Minimally Invasive Pectus Excavatum Correction and Endoscopic Port Access Mitral Valve Surgery.

Minimally Invasive Nonresectional Mitral Valve Repair Long-term Results.

Objective: The aim was to assess the long-term outcomes, safety, and durability of total endoscopic mitral valve repair for Barlow mitral valve disease. Methods: A retrospective analysis of 98 patients undergoing minimal invasive total endoscopic mitral valve repair for Barlow mitral valve disease was conducted between May 2009 and December 2023. A non-resectional repair approach using artificial neochordae and/or ring annuloplasty was performed. Clinical and echocardiographic follow-ups were completed. Rates per patient-years with 95% confidence intervals (CI) for all time-to-event outcomes were calculated. Results: The mean age was 59 ± 12, and 43% were female. Minimally invasive mitral valve repair was successfully performed in all 98 patients with no conversions to sternotomy or mitral valve replacement. There was no mitral valve-related reoperation during the hospital stay. Procedural safety was as follows: no in-hospital mortality, no stroke, and no perioperative myocardial infarction. The mean follow-up was 4.1 ± 3.1 years. Survival at seven years was 87% (95% CI 63% to 96%). Freedom from myocardial infarction, stroke, and congestive heart failure was 89% (95% CI 60% to 97%), 93% (95% CI 82% to 97%), and 100%, respectively. Recurrent mitral valve insufficiency at Grade ≥ 2 was diagnosed in n = 4 (4.1%) of cases. Conclusions: Minimally invasive mitral valve repair using a non-resectional technique for Barlow disease can be performed with a low complication rate. The total endoscopic approach is safe in the long term, with minimal risk of reoperation and recurrent mitral valve insufficiency.

The mechanism and severity of mitral valve (MV) regurgitation (MR) play a critical role in guiding treatment decisions. Transthoracic echocardiography (TTE) is the primary diagnostic modality for evaluating MV disease. Discordant findings on TTE can be further quantified through transesophageal echocardiography (TEE). We describe the case of a young woman with worsening exertional dyspnea who was found to have restricted posterior MV leaflet and moderate to severe eccentric MR on TTE. TEE was subsequently performed to determine the exact mechanism of MR revealing the prolapse of the A2 segment of the MV. However, TEE significantly underestimated MR severity, downgrading it to visually mild to moderate MR and quantitatively moderate MR. This discrepancy highlights the potential for significant variation in MR severity assessment under general anesthesia, emphasizing the impact of hemodynamic loading conditions. In our case, intravenous sedatives may have altered the loading conditions reducing MR severity on TEE compared to TTE. Given her symptom severity, MV pathology, left ventricular dilatation, and the higher MR severity observed on TTE, she underwent surgical MV repair, in alignment with the Class I recommendation by the American College of Cardiology/American Heart Association (ACC/AHA) valvular heart disease guidelines. Postoperatively, she experienced significant improvement in symptoms and quality of life.

A Clip in time – Selecting Interventions for Severe Mitral Valve Regurgitation

Long term results of surgical management of anomalous origin of the left coronary artery from pulmonary artery (ALCAPA) and mitral incompetence

Isolated left ventricular noncompaction cardiomyopathy (IVNC) is a cardiomyopathy thought to be caused by arrest of normal embryogenesis of the endocardium and myocardium. This abnormality is often associated with other congenital cardiac defects. A 21-year-old man presented to the emergency department with worsening exertional dyspnea during the previous 2 months. Two-dimensional and Doppler echocardiography revealed an enlarged left atrium (LA) and a markedly dilated left ventricle (LV) with preserved LV systolic function, severe mitral valve regurgitation, and prolapse due to chordae rupture. The myocardium of the LV and right ventricle (RV) had excessively prominent trabeculations and deep intertrabecular recesses. He is the first patient in Korea who has undergone mitral valve replacement surgery because of severe mitral valve regurgitation and prolapse due to chordae rupture accompanied by IVNC.

