Reoperations after tricuspid valve repair: re-repair versus replacement

Background

Data demonstrating results of reoperation after initial tricuspid valve repair are scarce. We evaluated outcomes of tricuspid reoperations after tricuspid valve repair and compared the results of tricuspid re-repair with those of tricuspid valve replacement (TVR).

Methods

From 1994 to 2012, 53 patients (56±15 years, male:female =14:39) underwent tricuspid reoperations due to recurrent tricuspid regurgitation (TR) after initial repair. Twenty-two patients underwent tricuspid re-repair (TAP group) and 31 patients underwent TVR (TVR group).

Results

Early mortality occurred in 6 patients (11%). Early mortality and incidence of postoperative complications were similar between the 2 groups. There were 14 cases of late mortality including 9 cardiac deaths. Five- and 10-year free from cardiac death rates were 82% and 67%, respectively, without any intergroup difference. Recurrent TR (> moderate) developed in 6 TAP group patients and structural valve deterioration occurred in 1 TVR group patient (P=0.002). Isolated tricuspid valve surgery (P=0.044) and presence of atrial fibrillation during the follow-up (P=0.051) were associated with recurrent TR after re-repair. However, the overall tricuspid valve-related event rates were similar between the 2 groups with 5- and 10-year rates of 61% and 41%, respectively.

Conclusions

Tricuspid valve reoperation after initial repair resulted in high rates of operative mortality and complications. Long-term event-free rate was similar regardless of the type of surgery. However, great care might be needed when performing re-repair in patients with atrial fibrillation and those who had isolated tricuspid valve disease due to high recurrence of TR after re-repair.     

In vitro study of coronary flow occlusion in transcatheter aortic valve implantation

Background

Transcatheter aortic valve implantation (TAVI) has been developed recently for patients with high morbidities and who are believed to be not tolerate standard surgical aortic valve replacement. Nevertheless, the TAVI is associated with complications such as potential obstruction of coronary ostia, mitral valve insufficiency, and stent migration although it seems promising. Impairment of the coronary blood flow after TAVI is catastrophic and it was believed to be associated with the close position of the coronary orifice and the aortic leaflets and valve stent. However, few data was available as to the anatomic relationship between valve stent and aortic root anatomic structures including the coronary arterial ostia, aortic leaflets.

Methods

The aortic roots were observed in 40 hearts specimens. The width of aortic leaflet, height of aortic sinus annulus to the sinutubular junction (STJ), distance between aortic sinus annulus to its corresponding coronary ostia, and coronary arterial ostia to its corresponding STJ level were measured. Moreover, the relationships of valve stent, aortic leaflets and coronary ostia before/post stent implantation and after the open of aorta were evaluated respectively.

Results

Approximate three quarters of the coronary ostia were located below the STJ level. The mean distances from left, right and posterior aortic sinus annulus to the related STJ level was comparable, which was 18.5±2.7, 18.9±2.6, 18.7±2.6 mm, respectively. Meanwhile, the height of left and right aortic sinus annulus to its corresponding coronary ostia was 16.6±2.8 and 17.2±3.1 mm for left and right side respectively.

Conclusions

Most of the coronary ostia were located below the STJ level and could be covered by the leaflets. This highlights the need of modified stents to prevent occlusion of coronary flow after TAVI.     

Left ventricular systolic and diastolic function in subjects with a bicuspid aortic valve without significant valvular dysfunction

BACKGROUND:

The bicuspid aortic valve (BAV) represents the most common cardiac congenital malformation in adults. It is frequently associated with dilation, aneurysm and dissection of the ascending aorta.

OBJECTIVE:

To evaluate left ventricular systolic and diastolic function in subjects with BAVs.

METHODS:

Thirty-five subjects with BAV (mean [± SD] age 25.9±5.7 years [range 17 to 36 years]; 18 male, 17 female) with either no valvular impairment or mild valvular impairment were recruited along with 30 control subjects (24.5±4.4 years of age [range 15 to 35 years]; 15 male, 15 female) who were matched for age, sex and body surface area. Left ventricular systolic and diastolic function were evaluated using conventional and tissue Doppler echocardiography. Left ventricular systolic and diastolic parameters were compared between the two groups.

