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Can We Predict Failure of Mitral Valve Repair?

ABSTRACT: OBJECTIVE:To identify echocardiographic and surgical risk factors for failure after mitral valve repair. METHODS:We identified a total of 77 consecutive patients from our institutional mitral valve surgery database who required redo mitral valve surgery due to recurrence of mitral regurgitation after primary mitral valve repair. A control group of 138 patients who had a stable echocardiographic long-term result was included based on propensity score matching. Systematic analysis of echocardiographic parameters was performed before primary surgery; after mitral valve repair and prior to redo surgery. Risk factor analysis was performed using multivariate Cox regression model. RESULTS:Redo surgery was associated with the presence of pulmonary hypertension ? 50 mmHg (p = 0.02), a mean transmitral gradient > 5 mmHg (p = 0.001), left ventricular ejection fraction ? 45% (p = 0.05) before surgery and mitral regurgitation ?moderate at time of discharge (p = 0.002) in the whole cohort. Patients with functional mitral valve regurgitation had a higher tendency to undergo redo surgery if preoperative left ventricular end-diastolic diameter exceeded 65 mm (p = 0.043) and if postoperative tenting height exceeded 6 mm (p = 0.018). Low ejection fraction was not significantly associated with the need for redo mitral valve surgery in the functional subgroup. CONCLUSIONS:Recurrent mitral regurgitation is still a valuable problem and is associated with relevant perioperative mortality. Patients with severe mitral regurgitation should undergo early mitral valve repair surgery as long as systolic pulmonary artery pressure is low, left ventricular ejection fraction is preserved, and LVEED is deceeds 65 mm.

SUBMITTER: Gasser S

PROVIDER: S-EPMC6517919 | biostudies-literature | 2019 Apr

REPOSITORIES: biostudies-literature

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Can We Predict Failure of Mitral Valve Repair?

Gasser Simone S von Stumm Maria M Sinning Christoph C Schaefer Ulrich U Reichenspurner Hermann H Girdauskas Evaldas E

Journal of clinical medicine 20190417 4

<h4>Objective</h4>To identify echocardiographic and surgical risk factors for failure after mitral valve repair.<h4>Methods</h4>We identified a total of 77 consecutive patients from our institutional mitral valve surgery database who required redo mitral valve surgery due to recurrence of mitral regurgitation after primary mitral valve repair. A control group of 138 patients who had a stable echocardiographic long-term result was included based on propensity score matching. Systematic analysis o ...[more]

PMID: 30999593

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Project description:ObjectiveIntraoperative predictors of functional mitral valve (MV) stenosis after surgical repair of mitral regurgitation (MR) caused by prolapse remain poorly characterised. This study evaluated the effect of annuloplasty size on postoperative MV haemodynamics during exercise and evaluated predictors of MV hemodynamics.Methods104 patients were randomly assigned to leaflet resection or preservation for surgical repair of MR in the Canadian Mitral Research Alliance CardioLink-2 study. In this post hoc analysis, we compared MV haemodynamics between the two surgical groups and examined the relationship between annuloplasty size and MV haemodynamics 1 year after repair in the combined groups. Echocardiograms were performed at baseline and intraoperatively. Exercise transthoracic echocardiography was performed 1 year postoperatively. Multivariable linear regression analysis was used to identify predictors of exercise MV gradients at follow-up.ResultsMean age of participants was 65±10 years, and 83% were male. Median annuloplasty size was 34 (IQR 32-36). Dividing by the median, 48 (46%) had annuloplasty size of <34 mm and 56 (54%) had ≥34 mm. Mean and peak exercise gradients at 1 year were 11±5 mm Hg and 22±9 mm Hg in <34, and 6±3 mm Hg and 14±5 mm Hg in ≥34 (p<0.001). Rate of residual MR was similar in both groups. In multivariable analyses, annuloplasty size of ≥34 mm was associated with lower mean and peak exercise gradients at 12 months, after adjustment for repair type, age, sex, heart rate and body surface area (β -4.1, 95% CI -6 to -3, p<0.001, and β -7 95% CI -10 to -4, p<0.001, respectively). Intraoperative mean and peak MV gradients by transesophageal echocardiography independently predicted mean and peak resting and exercise gradients at follow-up (p<0.001). Similar results were obtained in both leaflet resection and preservation.ConclusionAnnuloplasty size of ≥34 mm is associated with a 4 and 7 mm Hg reduction in mean and peak exercise MV gradients, respectively, 1 year post MV repair regardless of the repair strategy used. Intraoperative TEE MV gradients predict exercise MV gradients 1 year post repair.Trial registration numberNCT02552771.

Project description:BACKGROUND:In the COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation) trial, transcatheter mitral valve repair (TMVr) led to reduced heart failure (HF) hospitalizations and improved survival in patients with symptomatic HF and 3+ to 4+ secondary mitral regurgitation (MR) on maximally-tolerated medical therapy. Given the advanced age and comorbidities of these patients, improvement in health status is also an important treatment goal. OBJECTIVES:The purpose of this study was to understand the health status outcomes of patients with HF and 3+ to 4+ secondary MR treated with TMVr versus standard care. METHODS:The COAPT trial randomized patients with HF and 3+ to 4+ secondary MR to TMVr (n = 302) or standard care (n = 312). Health status was assessed at baseline and at 1, 6, 12, and 24 months with the Kansas City Cardiomyopathy Questionnaire (KCCQ) and the SF-36 health status survey. The primary health status endpoint was the KCCQ overall summary score (KCCQ-OS; range 0 to 100; higher = better; minimum clinically important difference = 5 points). RESULTS:At baseline, patients had substantially impaired health status (mean KCCQ-OS 52.4 ± 23.0). While health status was unchanged over time in the standard care arm, patients randomized to TMVr demonstrated substantial improvement in the KCCQ-OS at 1 month (mean between-group difference 15.9 points; 95% confidence interval [CI]: 12.3 to 19.5 points), with only slight attenuation of this benefit through 24 months (mean between-group difference 12.8 points; 95% CI: 7.5 to 18.2 points). At 24 months, 36.4% of TMVr patients were alive with a moderately large (≥10-point) improvement versus 16.6% of standard care patients (p < 0.001), for a number needed to treat of 5.1 patients (95% CI: 3.6 to 8.7 patients). TMVr patients also reported better generic health status at each timepoint (24-month mean difference in SF-36 summary scores: physical 3.6 points; 95% CI: 1.4 to 5.8 points; mental 3.6 points; 95% CI: 0.8 to 6.4 points). CONCLUSIONS:Among patients with symptomatic HF and 3+ to 4+ secondary MR receiving maximally-tolerated medical therapy, edge-to-edge TMVr resulted in substantial early and sustained health status improvement compared with medical therapy alone. (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation [The COAPT Trial] [COAPT]; NCT01626079).

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Can We Predict Failure of Mitral Valve Repair?

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Can We Predict Failure of Mitral Valve Repair?

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