The long-term results of commissure plication annuloplasty for congenital mitral insufficiency.

BACKGROUND: Mitral valve repair in the pediatric population remains demanding because of a diversity of apparatus anomalies and the young age of the patients. METHODS: We reviewed our clinical results for mitral valve repairs for congenital mitral insufficiency. Forty-nine consecutive patients aged 2 months to 34 years (mean, 4.4 years) had mitral valve repair between June 1984 and December 1996. Forty-one patients (83.7%) had associated cardiac anomalies. The predominant pathologies for the regurgitations were chordal anomalies in 34 patients (69%), annular dilatation in 8 (16%), and leaflet anomalies in 7 (14%). Mitral valve repair included commissure plication annuloplasty in 43 patients (88%), modified DeVega in 11, cleft closure in 5, plication of the anterior leaflet in 3, triangular resection of the anterior leaflet in 2, chordal shortening in 1, and placement of artificial chordae in 1. Several combined techniques were required in 19 patients. RESULTS: There were no early or late deaths. The follow-up period was from 6 to 166 months (mean, 88.4 months). Forty-seven patients (95.9%) were in New York Heart Association class I. The long-term echocardiographic studies showed that 2 of 30 patients without reoperation had moderate regurgitation. The actuarial freedom from reoperation was 85.6% (95% confidence limits, 72.8%, 98.4%) at 13 years. Five patients (10.2%) required valve replacement from 13 days to 75 months after the valve repair. Two patients had cerebral ischemic events as a result of cardiomegaly and atrial fibrillation. CONCLUSIONS: Valve repair for congenital mitral insufficiency gave adequate results in combination with commissure plication annuloplasty and other techniques with excellent long-term functional status.     

Clinical results of commissure plication annuloplasty for mitral regurgitation in children

Purpose  We evaluated the clinical results of commissure plication annuloplasty for mitral regurgitation (MR) in children. Methods  Twenty-eight patients underwent a valve repair with commissure plication annuloplasty for MR from 1988 to 2005. The mean age was 2.7 ± 3.3 years. Several appropriate techniques were combined (cleft closure in 5 patients, chordal shortening in 2 patients, artificial chordal replacement in 4 patients, leaflet fixation in 2 patients, and so on). The mean follow-up period was 6.2 years. Results  There was one operative death (3.6%) and no late deaths. Two patients underwent a second repair 19 and 23 months after their initial repairs. The actuarial freedom from the reoperation rate was 90.4% ± 0.6% at 10 years. The freedom from moderate MR or more was shown to decrease over time, 87.8% ± 0.7% at 5 years and 78.0% ± 11.0% at 10 years. Furthermore, the 10-year freedom from mild MR or more was 56.5% ± 11.9%. A progression of MR was seen. Most of the residual or recurrent MR cases weighed less than 10 kg at operation. Conclusions  The combination of commissure plication annuloplasty and several appropriate techniques provided adequate results for MR in children. Since a progression of MR was observed, a careful follow-up is therefore needed in such cases.     

Late results of isolated mitral annuloplasty for "functional" ischemic mitral insufficiency

BACKGROUND: Repair of functional ischemic mitral regurgitation (MR) due to annular deformity and leaflet restriction remains a challenge for the surgeon and lacks well-documented outcomes. We investigated outcomes in the treatment of functional ischemic MR corrected by annuloplasty techniques alone. METHODS: From May 1980 to July 1999, 174 patients underwent repair for functional ischemic mitral insufficiency with annuloplasty alone (128 ring annuloplasty; 46 suture annuloplasty). Acute insufficiency was present in 25 (14.4%). Concomitant procedures included CABG (n = 152; 87.4%). Patients were studied longitudinally with annual follow-up and echocardiograms. RESULTS: Overall hospital mortality was 17.8% and was increased by NYHA Class 4 (23.8% vs. 8.7%; p = 0.011), diabetes (25.0% vs. 13.6%; p = 0.059), and chronic mitral insufficiency (16.4% vs. 8.0%; p = 0.070). Multivariate analysis revealed age (beta = 0.099; p = 0.049) and ejection fraction < 30% (beta = 1.260; p = 0.097) as significant predictors of hospital death. Mean postoperative mitral insufficiency was 0.84 +/- 0.86 (scale of 0-4). NYHA Class 4 (beta = 2.33; p = 0.034) and simple suture annuloplasty (beta = 2.08; p = 0.07) were associated with increased risk of late cardiac death. Cumulative incidence of mitral reoperation was 7.7% at 5 years. At follow-up, 89.7% of patients were in NYHA Class 1 or 2 with 83.4% having none or only mild mitral insufficiency. CONCLUSIONS: Ring annuloplasty is associated with a survival benefit when compared to simple suture repair in ischemic patients who require annuloplasty alone to correct the MR. Mitral reconstruction with a ring annuloplasty offers durable results in this homogeneous subset of functional ischemic MR patients. Ischemic mitral insufficiency is associated with significant late mortality.     

