Prognosis for Mitral Valve Repair Surgery in Functional Mitral Regurgitation

Purpose: Our aim was to evaluate the development of new significant mitral regurgitation and long-term survival after mitral repair surgery in functional mitral regurgitation.Methods: A retrospective observational analysis of the recurrence of functional mitral regurgitation (ischemic and nonischemic) and global mortality during follow-up of 176 patients who underwent mitral repair surgery between 1999 and 2018 in our center was conducted.Results: The etiology of functional mitral regurgitation was ischemic in 55.7% of cases. After surgery, mitral regurgitation was 0-I in 92.3% of cases. We conducted a long-term clinical follow-up of a mean 42.2 months and an echocardiographic follow-up of a mean 41.8 months. We observed mitral regurgitation of at least grade II in 52 patients (36.9%). Survival at 1, 3, and 5 years was 78.8%, 66.7%, and 52.3%, respectively. Predictive factors for global mortality were age (hazard ratio = 1.038, p = 0.01) and a depressed preoperative ejection fraction. After a competing risk analysis, we found the only predictive factor for the recurrence of mitral regurgitation in our series to be age (sub-hazard ratio = 1.03, 95% confidence interval = 1.01–1.06, p = 0.016).Conclusion: Repair surgery for functional mitral regurgitation shows age as the only independent predictor of recurrence. Age and depressed ejection fraction were predictors of mortality.     

“缘对缘”二尖瓣成形术对左心室舒张功能的影响

目的探讨＂缘对缘＂二尖瓣成形术对术后左心室舒张功能的影响,以了解该成形方法的有效性及安全性。方法将2006年2月至2007年12月北京安贞医院收治的30例中至重度二尖瓣关闭不全患者,按手术方法不同分为两组,对照组：15例,二尖瓣后叶脱垂患者施行后叶楔形切除二尖瓣成形术;实验组：15例,前叶或双叶脱垂患者施行＂缘对缘＂二尖瓣成形术;所有患者均用二尖瓣成形环（Medtronic成形环）成形。用漂浮Swan-Ganz导管监测术前、术毕、术后2 h、4 h、6 h和12 h的血流动力学变化。术前和术后1周,运用脉冲多普勒、组织多普勒测定患者左心室舒张功能指标,包括术前和术后左心室舒张峰值血流速度E峰与A峰的比值（E/A）,舒张期E峰血流速度与舒张早期二尖瓣环的最大运动速度的比值（E/Em）,舒张早期二尖瓣环的最大运动速度与舒张晚期二尖瓣环的最大运动速度的比值（Em/Am）。结果两组患者二尖瓣成形二尖瓣瓣口面积均较本组术前明显减小（对照组3.63±1.06 cm2vs.7.18±2.41 cm2;实验组3.44±1.02 cm2vs.6.51±3.06 cm2;P〈0.05）,二尖瓣反流均较本组术前明显减少（对照组0.53±0.64 cm2vs.3.60±0.51 cm2;实验组0.67±0.82 cm2vs.3.40±0.63 cm2,P〈0.05）;但术前、术后两组间二尖瓣瓣口面积和二尖瓣反流比较差异无统计学意义（P〉0.05）。实验组术后E/A、E/Em和Em/Am与术前比较差异无统计学意义（E/A 1.28±0.36 vs.1.95±1.06;E/Em 8.79±2.16 vs.8.13±3.02;Em/Am 1.39±0.38 vs.1.31±0.41;P〉0.05）,两组间比较差异无统计学意义（P〉0.05）。实验组肺动脉楔压与对照组比较差异亦无统计学意义（13.60±4.37 mm Hg vs.12.20±3.53 mm Hg,P〉0.05）。结论＂缘对缘＂二尖瓣成形术效果良好,对左心室舒张功能无明显影响,双孔二尖瓣具有与正常二尖瓣相似的的血流动力学特征。     

The Impact of Preoperative and Postoperative Pulmonary Hypertension on Long-Term Surgical Outcome after Mitral Valve Repair for Degenerative Mitral Regurgitation

