Dataset Information

Residual Mitral Regurgitation After Repair for Posterior Leaflet Prolapse-Importance of Preoperative Anterior Leaflet Tethering.

ABSTRACT: BACKGROUND:Carpentier's techniques for degenerative posterior mitral leaflet prolapse have been established with excellent long-term results reported. However, residual mitral regurgitation (MR) occasionally occurs even after a straightforward repair, though the involved mechanisms are not fully understood. We sought to identify specific preoperative echocardiographic findings associated with residual MR after a posterior mitral leaflet repair. METHODS AND RESULTS:We retrospectively studied 117 consecutive patients who underwent a primary mitral valve repair for isolated posterior mitral leaflet prolapse including a preoperative 3-dimensional transesophageal echocardiography examination. Twelve had residual MR after the initial repair, of whom 7 required a corrective second pump run, 4 underwent conversion to mitral valve replacement, and 1 developed moderate MR within 1 month. Their preoperative parameters were compared with those of 105 patients who had an uneventful mitral valve repair. There were no hospital deaths. Multivariate analysis identified preoperative anterior mitral leaflet tethering angle as a significant predictor for residual MR (odds ratio, 6.82; 95% confidence interval, 1.8-33.8; P=0.0049). Receiver operator characteristics curve analysis revealed a cut-off value of 24.3° (area under the curve, 0.77), indicating that anterior mitral leaflet angle predicts residual MR. In multivariate regression analysis, smaller anteroposterior mitral annular diameter (P<0.001) and lower left ventricular ejection fraction (P=0.002) were significantly associated with higher anterior mitral leaflet angle, whereas left ventricular and left atrial dimension had no significant correlation. CONCLUSIONS:Anterior mitral leaflet tethering in cases of posterior mitral leaflet prolapse has an adverse impact on early results following mitral valve repair. The findings of preoperative 3-dimensional transesophageal echocardiography are important for consideration of a careful surgical strategy.

SUBMITTER: Sakaguchi T

PROVIDER: S-EPMC6015386 | biostudies-literature | 2018 Jun

REPOSITORIES: biostudies-literature

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Residual Mitral Regurgitation After Repair for Posterior Leaflet Prolapse-Importance of Preoperative Anterior Leaflet Tethering.

Sakaguchi Taichi T Kagiyama Nobuyuki N Toki Misako M Hiraoka Arudo A Hayashida Akihiro A Totsugawa Toshinori T Tamura Kentaro K Chikazawa Genta G Yoshitaka Hidenori H Yoshida Kiyoshi K

Journal of the American Heart Association 20180601 11

<h4>Background</h4>Carpentier's techniques for degenerative posterior mitral leaflet prolapse have been established with excellent long-term results reported. However, residual mitral regurgitation (MR) occasionally occurs even after a straightforward repair, though the involved mechanisms are not fully understood. We sought to identify specific preoperative echocardiographic findings associated with residual MR after a posterior mitral leaflet repair.<h4>Methods and results</h4>We retrospective ...[more]

PMID: 29858366

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Project description:ImportanceThe overall prevalence of mitral valve replacement (MVR) or MV repair at the time of cardiac surgery in the setting of isolated anterior mitral leaflet degenerative pathologic status in the US population is unknown.ObjectiveTo investigate the prevalence of MVR and MV repair using the Society of Thoracic Surgeons' Adult Cardiac Surgery Database.Design, setting, and participantsIn a cross-sectional study, all patients diagnosed with isolated anterior mitral leaflet degenerative regurgitation who underwent either surgical MVR or MV repair between July 1, 2011, and June 30, 2022, were identified. Linear regression analysis was used to assess trends over time.Main outcomes and measuresAssessment of the trends in MV repair and MVR over time.ResultsA total of 16 259 patients (9624 [59.2%] men) were identified, and the median age was 68 (IQR, 58-74) years. A total of 7214 patients (44.4%) had MVR, and 9045 (55.6%) had MV repair. There was a declining trend of MV repair from 58.0% in 2011 to 51.6% in 2022 (P = .05). The MVR group was older (median [IQR] age, 70 [62-77] vs 67 [58-74] years; P < .001) and had more comorbidities. A total of 85.1% of all patients underwent concomitant procedures. In 81.7% of MVR cases, no attempt at MV repair was made. The median (IQR) annual hospital volume was lower with MVR vs MV repair (2.50 [1.50-5.00] vs 4.00 [2.00-7.00]; P < .001). Conventional surgical approaches were most common (91.5%) but with a declining trend (P < .001). Minimally invasive approaches were used in 13.1% (robotic, 4.6%), and with an inclining trend from 5.0% in 2011 to 12.0% in 2022 (P < .001). Annuloplasty was performed in 88.8% of MV repair cases. Its use as a sole mean of MV repair decreased from 48.0% in 2011 to 13.9% in 2022 (P < .001). Repair maneuvers in addition to annuloplasty were neochordae (overall 40.1%, increasing from 22.5% in 2011 to 62.3% in 2022; P < .001), leaflet resection (overall 10.2%, decreasing from 13.1% in 2011 to 7.9% in 2022, P = .002), edge-to-edge MV repair (overall 5.3%, decreasing from 6.9% in 2011 to 4.5% in 2022; P = 0.04), and chordal transfer (overall 2.4%, decreasing from 2.7% in 2011 to 0.7% in 2022; P = .004).Conclusions and relevanceIn this cross-sectional study, MV repair was the preferred option for degenerative mitral valve disease but was only slightly more commonly performed than MVR for isolated anterior leaflet pathologic status. A large proportion of MVR was performed without an MV repair attempt, suggesting reluctance to repair this pathologic condition.