Barlow's mitral valve disease with late systolic mitral regurgitation provides diagnostic and therapeutic challenges. The mechanisms of the regurgitation are still unclear. We hypothesized that the onset and the severity of late systolic regurgitation are determined by annulus dynamics and the mechanical stresses imposed by the left ventricle. Ten patients with Barlow's mitral valve disease and mitral annulus disjunction (MAD) were compared with 10 healthy controls. Resting blood pressure was measured, and transthoracic three-dimensional echocardiography was analyzed using a holographic display that allows tracking and measurements of mitral annulus surface area (ASA) throughout the cardiac cycle. A novel annulus elastance index (dASA/dP) was calculated between aortic valve opening and onset of mitral regurgitation. Severity of MAD was quantified as the disjunction index (mm × degree). Leaflet coaptation area was calculated using a finite element model. Peak systolic ASAs in controls and patients were 9.3±0.6 and 21.1±3.1cm², respectively (P<.001). In patients, the ASA increased rapidly during left ventricular ejection, and onset of mitral regurgitation coincided closely with peak upslope of annulus area change (dASA/dt). The finite element model showed a close association between rapid annulus displacement and coaptation area deficit in Barlow's mitral valve disease. Systolic annulus elastance index (0.058±0.036cm²/mm Hg) correlated strongly with disjunction index (r=0.91, P<.0001). Moreover, regurgitation volume showed a positive correlation with systolic blood pressure (r=0.80, P<.01). The present pilot study supports the hypothesis that annulus dilatation may accentuate mitral valve regurgitation in patients with Barlow's mitral valve disease. A novel annulus elastance index may predict the severity of mitral valve regurgitation in selected patients.

Mitral Valve Repair Is Durable in Patients With Rheumatoid Arthritis

Mitral valve regurgitation poses a significant public health burden, with more than 3 million people in the US alone suffering from moderate or severe mitral valve regurgitation. Surgical correction with mitral valve repair or replacement is the mainstay of therapy. However, a significant proportion of elderly patients are not eligible for mitral valve repair or replacement due to prohibitive surgical risk from increased age, poor ventricular function, or associated comorbidities. Percutaneous mitral valve repair/replacement techniques have been developed to fill this void. The most advanced percutaneous technique with the highest safety and efficacy to date is the edge-to-edge MitraClip repair system. The majority of other catheter-based mitral valve repair/replacement devices are at early developmental stages, but have shown encouraging initial results in feasibility trials. Transcatheter mitral valve replacement holds promise to emerge as the leading transcatheter treatment of choice in the fu...

In this bicentric study, we report the outcomes of combined transcatheter aortic valve replacement combined with minimally invasive mitral valve surgery. We included a cohort of six patients (79.6 ± 3.2 years, 83% women) with high-risk profiles and deemed to be non-operable with combined mitral and aortic valvular disease. All patients had unsuitable anatomies for transcatheter mitral valve edge-to-edge repair (TEER). Moreover, most of the patients (5/6) suffered a combined aortic valve lesion, which complicates the efficiency of cardioplegia in the case of CBP through minimally invasive incisions. The first stage was implanting a TAVI valve to achieve aortic valve competency and hence facilitate the infusion of cardioplegia after clamping the aorta during endoscopic mitral valve surgery. After one week, we performed the minimally invasive mitral valve repair. Most patients (n = 5; 83%) underwent successful endoscopic mitral valve repair. Intraoperatively, the mean ischemic time was 42 min, and the total bypass time was 72 min. Postoperatively, the mean intubation time was 0 h. Postoperative complications included reoperation for bleeding in one patient (16.7%) and a new heart block requiring pacemaker implantation in one patient (16.7%). There was neither in-hospital mortality nor 1-year mortality.