Purpose: The aim of this study is to elucidate the impact of preoperative and postoperative pulmonary hypertension (PH) on long-term clinical outcomes after mitral valve repair for degenerative mitral regurgitation.Methods: A total of 654 patients who underwent mitral valve repair for degenerative mitral regurgitation between 1991 and 2010 were retrospectively reviewed. Patients were divided into PH(+) group (137 patients) and PH(–) group (517 patients). Follow-up was complete in 99.0%. The median follow-up duration was 7.5 years.Results: Patients in PH(+) group were older, more symptomatic and had higher tricuspid regurgitation grade. Thirty-day mortality was not different between 2 groups (p = 0.975). Long-term survival rate was lower in PH(+) group; 10-year survival rate after the operation was 85.2% ± 4.0% in PH(+) group and 89.7% ± 1.8% in PH(–) group (Log-rank, p = 0.019). The incidence of late cardiac events were not different between groups, however, the recurrence of PH was more frequent in PH(+) group. The recurrence of PH had an adverse impact on survival rate, late cardiac events and symptoms. Univariate analysis showed age and preoperative tricuspid regurgitation grade were the predictors of PH recurrence.Conclusion: Early surgical indication should be advocated for degenerative mitral regurgitation before the progression of pulmonary hypertension and tricuspid regurgitation.     

Concomitant Mitral Regurgitation in Patients Undergoing Surgical Aortic Valve Replacement for Aortic Stenosis: A Systematic Review

Background: Concomitant mitral regurgitation (MR) is frequently seen in patients undergoing surgical aortic valve replacement (AVR) for severe aortic stenosis (AS). When the severity of MR is moderate or less, the decision to undertake simultaneous mitral valve intervention can be challenging.Methods: A systematic search of Medline, PubMed (NCBI), Embase and Cochrane Library was conducted to qualitatively assess the current evidence for concomitant mitral valve intervention for MR in patients with AS undergoing AVR. The primary outcome for this systematic review was the postoperative change in the severity of MR and other outcomes of interest included factors that predict improvement or persistence of MR and long-term impacts of residual MR.Results: A total of 17 studies were included. The percentage of patients demonstrating improvement in MR severity following AVR ranged from 17.2% to 72%; the studies that exclusively included patients with moderate functional MR and reported longer term echocardiographic follow-up of greater than 12 months demonstrated an improvement in MR severity of 45% to 72%.Conclusion: This systematic review demonstrates that a proportion of patients can exhibit an improvement in MR following isolated surgical AVR, but whether this confers any long-term morbidity and mortality benefit remains unclear.     

Repair of Delayed Left Ventricular Rupture After Mitral Valve Replacement: Report of a Case

Rupture of the left ventricle (LV) after mitral valve replacement (MVR) is a devastating complication, associated with high mortality. A 64-year-old woman with a type I delayed LV rupture, which occurred after MVR with a 27-mm St. Jude Medical mitral prosthesis for mitral stenosis, was successfully treated by a combination of intracardiac and extracardiac surgical repair techniques. The extracardiac repair involved approximating the edges of myocardium around the tear with large sutures bolstered by strips of Teflon felt, then covering the epicardial hematoma with another porcine pericardial patch, using gelatin resorcinol formaldehyde glue and collagen sheets. The intracardiac repair involved suturing the edges of an oval piece of porcine pericardium to the endocardium around the laceration. No LV pseudoaneurysm was detected postoperatively on echocardiography or computed tomography scans. The patient is well 2 years after the operation.     

Surgical Strategy for Ischemic Mitral Regurgitation Adopting Subvalvular and Ventricular Procedures

Purpose: The progression of left ventricular (LV) remodeling and subsequent mitral valve tethering impair the results of reduction annuloplasty for ischemic mitral regurgitation (MR).Methods: We studied 90 patients who underwent surgical repair of ischemic MR between 1999 and 2013 according to our surgical strategy adding submitral and ventricular procedures to annuloplasty as follows: annuloplasty alone (stage 1, n = 30), additional papillary muscle approximation (PMA) for progression of tethering (stage 2, n = 26), and additional left ventriculoplasty with PMA for progression of LV remodeling and tethering (stage 3, n = 34).Results: The preoperative New York Heart Association (NYHA) functional classes (2.5 ± 0.7, 3.1 ± 0.7 and 3.3 ± 0.7 for stages 1, 2 and 3, respectively, P <0.001), LV end-diastolic diameters (56 ± 7 mm, 66 ± 5 mm and 70 ± 7 mm, P <0.001), and LV ejection fractions (45 ± 12%, 32 ± 9% and 27 ± 9%, P <0.001) significantly differed among the stages. In contrast, the MR grades did not significantly differ (2.9 ± 0.8, 3.0 ± 1.0, and 2.9 ± 1.1, respectively; P = 0.93). Both the rates of cardiac-related survival and freedom from reoperation were comparable among the 3 groups (log-rank P = 0.92 and 0.58, respectively).Conclusion: Additional submitral and ventricular procedures can compensate for the possible impairment of the outcomes after annuloplasty alone for ischemic MR in patients with severe LV remodeling and tethering.     