Project description:ObjectiveMitral valve repair is superior to replacement for degenerative disease, but long-term outcomes of anterior versus posterior leaflet repair remain poorly defined. We propensity matched anterior and posterior repairs to compare long-term outcomes.MethodsPatients undergoing first-time degenerative mitral repair between 1992 and 2018 were identified. Primary outcome was overall survival. Secondary outcomes were postprocedural residual mitral regurgitation and reoperation. From 1025 patients, 1:1 propensity score matching was performed, yielding 309 anterior (isolated anterior = 85, bileaflet = 224) and 309 isolated posterior repairs.ResultsAge was 58 ± 15 years, ejection fraction was 57% ± 10%, and matched groups were well balanced. Anterior repairs had longer bypass (122 ± 53 vs 109 ± 43 minutes, P = .001) and crossclamp (94 ± 44 vs 85 ± 62 minutes, P = .033) times. Mean residual mitral regurgitation grade was 0.44 (95% confidence interval, 0.24-0.65) for anterior repair and 0.30 (95% confidence interval, 0.13-0.47) for posterior repair (P = .31). Overall, 92% (569/618) of matched patients had no residual mitral regurgitation, with no differences in mitral regurgitation grade between groups (P = .77). Survival did not differ between anterior (10 years: 72% ± 7%; 15 years: 63% ± 7%) and posterior (10 years: 74% ± 7%; 15 years: 60% ± 8%) groups (log-rank P = .93). Linearized incidence of reoperation was 0.62% per patient-year, including 0.74% for anterior and 0.48% for posterior repairs. Cumulative incidence of reoperation at 15 years was 7.5% after anterior repair and 4.9% after posterior repair (Gray's test P = .26).ConclusionsNo long-term survival or reoperation difference was found between posterior and anterior repair. On the basis of these findings, surgeons at centers of excellence should aim for repair of both anterior and posterior leaflet pathology with the same decision-making threshold over valve replacement for degenerative mitral disease.

Project description:Rationale: Ischemic mitral regurgitation (IMR) is frequently observed following myocardial infarction (MI) and is associated with higher mortality and poor clinical prognosis if left untreated. Accumulating evidence suggests that mitral valve (MV) leaflets actively remodel post-MI, yet the cellular mechanisms underlying these responses and how this affects tissue function remain largely unknown. Objective: We sought to elucidate MV remodeling post-MI at the tissue, cellular, and transcriptomic levels. Methods and Results: The mechanical behavior of ovine MV leaflets pre-MI and 8 weeks post-MI reveal a significant decrease in radial direction extensibility, which essentially eliminated the mechanical anisotropy typically observed in healthy MVs. Quantitative histology and ultrastructural assessment by transmission electron microscopy revealed altered leaflet composition and architecture at 8 weeks post-MI. Assessment of the MV interstitial cell (MVIC) nuclear aspect ratio, a metric of cellular deformation, revealed that MVICs were on average rounder following MI. RNA sequencing (RNA-seq) indicated that YAP-induced genes were elevated at 4 weeks post-MI and genes related to extracellular matrix organization were some of the most downregulated in sheep with IMR compared to sheep without IMR at 4 weeks post-MI. Additionally, RNA-seq revealed the possible recruitment of immune cells in this remodeling process due to the drastic elevation of CXCL9 and CLEC10A. Conclusions: This multiscale assessment revealed significant mechanical and microstructural changes due to MI. RNA-seq provided a baseline for global gene expression changes in response to MI with and without IMR and suggests YAP-induced mechanotransduction, altered expression of ECM-related genes, and recruitment of immune cells as mechanisms contributing to altered MV biomechanics post-MI. Conclusions: This multiscale assessment revealed significant mechanical and microstructural changes due to MI. RNA-seq provided a baseline for global gene expression changes in response to MI with and without IMR and suggests YAP-induced mechanotransduction, altered expression of ECM-related genes, and recruitment of immune cells as mechanisms contributing to altered MV biomechanics post-MI.

Dataset Information

Residual Mitral Regurgitation After Repair for Posterior Leaflet Prolapse-Importance of Preoperative Anterior Leaflet Tethering.

Publications

Residual Mitral Regurgitation After Repair for Posterior Leaflet Prolapse-Importance of Preoperative Anterior Leaflet Tethering.

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