Early and late results of reconstructive operation for congenital mitral regurgitation in pediatric age group

Sixty-six children aged between 8 months and 15 years (average age 5.5 +/- 3.8 years) underwent mitral reconstructive operations for congenital mitral regurgitation between June 1969 and February 1987. The pathologic findings of the mitral valves were annular dilatation in 37 patients, cleft of the leaflet in eight, hypoplasia of the leaflet in 44, perforation of the leaflet in one, chordal elongation in 22, chordal absence in 16, and chordal shortening in seven. The methods of repair consisted of asymmetric annuloplasty (Kay-Reed method) in 61 patients, De Vega-type annuloplasty in one, plication of redundant leaflet in 15, and closure of cleft or perforation in nine. The single operative death (1.5%) was due to heart block. Follow-up data were available over 373.8 patient-years (average 5.7 years). The four late deaths (6.0%) were due to heart failure in two patients, pneumonia in one, and hepatitis in one. The actuarial survival rate was 93.1% +/- 3.1% at 7 years and 88.4% +/- 5.1% after 17 years. Valvuloplasty failed in 19 of the long-term survivors. One of these patients underwent mitral valve replacement 11 years after initial operation. The rate of freedom from reoperation was 86% +/- 10% after 17 years. The rate of freedom from valvuloplasty failure was 80% +/- 6.7% after 5 years, 67% +/- 7.2% after 10 years, and 44% +/- 11.9% after 15 years.     

后环缝缩矫正二尖瓣关闭不全

目的总结二尖瓣后环缝缩治疗二尖瓣关闭不全（ＭＩ）的临床经验。方法回顾近１０年采用后瓣环缝缩成形治疗ＭＩ的３５例,其中２７例合并先天性畸形,轻度ＭＩ３例,中度ＭＩ２４例,重度ＭＩ８例。全后瓣环缝缩７例,部分后瓣环缝缩２８例,同时行腱索成形７例,瓣叶成形１４例。结果全组无手术死亡。２１例（６００％）完成纠正ＭＩ,１１例（３１４％）基本纠正,３例（８６％）仍轻中度ＭＩ。随访３个月～１０年,３４例心功能Ｉ级,１例术后５年因肺动脉高压死于右心衰。结论二尖瓣后环缝缩是一种简单、安全和有效的瓣环成形方法     

Conservative surgery of congenital isolated mitral valve anomalies in children. Early and late results

Conservative surgery for non-av-canal mitral valve anomalies was performed in 30 children under 15 years of age between 1965 and 1986 at our institution. In 14/30 (47%) children these anomalies were isolated (without other intra- or extracardiac defects). Mean age of the 14 children was 6.7 years (range 9 months to 15 years). Preoperatively mitral insufficiency was found in 12 cases, stenosis in one and combined insufficiency and stenosis in one case. The following morphological substrates of mitral valve were found: annular dilation 3, leaflet anomalies 20, chordal anomalies 4, papillary muscle anomaly 1. Surgical technique was as follows: annuloplasty 9, plication of leaflet 4, closure of cleft 10, commissurotomy 2, displacement of papillary muscle 1. Early mortality was 1/14 (7%) patients. There was no death during a mean follow-up interval of 14.8 years (range 30 days to 25 years). Actuarial survival was 93% after 10 and 15 years (95% confidence limits 78-100%). A total of 2 reoperations was necessary (delay 16 day and 46 months). In both cases valve replacement was performed (valve size 27 and 29 mm). Actuarial reoperation-free interval was 77% after 10 and 15 years (95% confidence limits 53-100%). In conclusion conservative surgery for isolated mitral valve disease gives good long-term results. When reoperation is necessary, adult-sized prosthesis can be implanted. Conservative surgery is the procedure of choice for congenital mitral valve disease.     