Clinical Outcomes of a Customized Mitral Valve Plasty for Functional Mitral Regurgitation with a Low Ejection Fraction and Implications for Preoperative Right Ventricular Function

Purpose: To evaluate clinical outcomes of customized mitral valve plasty (MVP) for the treatment of functional mitral regurgitation (FMR) with a low ejection fraction (EF) and to determine which preoperative factors affected the clinical outcome.Methods and Results: MVP was adjusted according to the degree of left ventricle (LV) remodeling. We performed mitral annuloplasty (MAP) alone in 14 patients and added subvalvular procedures (SVPs) in 22 patients at a high risk of recurrent MR. During follow-up, reverse LV remodeling was obtained and the 3-year and 5-year non-recurrence rates of MR grade ≥2 were 94% and 89%, respectively. Two patients died during their hospital stay, and four more patients died of cardiac causes during follow-up. The 3-year and 5-year rates of freedom from cardiac-related mortality were 86% and 81%, respectively; no significant difference was observed between the two treatment groups. Right ventricular fractional area change (RVFAC) was a significant predictor of cardiac mortality. Patients with an RVFAC of <26% had significantly poorer cardiac-related mortality (71% at 3 years) than those with an RVFAC of ≥26% (95% at 3 years).Conclusion: Customized MVP provided durable mitral competence and reverse LV remodeling. Preoperative RV function was associated with cardiac-related mortality.     

二尖瓣置换术后左心室破裂的预防及治疗

目的分析二尖瓣置换术后左心室破裂发生的基本情况、转归及经验教训,探讨进一步提高诊治技术的方法及目前面临的困难。方法复习上海长海医院1990年1月~2008年12月期间4 489例接受二尖瓣置换及二尖瓣、主动脉瓣联合置换手术患者的临床资料,共有14例（0.3%）发生术后左心室破裂。其中早期破裂6例,延迟性破裂8例,Ⅰ型破裂1例,Ⅱ型破裂5例,Ⅲ型破裂8例。早期破裂6例,均在体外循环心脏停跳下进行修补,3例采用单纯心外缝合修补,3例采用心内及心外联合修补方法。延迟性破裂8例,均在监护室紧急开胸探查证实诊断,6例在床边缝合修补,2例暂时控制出血后回手术室修补,修补方式均为单纯心外修补。7例（50.0%）1次修补成功,因修复难度较大导致4例（28.6%）进行了2次修补,3例（21.4%）进行了3次及以上修补。结果 12例死亡,2例存活,存活者均为早期破裂患者,且均为采用心内及心外联合修补法的患者。结论对于左心室破裂的防治目前仍以预防为主,早期性破裂患者可综合应用多种方法提高治疗成功率,延迟性破裂者生存率极低,是目前治疗上面临的主要难题,尽早控制出血并恢复重要器官的血流灌注为改善预后的关键。     

Mitral valve repair for severe mitral valve regurgitation during left ventricular assist device implantation

Background

The management of severe mitral regurgitation (MR) at the time of left ventricular assist device (LVAD) implantation is controversial. We adopted an approach of systematic repair of severe MR at the time of LVAD implantation and report our experience.