RESULTS:

In subjects with BAVs, the ratio of mitral early diastolic velocity to late diastolic velocity was lower (0.95±0.4 versus 1.27±0.9; P=0.001), the ratio of mitral early diastolic velocity to myocardial early diastolic velocity was higher (10.1±3.2 versus 6.5±2.4; P=0.001) and the myocardial early diastolic velocity was lower (8.4±2.1 versus 15.3±3.6; P<0.001) compared with control subjects. In addition, the myocardial performance index was higher in subjects with BAVs than in control subjects (P=0.03). The left ventricular ejection fraction was also lower (53±11% versus 64±13%; P<0.001). No other statistically significant differences were observed between the two groups with regard to left ventricular systolic and diastolic parameters. In addition, the number of mitral valve prolapses and atrial septal aneurysms was higher in subjects with BAVs.

CONCLUSION:

BAVs may be associated with left ventricular systolic and diastolic dysfunction.     

Tricuspid annular plane systolic excursion (TAPSE) can predict the outcome of isolated tricuspid valve surgery in patients with previous cardiac surgery?

Background

Isolated tricuspid valve replacement is rare when performed as a re-operation after a left side operation. It is important to know the factors that determine mortality and morbidity. Tricuspid Annular Plane Systolic Excursion (TAPSE) is a scoring system that is used with non-invasive Doppler echocardiography to determine right ventricular (RV) function. This study analyzed TAPSE scores and adverse outcomes of isolated tricuspid valve surgery in patients with previous cardiac surgery.

Methods

All patients who underwent tricuspid valve replacement between January 2014 and December 2015 were retrospectively reviewed. Patients having concomitant mitral or aortic valve surgery were excluded. These patients were divided into two groups: TAPSE >14 mm and TAPSE ≤14 mm. In-hospital outcomes were compared.

Results

A total of 26 patients with severe tricuspid valve regurgitation underwent tricuspid valve replacement. There were 5 males (19.2%) and 21 females (80.8%). The average age at operation was 54.77±9.61 years (range, 27–69 years). There were 16 patients in the TAPSE >14 mm group and 10 patients in the TAPSE ≤14 mm group. The BNP in the TAPSE >14 mm group was significant (TAPSE >14 mm 672.34±229.98 versus TAPSE ≤14 mm 1,054.79±684.69, P=0.03). The median cardiopulmonary bypass (CPB) time and red blood cell (RBC) transfusions in the two groups were not different. The need for prolonged ventilatory support (>48 h) in the two groups was also not different (TAPSE> 14 mm 91.2±12.31 vs. TAPSE ≤14 mm 39.00±36.80, P=0.46). Moreover, hospital stays were similar between the two groups. No differences were found in postoperative renal and respiratory complications.

Conclusions

It is important to determine the right ventricule function quantitatively. The TAPSE score is an important parameter that determines the cardiac index and right ventricle function. It should be used for the prediction of mortality and morbidity with all the other parameters as a whole.     

Initial Experience of Two National Centers in Transcatheter Aortic Prosthesis Implantation

Background

Transcatheter aortic valve implantation is an effective alternative to surgical treatment of severe aortic stenosis in patients who are inoperable or at high surgical risk.

Objectives

To report the immediate and follow-up clinical and echocardiographic results of the initial experience of transcatheter aortic valve implantation.

Methods

From 2009 June to 2013 February, 112 patients underwent transcatheter aortic valve implantation.

Results

Mean age was 82.5 ± 6.5 years, and the logistic EuroSCORE was 23.6 ± 13.5. Procedural success was 84%. After the intervention, a reduction in the mean systolic gradient was observed (pre: 54.7 ± 15.3 vs. post: 11.7 ± 4.0 mmHg; p < 0.01). Cerebrovascular accidents occurred in 3.6%, vascular complications in 19% and permanent pacemaker was required by 13% of the patients. Thirty-day mortality and at follow-up of 16 ± 11 months was 14% and 8.9% respectively. The presence of chronic obstructive pulmonary disease was the only predictor of mortality at 30 days and at follow-up. During follow up, aortic valve area and mean systolic gradient did not change significantly.

Conclusions

Transcatheter aortic valve implantation is an effective and safe procedure for the treatment of aortic stenosis in high-surgical risk or inoperable patients. The presence of chronic obstructive pulmonary disease was the only independent predictor of mortality identified both in the first month post-intervention and at follow-up.     