Background Mitral valve abnormalities (MVA) include mitral valve regurgitation (MR), mitral valve prolapse (MVP), Barlow's mitral valve disease, and parachute MV. The prevalence of MVA has yet to be determined in an unselected population of newborns. Objective To determine the prevalence of MVA in unselected newborns and to assess the left ventricular (LV) structure and function in the neonatal heart with MR. Methods Transthoracic echocardiography (TTE) was performed within 28 days after birth in unselected neonates consecutively included in a prospective, multicenter, population-based study (2016–2018 (n=25,751)). TTE's were systematically reviewed for MR, MVP, Barlow's MV disease, and parachute MV. In a subgroup of 400 newborns with MR, the regurgitation was further classified as either traceable MR, mild MR, or moderate/severe MR based on the ratio of the trans-mitral jet in systole over the diastolic filling duration using M-mode in the 4-chamber view of the LV. Results Of 25,751 included newborns, we found a prevalence of MVA of 26.7%. (6,883/ 25,751). The prevalence of MR was 26.2%, MVP was 0.35%, Barlow's disease was 0.13%, and parachute mitral valve was 0.027%. MR was more frequent in females compared to males (50.4 vs 48.2%, p<0.01). Newborns with MR had enlarged left atrial diameter (11.91±2.03 mm vs 11.53±2.02 mm, p<0.01) and LV end-diastolic and end-systolic diameter (LVIDd 19.98±1.88 mm vs 19.87±1.83 mm, p<0.01, LVIDs 13.48±1.47 mm vs 13.31±1.41 mm, p<0.01), thicker LV posterior wall (2.19±0.60 mm vs 2.05±0.52 mm, p<0.01), increased early and atrial mitral inflow velocities (MV E velocity (0.65±0.14 m/sec vs 0.61±0.13 m/sec, p<0.01), MV A velocity (0.60±0.13 m/sec vs 0.57±0.13 m/sec, p<0.01)), but lower fractional shortening (32.54±4.22% vs. 32.96±4.17%, p<0.01) as compared to newborns without MVA. In subgroup analysis MR severity was classified as traceable in 44% (175/400) of cases, mild MR in 52% (209/400) of cases and moderate/severe MR in 4% (16/400) of cases. Comparing traceable MR with moderate/severe MR (19.48±1.88 mm vs 20.96±2.64 mm, p=0.01) and comparing mild MR with moderate/severe MR (19.85±1.92 mm vs 20.96±2.64 mm, p=0.04) showed significant increases in LV end-diastolic diameter. Conclusion Over one fourth of all newborns had a MV abnormality of which mitral regurgitation accounted for the vast majority. The presence of MR was associated with asymmetric LV remodeling and discrete changes in LV function. Subgroup analysis revealed that increment in MR severity was primarily associated with an increase in LV end-diastolic diameter. Funding Acknowledgement Type of funding source: Public hospital(s). Main funding source(s): Herlev-Gentofte Hospital

Vohra et al. [1] have reported on a rarely studied form of functional mitral regurgitation due to atrial fibrillation. Atrial fibrillation is not an uncommon cause of functional mitral valve regurgitation, the mechanism being annular dilatation which accompanies dilatation of the atrium (Carpentier Type I dysfunction). Although Vohra et al. [1] have suggested that this is a rare condition, we suspect that it is actually common, but that it is often unrecognized or undocumented. Considering that atrial fibrillation has an estimated prevalence of 1% in adults with up to 3 million being affected in the USA alone [2], there are probably several million affected adults at any time with atrial remodelling as a consequence of atrial fibrillation, a substantial minority of whom probably have mitral regurgitation. One study has found a 6.4% incidence of functional mitral valve regurgitation in patients at first presentation of atrial fibrillation [3]. It is therefore likely that this condition is much more common than appreciated. Vohra et al. [1] have reported on 20 such patients who underwent mitral valve repair with ring annuloplasty. The median ring size was 30 mm, distinguishing it from the typical form of functional mitral valve regurgitation, secondary to left ventricular dysfunction, which is generally treated with smaller annuloplasty rings. The authors have demonstrated the resolution of significant mitral valve regurgitation in all patients and reverse modelling of the left atrium immediately after surgery. The long-term echocardiographic data were not available. The cohort of 20 patients has been identified retrospectively from hospital charts, making it difficult to be certain as to whether atrial fibrillation was the aetiology of the mitral valve regurgitation, as aetiology for mitral valve regurgitation is notoriously difficult to classify retrospectively [4]. Sufficient information is rarely available in the operative reports to allow for the classification of the cases. A more robust approach would have been a prospective means of classifying such patients such as defining and documenting the aetiology of the mitral valve regurgitation at the time of the mitral valve repair or preoperative evaluation. With the retrospective classification, it is almost inevitable that some patients were misclassified and erroneously included or excluded from the cohort [4]. Although the authors have suggested that indications for surgery have followed standard guidelines, there are several suggestions that their cohort represents a very sick patient group in which surgery was inappropriately delayed—for example, 85% of patients were severely symptomatic (New York Heart Association III or IV), the average age was 77 years and 35% had impaired left ventricular dysfunction. The goal of current practice guidelines is that surgery is undertaken before patients are severely symptomatic and have left ventricular dysfunction [5]. The authors are, therefore, to be commended for achieving such excellent results in a very sick cohort, with no mortality or major morbidity despite a predictive EuroSCORE of 8.1. However, clearly, measures to allow for earlier access to mitral valve surgery are necessary in their referral population. There may have been the potential for better medical management of atrial fibrillation in these patients in the months or years preceding surgery. For example, percutaneous ablation had not been attempted in any of these patients—this could have averted the onset of severe mitral valve regurgitation in some patients. Some aspects of their surgical management could be challenged—for example, if atrial fibrillation was deemed to be the cause of the regurgitation, then why was the appendage ligated in only 12 of 20 patients and an ablative procedure performed in only 10? Is the surgery not essentially an operation for atrial fibrillation and its consequences? An analogy would be repairing functional ischaemic mitral regurgitation without addressing coronary stenosis. It may well be that, as this was a retrospective study, the critical role of the atrial fibrillation may not have been appreciated in all patients at the time of surgery. We would generally almost always attempt a ‘cure’ of atrial fibrillation, if that was felt to be aetiology of the regurgitation. Also the choice of pulmonary vein isolation in some patients may be insufficient to treat the chronic atrial fibrillation necessary to induce functional mitral regurgitation—if the atrial fibrillation was paroxysmal in those three cases, then it is less probable to have been the primary aetiology of the regurgitation, as advanced atrial remodelling is not a usual characteristic of paroxysmal atrial fibrillation [6]. Although the authors have demonstrated excellent results with this patient group, it should be noted that there are recent data suggesting that conversion to sinus rhythm alone can lead to a substantial reduction in the severity of functional mitral regurgitation [3]. With conversion to sinus rhythm, the atrium can

