Minimally Invasive Nonresectional Mitral Valve Repair Can Be Performed With Excellent Outcomes

doi:10.1016/j.athoracsur.2019.07.029

The Annals of Thoracic Surgery

Volume 109, Issue 2, February 2020, Pages 437-444

Presented at the Annual Meeting of the Heart Valve Society, Barcelona, Spain, April 11-13, 2019.

https://doi.org/10.1016/j.athoracsur.2019.07.029 Get rights and content

Background

To review the efficacy of a minimally invasive surgical technique for mitral valve (MV) repair, we analyzed a nonresectional technique for degenerative mitral regurgitation.

Methods

A retrospective analysis was performed on 101 consecutive patients who underwent a minimally invasive MV repair for severe degenerative mitral regurgitation between 2014 and 2017. All patients underwent a right lateral minithoracotomy and femoral cannulation and were repaired by a nonresectional technique using neochord loop implantation and ring annuloplasty. Patients were followed with longitudinal echocardiograms.

Results

The median age was 58 years (interquartile range [IQR], 49-64), and 31% were women. The procedure was successfully performed using a right minithoracotomy in all patients except for 1 who required an extended thoracotomy. A median of 4 neochords were placed. The median length was 16 mm (IQR, 14-18), and ring size was 34 mm (IQR, 32-36). Concomitant procedures included left atrial appendage exclusion in 10 patients (10%) and patent foramen ovale closure in 13 (13%). Median cardiopulmonary bypass time was 152 minutes (IQR, 142-164), and aortic cross-clamp time was 90 minutes (IQR, 81-98). Operative mortality was 0% and 1-year survival 100%. At 3 years freedom from recurrent at least moderate mitral regurgitation was 100%, and no patient required a valve-related reoperation. At 1 year the median left atrial diameter decreased by 15% (44 vs 37 mm, P < .001), the left ventricular end-diastolic diameter decreased by 14% (53 vs 46 mm, P < .001), and MV gradients remained low (3.1 vs 2.9 mmHg, P = .54).

Conclusions

Minimally invasive MV repair using a nonresectional technique can be performed for severe degenerative mitral regurgitation with a low complication rate, excellent durability, and promising left ventricular reverse remodeling.

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Section snippets

Study Population

A retrospective cohort analysis was performed on all consecutive adult patients who underwent a minimally invasive MV repair for at least moderate to severe DMR at our institution between January 2014 and December 2017. All patients were operated on by a single surgeon (S.M.). Postoperatively, patients were followed with transthoracic echocardiography (TTE) at 6 months and then per routine clinical practice with annual or semiannual TTEs at the discretion of their primary care team. Follow-up

Results

One hundred one consecutive patients underwent a minimally invasive MV repair at our institution between January 2014 and December 2017. All patients had DMR. Baseline clinical characteristics are summarized in Table 1, and preoperative echocardiographic data and operative details are summarized in Table 2. The median age was 58 years (interquartile range [IQR], 49-64), and 31% were women. Eight patients (8%) presented with New York Heart Association class III/IV heart failure, and the median

Comment

In this study we demonstrate that minimally invasive MV repair can be performed for at least moderate to severe DMR using a nonresectional technique with neochord implantation and ring annuloplasty with a low complication rate and excellent midterm durability. Furthermore this approach demonstrates promising LA and left ventricular reverse remodeling within the first 6 months to 1 year after surgery. This technique should be considered for minimally invasive MV repair in appropriate patients.