Early experience with mitral valve reconstruction for mitral insufficiency

Mitral valve repair for mitral regurgitation has been reported to have more favorable early and late results than mitral valve replacement. From July 1985 through July 1990, 63 patients have undergone valve repair at Good Samaritan Hospital. Twenty-two men and 41 women whose ages ranged from 34 to 81 years (mean 67.9 years) were treated. Twenty-eight patients were in New York Heart Association functional class III or IV. Twelve (19%) had undergone prior cardiac surgery. Isolated valve repair was performed in 18 patients. Valve repair was combined with coronary artery bypass grafting, other valve procedures, or aneurysm resection in the remainder (71%). Two patients (3%) died while in the hospital, and four deaths (one valve-related) occurred after discharge. Leaflet resection for ruptured chordae was done in 24 patients (38%), chordal shortening in 5 patients (8%), and leaflet transposition in 2 patients. Rigid ring annuloplasty (Carpentier) was performed in 62 patients. Eight patients required mitral valve replacement at the same operation because of unsatisfactory valve repair. Results of valve repair evaluated by echocardiography at discharge show that 48 patients (88%) are free of significant regurgitation. Follow-up to date reveals that all surviving patients who underwent valve repair have clinically improved and are stable. Four of five patients with moderate mitral regurgitation are currently asymptomatic. There have been two valve-related late failures requiring reoperation. Based on this early experience, we conclude that valve repair compared with mitral valve replacement has a low operative mortality with good early results. Continued efforts to preserve native mitral valve function in the presence of mitral regurgitation appear justified.     

Three-dimensional geometric comparison of partial and complete flexible mitral annuloplasty rings

BACKGROUND: It has previously been shown in sheep that mitral annular physiologic dynamics during the cardiac cycle are abolished by complete ring annuloplasty, but recent clinical studies suggest that flexible partial ring annuloplasty preserves normal mitral annular dynamics. METHODS: Eight radiopaque markers were sutured equidistantly around the mitral anulus in 3 groups of sheep: no-ring control animals (n = 16); animals with a flexible Tailor partial ring annuloplasty (n = 6; St Jude Medical, Inc, St Paul, Minn); and animals with a flexible Duran ring annuloplasty (n = 7; Medtronic, Inc, Minneapolis, Minn). After 7 to 10 days' recovery, 3-dimensional marker coordinates were measured by biplane cinefluoroscopy. Mitral annular area and folding (defined as displacement of the mitral anulus from a least-squares plane) and mitral annular septal-lateral and commissure-commissure dimensions were calculated from the 3-dimensional marker coordinates throughout the cardiac cycle every 17 ms. RESULTS: In the no-ring control group mitral annular area varied from 8.0 +/- 0.2 to 7.2 +/- 0.2 cm(2) (10% +/- 2%), and the septal-lateral and commissure-commissure dimensions varied from 27.7 +/- 0.4 to 25.9 +/- 0.4 mm (7% +/- 1%) and from 38.2 +/- 0.8 to 36.4 +/- 0.8 mm (5% +/- 1%), respectively (mean +/- standard error of the mean, P <.001 for all comparisons). In the Duran ring annuloplasty and Tailor partial ring annuloplasty groups, the anulus was fixed in size throughout the cardiac cycle (area = 4.8 +/- 0.1 and 5.3 +/- 0.3 cm(2), septal-lateral = 21.8 +/- 0.7 and 22.0 +/- 0.8 mm, and commissure-commissure = 27.7 +/- 0.7 and 31.2 +/- 1.7 mm). Mitral annular folding did not differ significantly between the control and Tailor partial ring annuloplasty groups but was dampened in the Duran ring annuloplasty group. CONCLUSIONS: Partial Tailor flexible ring annuloplasty fixed mitral annular area and dimensions throughout the cardiac cycle in sheep; however, it preserved physiologic mitral annular folding dynamics, which might be important in terms of long-term valve function and prevention of left ventricular outflow tract obstruction.     

Early and late results of mitral valve repair for mitral valve regurgitation. Significant risk factors of reoperation

BACKGROUND: Mitral valve repair for mitral valve regurgitation has many advantages over mitral valve replacement. However, durability and reoperation after mitral valve repair still remain major problems. We examined the outcome of mitral valve repair for mitral valve regurgitation and analyzed several pre- and intraoperative potential risk factors to determine the significant risk factors of reoperation. METHODS: From February 1981 to November 1996, 86 patients underwent mitral valve repair for mitral regurgitation or combined mitral regurgitation and stenosis. The mean age was 53 years, and 88.4% were New York Heart Association class III or IV. The causes of mitral valve disease were degenerative disease in 53 patients, rheumatic disease in 15, infective endocarditis in 11, and ischemic disease in 7. There were 2 early and 8 late deaths. RESULTS: Actuarial overall survival including early death at 10 years was 83.2+/-6.1%, freedom from reoperation was 86.8+/-5.3%, freedom from thromboembolism was 90.9+/-6.2%, and freedom from infective endocarditis was 98.5+/-1.5%. There was no bleeding event. At the last follow-up, most patients were in New York Heart Association class I or II. Prolapse of anterior leaflet and rheumatic mitral regurgitation were identified as independent predictors for reoperation. CONCLUSIONS: The repair techniques for anterior leaflet prolapse and patient selection in rheumatic mitral disease are important for improving long-term results of mitral valve repair for mitral regurgitation.     