Patient-prosthesis mismatch in the mitral position affects midterm survival and functional status

BACKGROUND:

The definition and incidence of patient-prosthesis mismatch (PPM) in the mitral position are unclear.

OBJECTIVES:

To determine the impact of PPM on late survival and functional status after mitral valve replacement with a mechanical valve.

METHODS:

Between 1992 and 2005, 714 patients (mean [± SD] age 60±10 years) underwent valve replacement with either St Jude (St Jude Medical Inc, USA) (n=295) or Carbomedics (Sulzer Carbomedics Inc, USA) (n=419) valves. There were 52 concomitant procedures (50 tricuspid annuloplasties, 25 foramen oval closures and 20 radiofrequency mazes). The mean clinical follow-up period was 4.4±3.3 years. The severity of PPM was established with cut-off values for an indexed effective orifice area (EOAi) of lower than 1.2 cm²/m², lower than 1.3 cm²/m² and lower than 1.4 cm²/m². Parametric and nonparametric tests were used to determine predictors of outcome.

RESULTS:

The prevalence of PPM was 3.7%, 10.1% and 23.5% when considering values of lower than 1.2 cm²/m², lower than 1.3 cm²/m² and lower than 1.4 cm²/m², respectively. When considering functional improvement, patients with an EOAi of 1.4 cm²/m² or greater had a better outcome than those with an EOAi of lower than 1.4 cm²/m² (OR 1.98; P=0.03). When building a Cox-proportional hazard model, PPM with an EOAi of less than 1.3 cm²/m² was an independent predictive factor for midterm survival (HR 2.24, P=0.007). Other factors affecting survival were age (HR 1.039), preoperative New York Heart Association class (HR 1.96) and body surface area (HR 0.31).

CONCLUSIONS:

In a large cohort of patients undergoing mitral valve replacement with mechanical prostheses, PPM defined as an EOAi of lower than 1.3 cm²/m² significantly decreased midterm survival. This level of PPM was observed in 10.2% of patients. Patients with an EOAi of 1.4 cm²/m² or greater had greater improvement of their functional status.     

Redo aortic valve surgery versus transcatheter valve-in-valve implantation for failing surgical bioprosthetic valves: consecutive patients in a single-center setting

Background

Due to a considerable rise in bioprosthetic as opposed to mechanical valve implantations, an increase of patients presenting with failing bioprosthetic surgical valves in need of a reoperation is to be expected. Redo surgery may pose a high-risk procedure. Transcatheter aortic valve-in-valve implantation is an innovative, less-invasive treatment alternative for these patients. However, a comprehensive evaluation of the outcome of consecutive patients after a valve-in-valve TAVI [transcatheter aortic valve-in-surgical aortic valve (TAV-in-SAV)] as compared to a standard reoperation [surgical aortic valve redo-operation (SAV-in-SAV)] has not yet been performed. The goal of this study was to compare postoperative outcomes after TAV-in-SAV and SAV-in-SAV in a single center setting.

Methods

All SAV-in-SAV and TAV-in-SAV patients from January 2001 to October 2014 were retrospectively reviewed. Patients with previous mechanical or transcatheter valves, active endocarditis and concomitant cardiac procedures were excluded. Patient characteristics, preoperative data, post-procedural complications, and 30-day mortality were collected from a designated database. Mean values ± SD were calculated for all continuous variables. Counts and percentages were calculated for categorical variables. The Chi-square and Fisher exact tests were used to compare categorical variables. Continuous variables were compared using the t-test for independent samples. A 2-sided P value <0.05 was considered statistically significant.