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La reparación quirúrgica de la insuficiencia mitral por prolapso de uno o varios segmentos del velo anterior, tanto aislada como en combinación con patología comisural o de velo posterior, es compleja. Las técnicas resectivas presentan menos indicaciones y peores resultados que en el prolapso del velo posterior (PrVP). Las técnicas de preservación son la transposición o acortamiento de cuerdas o de músculos papilares, la reparación borde-con-borde o, más frecuentemente, la implantación de neocuerdas. En este trabajo se pretenden revisar las diferentes variantes técnicas para el abordaje del prolapso del velo anterior mitral, que en el caso de la implantación de neocuerdas son tremendamente variadas, junto a sus indicaciones y resultados.
Surgical mitral valve repair due to anterior leaflet prolapse is complex, both isolated or combined with commisural and/or posterior leaflet pathology. Resective techniques are less indicated and are associated with worse long-term results that those observed after posterior leaflet resection. Leaflet preservation techniques are pappilary muscle or chordae transposition or shortening, the edge-to-edge repair and, more frequently, artificial neochordae implantation. This paper aims to describe the most important techniques used for anterior leaflet prolapse repair, extremely numerous in the neochordae implantation subset, in addition to their indications and results.
Mitral valve diseases: Pathophysiology and interventions
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Citation Excerpt :
MV repair in the case of endocarditis is based on removal of infected tissue and the use of a pericardial patch or repair using primary suturing, along with artificial chordae implant and ring annuloplasty. Annuloplasty with a closed, undersized ring is also used in the operation for ischemic MR.62,65–67 Less perioperative complications (especially blood loss), decreased chances of surgical wound infection, as well as a shorter recovery period have been the main advantages of MIMVS.63,68,69
Valvular heart disease is common and increasingly prevalent among the elderly. The end result of valvular pathologies is cardiac failure and can lead to sudden death; thus, diagnosis and interventions are very important in the early stages of these diseases. The usual treatment methods of mitral regurgitation include percutaneous mitral valve repair, mitral valve replacement and minimally invasive surgery, whereas the treatment methods of mitral stenosis include percutaneous transluminal mitral commissurotomy and mitral commissurotomy as well as open surgical repair. Nonetheless, ongoing clinical trials are a clear indicator that the management of valve diseases is ever evolving. The focus of this paper is on the various pathologies of the mitral valve, their etiology and clinical management, offering a comprehensive view of mitral valve diseases.
Current status of the treatment of degenerative mitral valve regurgitation
2021, Revista Portuguesa de Cardiologia
Citation Excerpt :
A recent Italian multicenter study showed that MIMVS has increased dramatically in recent years in 10 cardiac surgical centers in Italy, from 27.5% in 2011 to 71.7% in 2017.64 Axtell et al. showed excellent results in a series of 101 patients undergoing MVr with right minithoracotomy, with no operative mortality and 100% survival at one year.65 Interestingly, during the timeframe of their study, 181 patients underwent sternotomy; the reasons mentioned for not performing MIMVS in this series were the presence of moderate or greater aortic valve insufficiency, aortoiliac disease, significant mitral annular calcification, severe pectus excavatum, predicted operative mortality exceeding 4%, and previous cardiac surgery.
Degenerative mitral valve disease (myxomatous degeneration or fibroelastic deficiency) is the most common indication for surgical referral to treat mitral regurgitation. Mitral valve repair is the procedure of choice whenever feasible and when the results are expected to be durable. Posterior leaflet prolapse is the commonest lesion, found in up to two-thirds of patients. It is the easiest to repair, particularly when limited to one segment. In these cases, rates of repairability and procedural success approach 100%, and there is now ample evidence that the immediate and long-term results are better than those of valve replacement. Notably, minimally invasive valvular procedures, surgical or interventional, have attracted increasing interest in the last decade. When performed by experienced groups, mitral valve repair is unrivaled irrespective of the severity of lesions, from simple to complex, which leaflets are involved, and the type of degenerative involvement (myxomatous or fibroelastic). Its results should be viewed as the benchmark for other present and future technologies. By contrast, percutaneous mitral valve repair is still in its infancy and its results so far fall short of those of surgical repair. Nevertheless, continued investment in transcatheter procedures is of great importance to enable development and improved accessibility, particularly for patients who are considered unsuitable for surgery. In this review, we analyze the current status of management of degenerative mitral valve disease, discussing mitral valve anatomy and pathology, indications for intervention, and current surgical and transcatheter mitral valve procedures and results.
A doença valvar mitral degenerativa – deficiência mixomatosa ou fibroelástica – é a indicação mais comum de referência cirúrgica para tratamento da regurgitação mitral. A plastia da válvula mitral é o procedimento de escolha sempre que possível e os resultados são duradouros. O prolapso do folheto posterior é a lesão mais comum, encontrada em cerca de dois terços dos pacientes. É mais fácil de reparar, principalmente quando limitado a um segmento. Nesses casos, as taxas de reparabilidade e de sucesso aproximam-se dos 100% e agora há ampla evidência de que os resultados imediatos e a longo prazo são melhores do que os da substituição valvular. Os procedimentos valvares minimamente invasivos, cirúrgicos ou de intervenção, têm ganhado crescente interesse na última década. Quando realizada por grupos experientes, a plastia da valva mitral não tem rival, independentemente da gravidade das lesões, das simples às complexas, de quais os folhetos envolvidos e do tipo de patologia degenerativa (deficiência mixomatosa versus fibroelástica). Os resultados devem ser usados como referência para outras tecnologias presentes e futuras. Por outro lado, o tratamento percutâneo da válvula mitral ainda é incipiente e os resultados, até ao momento, ficam aquém dos da correção cirúrgica. No entanto, o investimento contínuo em procedimentos transcateter é de extrema importância para possibilitar a evolução e acessibilidade aos pacientes, principalmente àqueles aos quais é recusada a cirurgia. Nesta revisão, analisamos o estado atual do tratamento da doença degenerativa da válvula mitral, discutindo a anatomia e patologia valvular, as indicações para a intervenção, os procedimentos e resultados cirúrgicos e transcateter atuais.
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Original articleAdult cardiacMinimally Invasive Nonresectional Mitral Valve Repair Can Be Performed With Excellent Outcomes

Background

Methods

Results

Conclusions

Visual Abstract

Section snippets

Study Population

Results

Comment

Lancet

Can J Cardiol

Ann Thorac Surg

J Thorac Cardiovasc Surg

J Am Coll Cardiol

Ann Thorac Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Ann Thorac Surg

J Thorac Cardiovasc Surg

Original article
Adult cardiac
Minimally Invasive Nonresectional Mitral Valve Repair Can Be Performed With Excellent Outcomes