Midterm results of edge-to-edge mitral valve repair without annuloplasty

OBJECTIVE: Edge-to-edge mitral valve repair is usually performed in association with annuloplasty, with rare exceptions. We retrospectively analyzed the results of ringless edge-to-edge repair, particularly in view of minimally invasive and percutaneous approaches. METHODS: From November 1993 to December 2001, 81 patients underwent edge-to-edge mitral repair without associated annuloplasty. The cause was degenerative in most patients. In 32 patients the annulus was severely calcified. Type I lesions were present in 6 patients, type II lesions in 60 patients, and type III lesions in 15 patients. A double-orifice repair was done in 69 patients, and paracommissural repair was done in 12 patients. In 5 patients edge-to-edge repair was used as a rescue procedure. RESULTS: There were 3 hospital and 4 late deaths, for a 4-year survival of 85% +/- 6.7%. At latest follow-up, 63 patients were in New York Heart Association classes I or II, and 9 patients were in classes III or IV. Nine patients required reoperation (89% +/- 3.9% overall freedom from reoperation at 4 years). Annular calcification was associated with a greater reoperation rate (77% +/- 22% vs 95% +/- 4.6% freedom from reoperation, P =.03). Intraoperative water testing and postrepair transesophageal echocardiography predicted late failure. Only 1 of 42 patients required reoperation in the follow-up period when annular calcification, rheumatic disease, or rescue procedure were not present as risk factors. CONCLUSIONS: Our data confirm overall suboptimal results of the edge-to-edge technique when annuloplasty is not added to the repair. Annular calcification, rheumatic cause, and edge-to-edge repair done as a rescue procedure were associated with the worst outcome. Midterm results in selected patients encourage future developments in catheter-based edge-to-edge procedures.     

Adjustable annuloplasty for tricuspid insufficiency

De Vega described a technique for tricuspid annuloplasty using synthetic suture to reduce the size of the dilated annulus. We present our experience with an adjustable modification of de Vega's suture annuloplasty technique. The records of 12 patients followed for 15 to 30 months were reviewed. All 10 survivors had a significant drop in right-sided filling pressure (average, 39% decrease) and an associated improvement in clinical status. The 2 deaths in the series were not related to persistent tricuspid insufficiency. This technique represents a reliable, rapid, and readily teachable method for the surgical management of tricuspid insufficiency.     

Early and late results of mitral valve repair with anterior leaflet patch augmentation

OBJECTIVESThe aim of this study was to determine the long-term results of mitral valve (MV) repair with anterior leaflet patch augmentation.Open in a separate windowMETHODSBetween 2012 and 2015, 45 patients underwent MV repair using the anterior leaflet patch augmentation technique at our institution. The mean age of the patients was 65.9 ± 13.0 years (16 males). We reviewed the MV pathology and the surgical techniques used and assessed the early and late results.RESULTSIn terms of MV pathology, 43 patients (95.6%) had pure mitral regurgitation (MR) and 2 patients (4.4%) had mixed mitral stenosis and MR. Rheumatic changes were seen in 18 patients (40.0%). Postoperative echocardiography showed that 95.6% of patients had none to mild MR. During a median follow-up period of 5.5 years (range 0.1–8.3 years), there were 8 late deaths. Nine patients (20%) required reoperation. The mean interval between the initial operation and redo operation was 3.7 ± 3.1 years (range: 0.4–7.8 years). The causes of reoperation included patch dehiscence (n = 4), progression of mitral stenosis (n = 2), band dehiscence (n = 1), patch enlargement (n = 1) and unknown (n = 1). Eight patients underwent MV replacement and 1 underwent repeat MV repair. The freedom from reoperation at 3 and 5 years was 85.7 ± 6.7% and 81.2 ± 7.7%, respectively.CONCLUSIONSAnterior leaflet patch augmentation can provide excellent early results in the majority of the patients even in the presence of rheumatic pathology; however, we observed late reoperation in 20% of patients. Thus, this technique should be used with caution and careful follow-up with serial echocardiography is essential.