0001). Similarly, aortic cross-clamp time was longer in patients undergoing MIS (WMD, 0.632; 95% CI, 0.509-0.755; P < .0001). No differences were found in operative mortality, reoperation for bleeding, surgical site infection, or hospital stay.

Conclusions

MIS for MVD have similar short-term outcomes compared to MS. This adds value to the use of minimally invasive methods for multivalvular surgery, despite conferring longer operative times. However, the paucity in literature and learning curve associated with MIS warrants further evidence, ideally randomized control trials, to support these findings.

     

Minimally invasive off-pump valve-in-a-ring implantation: the atrial transcatheter approach for re-operative mitral valve replacement after failed repair

Objective: Based upon recent developments in transcatheter technology, this study was designed to evaluate the feasibility and haemodynamic performance of transcatheter valve-in-a-ring (VinR) implantation for potentially failed mitral repair using a minimally invasive, transatrial, off-pump approach. Methods: Adult sheep (54.3 ± 3.0 kg) underwent mitral valve repair with a 26 mm complete annuloplasty ring (Physio™) using standard conventional techniques. To simulate the redo operation, a transcatheter 23 mm pericardial prosthesis (Edwards Sapien™) mounted on a balloon-inflatable steel stent was deployed within the annuloplasty ring. VinR implantation was performed off-pump under rapid pacing in four and on-pump in three animals using an antegrade transatrial approach under fluoroscopic guidance. Results: Transcatheter VinR implantation was successful in all seven sheep. Mean transvalvular gradient was 4.9 ± 0.3 mmHg. VinR function was excellent with no leak in one, good with mild leak in five (trans-stent: four, paravalvular: one) and sufficient with moderate central leak in one animal, respectively. Valve deployment required 10.0 ± 0.7 min and all transcatheter prostheses were confirmed in good position on postmortem analysis, without any signs of valve dislocation or embolisation. In an in-vitro model, the minimum force required to dislodge the valve was 32.9 ± 5.2 N, which was well above the normal estimated forces generated by the left ventricle. One animal was kept alive to assess mid-term outcome and is still well 12 months after the VinR implantation. Conclusions: Transatrial, transcatheter mitral VinR implantation is feasible using a minimally invasive off-pump approach. VinR implantation is a promising concept for re-operative surgery for selected patients after failed mitral valve repair.     

Development of a high-fidelity minimally invasive mitral valve surgery simulator

Objectives

The aim of this study was to develop a high-fidelity minimally invasive mitral valve surgery (MIMVS) simulator.

Superior septal approach for mitral valve surgery: a word of caution

Objective: Superior septal approach provides excellent exposure of the mitral valve and the subvalvular structures. The unavoidable section of the sinus node artery is in relationship with this technique. We have studied the electrical changes associated after using this approach. Material and Methods: We studied 247 cases of mitral valve surgery from 1996 to 2003. The patient population was divided into two comparative groups: group I (128 cases) was represented by the superior septal approach and group II (119 cases) composed the conventional right lateral approach through the left atrium. Preoperatively, 48 patients (37.5%) in group I and 46 (38.6%) in group II were in a normal sinus rhythm. Mean follow-up was 30.7 months in group I and 33.5 months in group II. Results: There was no mortality in group I and eight cases (6.7%) in group II. A high incidence of changes as junctional rhythm was observed in group I, especially after weaning of cardiopulmonary bypass and on the first day after surgery (P>0.001). Postoperative P–R interval of the patients in sinus rhythm was 100±30 ms in group I and 148±24 ms in group II (P>0.05). P–R interval in group I was shorter than normal. P-wave morphology changed becoming inverted in leads II, III and aVF after surgery in these cases in group I. A full recuperation in P–R interval and the P-wave axis was seen in 52 cases (87.5%) in patients in group I after the third postoperative month. A definitive pacemaker implantation was need in two cases (1.5%) in group I and in six (5%) in group II (P>0.05). Conclusions: A superior septal approach is directly related with the loss of normal sinus rhythm because of the section of the sinus node artery. After a brief period of transient electrical changes, a new low atrial or coronary sinus rhythm slower than normal sinus rhythm appears. In consequence, a word of caution must be strongly considered in patients critically dependent on normal sinus rhythm, despite the low incidence of definitive electrical changes. Normal sinus rhythm appears again after the third postoperative month.     

Transapical beating heart mitral valve repair versus conventional surgery: a propensity-matched study

Open in a separate window OBJECTIVESTransapical Neochordae implantation (NC) allows beating heart mitral valve repair in patients with degenerative mitral regurgitation. The aim of this single-centre, retrospective study was to compare outcomes of NC versus conventional surgical (CS) mitral valve repair.METHODSData of patients who underwent isolated mitral valve repair with NC or CS from January 2010 to December 2018 were collected. A propensity score matching analysis was performed to reduce confounding due to baseline differences between groups. The primary end point was overall all-cause mortality; secondary end points were freedom from reoperation, freedom from moderate (2+) and from severe (3+) mitral regurgitation (MR) and New York Heart Association functional class in the overall population and in patients with isolated P2 prolapse (type A anatomy).RESULTSPropensity analysis selected 88 matched pairs. There was no 30-day mortality in the 2 groups. Kaplan–Meier analysis showed similar 5-year survival in the 2 groups. Patients undergoing NC showed worse freedom from moderate MR (≥2+) (57.6% vs 84.6%; P < 0.001) and from severe MR (3+) at 5-year follow-up: 78.1% vs 89.7% (P = 0.032). In patients with type A anatomy, freedom from moderate MR and from severe MR was similar between groups (moderate: 63.9% vs 74.6%; P = 0.21; severe: 79.3% vs 79%; P = 0.77 in NC and FS, respectively). Freedom from reoperation was lower in the NC group: 78.9% vs 92% (P = 0.022) but, in type A patients, it was similar: 79.7% and 85% (P = 0.75) in the NC and CS group, respectively. More than 90% of patients of both groups were in New York Heart Association class I and II at follow-up.CONCLUSIONSTransapical beating-heart mitral chordae implantation can be considered as an alternative treatment to CS, especially in patients with isolated P2 prolapse     

Port-access atrium retractors for totally endoscopic mitral valve surgery: The Tornado Retractor, the Butterfly Retractor, and the Semiautomatic Butterfly Retractor

Introduction  We developed three types of new atrial retractors that facilitate totally endoscopic mitral valve surgery. Technique  Tornado Retractor: This retractor, which is made of rigid thick wire has a unique appearance, and can be inserted atraumatically through a 3-mm skin incision. Butterfly Retractor: This retractor consists of two parts: a rigid thick rod and foldable blades. When unfolded, the blades have a width of 35 × 55 mm, but they can be inserted thorough the 15-mm thoracoport when folded. Semiautomatic Butterfly Retractor: This retractor has a wired foldable blade and a specially designed rod containing a spring. It can be inserted when closed through the 15-mm thoracoport, and the blades can be opened and fixed automatically after being placed in the thoracic cavity, and the surgeon can remove it through the port easily. These retractors were evaluated in the totally endoscopic robotic mitral valve repairs with human fresh frozen cadavers using the da Vinci^TM Surgical System. Conclusion  All the retractors allowed easier access to the heart and provided superior mitral valve presentation without impinging on the robotic arms.