Although the use of the surgical robot facilitates less invasive mitral valve surgery, both real and perceived limitations have slowed the application of this technology. Aim of the present investigation was to report the early and long-term results of robotic mitral valve repair in a single institution over a 10-year period. Between March 2012 and May 2022, a total of 278 consecutive patients underwent robotically assisted mitral valve repair at the Cliniques Universitaires Saint-Luc (Brussels, Belgium). Indications have evolved over time allowing the treatment of complex mitral valve lesions. Clinical and echocardiographic follow-up were 97.8% and 86.1% complete, respectively. Mean age of the study population was 57.8±11.9 years and 221/278 (79.5%) patients were male. Despite being asymptomatic or mildly symptomatic [New York Heart Association (NYHA) class I-II], most of the patients presented with severe mitral regurgitation (MR). Degenerative mitral valve disease was the most common cause of MR. All patients underwent successful mitral valve repair using different techniques, and 25/278 (9.0%) had one or more concomitant procedures associated. The mean cardio-pulmonary bypass and aortic cross clamp times were 153±37 and 106±25 minutes, respectively. There was no operative or in-hospital mortality. Overall survival rate was 97.8%±3.2%, 95.8%±3.2% and 93.7%±3.0% at 3, 7 and 10 years. One early (0.4%) reoperation with re-repair was recorded for ring disruption, while late mitral valve re-repair was necessary in 4/279 (1.4%) patients for recurrent severe MR in three of them and mitral endocarditis in one. The overall freedom from mitral valve reoperation was 98.1%±1.0% at 3, 7 and 10 years. Overall freedom from MR (grade 2+ or more) was 91.7%±3.2%, 77.8%±4.8% and 67.1%±9.2% at 3, 7 and 10 years, respectively. Robotic mitral valve repair is safe and is associated with excellent clinical and echocardiographic results. The use of robotic technologies allows, after an appropriate learning curve, to reproduce all conventional techniques to treat MR, regardless of the complexity of the valve lesion.

The effect of MitraClip implantation on left ventricular (LV) remodelling has been shown to be highly variable. The present study wants to assess patterns of LV remodelling and its relationship with outcome. Serial echocardiography before, 1 and 6 months after MitraClip implantation was performed in 79 pts with severe mitral regurgitation (MR) (age 74 ± 10 years, New York Heart Association III/IV 80%, LV ejection fraction 38 ± 13%, logistic EuroSCORE 21 ± 15, and functional MR 81%). LV reverse/adverse remodelling was defined as a >15% decrease/>10% increase in LV end-diastolic volume (LVEDV), respectively. Patients were followed over a period of 32 ± 16 months with all-cause mortality as the primary endpoint. A sustained (6 month) reduction of MR ≤ 2 post-MitraClip implantation was observed in 83% of patients. The average decrease in LVEDV 6 months after intervention was 13% ± 16%. Reverse remodelling at 6 months occurred in 40 patients (51%), and adverse remodelling occurred in 6 patients (8%). Patients with adverse remodelling showed a 38% increase of LVEDV at 1 month vs. no early change in LVEDV in patients with reverse remodelling. During follow-up, a total of 25 patients (32%) died. Patients with adverse remodelling died more frequently than patients with reverse remodelling [67% vs. 27%, adjusted odds ratio of 5.6 (95% CI 1.5-21)]. The majority of patients undergoing MitraClip implantation for severe MR showed LV reverse remodelling. However, there was a small group in whom afterload mismatch resulted in sustained adverse remodelling with subsequent high mortality.

Sizing for Mitral Annuloplasty: Where Does Science Stop and Voodoo Begin?