全保留二尖瓣及瓣下结构在重症二尖瓣关闭不全患者二尖瓣置换术中的应用

目的探讨全保留二尖瓣及瓣下结构在重症二尖瓣关闭不全患者二尖瓣置换术中的应用经验,评价其临床效果。方法回顾性分析2011年6月至2013年1月在广东省人民医院心血管外科因重症二尖瓣关闭不全行全保留二尖瓣及瓣下结构二尖瓣置换术17例患者的临床资料,其中男14例,女3例;年龄38~82（63.41±11.82）岁;合并心房颤动13例;术前纽约心脏学会（NYHA）心功能分级Ⅲ级5例,Ⅳ级12例;缺血性二尖瓣关闭不全7例,退行性二尖瓣关闭不全9例,风湿性二尖瓣关闭不全1例。结果所有患者均行全保留二尖瓣及瓣下结构的二尖瓣置换术,同期行冠状动脉旁路移植术4例;其中生物瓣11例,机械瓣6例。全组患者住院期间无死亡,均顺利出院,住院期间未并发低心排血量综合征,无左心室破裂。17例患者均随访,随访时间2~25（16.44±5.02）个月。随访期间1例患者因术后2个月发生二尖瓣重度瓣周漏死亡。其余患者人工二尖瓣功能良好,无抗凝和瓣膜引起的并发症,心功能较术前明显改善,心功能NYHA分级恢复至Ⅰ级11例,Ⅱ级4例,Ⅲ级1例。术后早期及随访期间心胸比率、左心房内径、左心室舒张期末内径及收缩期末内径与术前相比均明显减小。而术后早期左心室射血分数（LVEF）与术前相比有所降低[（50.94%±8.78%）vs.（55.31%±10.44%）,P=0.04],术前LVEF与随访期间的差异无统计学意义[（55.31%±10.44%）vs.（56.13%±9.67%）,P=0.73],随访期间LVEF与术后早期相比显著增加[（56.13%±9.67%）vs.（50.94%±8.78%）,P=0.02]。术后早期与随访期间人工二尖瓣压力减半时间（PHT）差异无统计学意义[（95.06±19.00）ms vs.（94.56±19.19）ms,P=0.91]。结论全保留二尖瓣及瓣下结构在重症二尖瓣关闭不全患者二尖瓣置换术中应用安全有效,可以改善左心室重构及术后心功能。     

二尖瓣前叶脱垂个性化成形67例临床分析

目的分析二尖瓣成形术矫治二尖瓣前叶脱垂的近、远期疗效,总结其临床经验。方法2002年1至2013年6月北京安贞医院心脏外科应用“缘对缘”成形、人工腱索、腱索缩短、“缘对缘”腱索转移法等各种成形击治疗二尖瓣前叶脱垂共67例,其中男41例、女26例,年龄18～71（46．34±7．68）岁,体重43～91（65．30±18．60）．术前心功能分级（NYHA）Ⅱ级5例,Ⅲ级27例,Ⅳ级35例。腱索断裂46例,腱索延长21例。二尖瓣反流面（15．36±4．53）cm^2,术前左心室射血分数29％～71％。所有患者出院前、术后6个月及以后每1～2年再次行超声心动图检查,以观察二尖瓣成形术矫治二尖瓣前叶脱垂的近、远期疗效。结果 围术期无死亡。除1例患者术后第3d出现瓣膜穿孔,1例术后6个月因成形环撕脱导致血红蛋白尿,再次行心瓣膜成形术外,其余患者均无需二次手术。随访67例,随访率100％,随访时间2～138（65．6±17.3）个月。随访期间无死亡,术后心功能分级（NYHA）全部恢复至Ⅰ级。术后复查超声心动图二尖瓣瓣口面积2_3～4：8（3．63±0．79）cm^2,均无明显反流,反移积（O．574±0．37）cm^2,术后左心房内径[（38．23±11．56）mm vs．（49．26±10．36）mm,P〈0．05]、左心室舒张期末p[（43．35±13．74）mm vs．（64．29±12．54）mm,P〈0．05]较术前明显缩小。结论几乎所有二尖瓣前叶脱垂患{可以通过个性化二尖瓣成形手术治疗获得良好的手术效果。     

Cardiac Valve Calcifications and Left Ventricular Hypertrophy in Hemodialysis Patients

Cardiac valve calcification (VC) is a common finding in end-stage renal disease patients. It was shown recently that VC is an independent predictor for all-cause and cardiovascular mortality in peritoneal dialysis patients. In hemodialysis (HD) patients, VC was associated with all-cause and cardiovascular mortality, but after adjusting for other cardiovascular risk factors and complications, as well as left ventricular mass index (LVMI), it lost significance. The aim of the study was to assess the relationship between VC and left ventricular hypertrophy in hemodialysis patients. Echocardiographic examination with mitral and aortic valves assessment and LVMI calculation was performed in 65 HD patients ages 49 ± 12, with duration of HD therapy 38 ± 32 months. VC were found in 32 of 65 patients (49%)—Group VC(+), mitral valve calcifications (MVC) in 10, aortic valve calcifications (AVC) in 9, and both valves calcifications (MVC + AVC) in 13 patients. Patients with VC were older, on HD therapy were longer, had higher systolic and pulse pressure, and had higher LVMI. Patients with both VCs had the highest LVMI. No significant differences were found with respect to Ca, P, PTH, and mean Ca × P product, but the incidence of Ca × P product above 4.43 mmol²/L² was higher in VC(+) compared with those without VCs. VC coexists with left ventricular hypertrophy, particularly when both valves are calcified. Even short-lasting incidents of increased Ca × P product may lead to cardiac VC.