Results

A total of 102 patients fulfilled the inclusion criteria, 50 patients (49%) underwent a transcatheter valve-in-valve procedure, while 52 patients (51%) underwent redo-surgery. Patients in the TAV-in-SAV group were significantly older, had a higher mean logistic EuroSCORE and exhibited a lower mean left ventricular ejection fraction than patients in the SAV-in-SAV group (78.1±6.7 vs. 66.2±13.1, P<0.001; 27.4±18.7 vs. 14.4±10, P<0.001; and 49.8±13.1 vs. 56.7±15.8, P=0.019 respectively). Postoperative pacemaker implantation and chest tube output were higher in the SAV-in-SAV group compared to the TAV-in-SAV group [11 (21%) vs. 3 (6%), P=0.042 and 0.9±1.0 vs. 0.6±0.9, P=0.047, respectively]. There was no significant difference in myocardial infarction, stroke or dialysis postoperatively. Thirty-day mortality was not significantly different between the two groups [TAV-in-SAV2 (4%) vs. SAV-in-SAV0, P=0.238]. Kaplan-Meier (KM) 1-year survival was significantly lower in the TAV-in-SAV group than in the SAV-in-SAV group (83% vs. 96%, P<0.001).

Conclusions

The present investigation shows that both groups, irrespective of different baseline comorbidities, show very good early clinical outcomes. While redo surgery is still the standard of care, a subgroup of patients may profit from the transcatheter valve-in-valve procedure.     

Mini-thoracotomy in redo mitral valve surgery: safety and efficacy of a standardized procedure

BackgroundRe-operative mitral valve surgery is sometimes burdened by a greater technical difficulty and a higher complications rate than the first operation. Minimally invasive cardiac surgery has become routine, and it could significantly reduce the surgical risk in redo surgery. The objective of our retrospective observational study is to assess the results of cardiac reoperations in patients with mitral valve disease approached trough a 5–7 cm right mini-thoracotomy.MethodsFrom February 2017 to December 2019, 65 patients underwent re-operative mitral valve surgery in our institution. Cardiopulmonary bypass (CPB) was started by cannulation of the femoral and jugular vein and femoral artery or alternatively right axillary artery. Patients enrolled had a mean age of 66.6±11.5 years. Patients were divided into three groups based on the procedure adopted: external aortic cross-clamp (EAC), EndoAortic balloon occlusion (EABO) and ventricular fibrillation (VF). Major complications were evaluated and compared with a propensity matched population of patients undergoing elective isolated mitral valve surgery via right minithoracotomy (MVS).ResultsThe average time between last operation and reoperation was 7.1±3.4 years. Fourteen patients (21%) underwent mitral valve repair and 51 patients (78%) underwent mitral valve replacement; 9 patients (14%) received tricuspid valve surgery. There was no statistically significant difference in CPB time between the groups. Seven patients (11%) had a postoperative renal failure, 5 patients (8%) underwent surgical reopening for bleeding; incidence of post-operative stroke and pace-maker implantation was 3% for both. No deaths were registered during in-hospital stay and at 30-days echocardiographic control all patients respect the criterions of device success according with MVARC. Propensity matched patients of group redo had a longer CPB time (100.8±42.7 versus 72.8±16.7 min, P<0.001) and cross-clamp time (71.9±30.7 versus 59±10.7 min, P<0.001) respect to first operation mitral valve surgery patients.ConclusionsMinimally invasive mitral valve redo surgery is a safe procedure. Less invasive techniques in redo surgery could minimize morbidity and mortality without prolonging the duration of CPB.     

Routine leaflet augmentation of left atrioventricular valve in the repair of atrioventricular septal defect

Introduction

A better understanding of the morphology of complete atrioventricular septal defects (CAVSD) has impacted on surgical techniques and results. On some occasions the leaflet tissue is deficient and repair becomes difficult which leads to atrioventricular valve (AVV) regurgitation following the surgical repair of the AVSD.

Objectives

This study was conducted to evaluate a modified technique in which two patches where used to close the complete atrioventricular septal defect (CAVSD) with augmentation of the left atrioventricular valve (AVV) with the ventricular septal defect (VSD) patch.

Methods

The technique was performed on 105 infants with CAVSD at a mean age of 11.7 ± 23 months (median 5.7, range 1–135). Both superior and inferior bridging leaflets are divided routinely to expose the VSD. An autologous pericardial patch, sized precisely, is sutured to the ventricular septum. A 3–4 mm of extra patch is fashioned beyond the plane of the annulus and sutured to the divided leaflet of the left AVV. A second autologous pericardial atrial patch is attached to the body of the VSD patch at the plane of the annulus allowing 3–4 mm of the VSD patch to augment the left AV valve.

Results

There was one early death among these infants. At early postoperative echo all infants had no significant residual lesions. The contribution of the patch-augmented left AV valve to competency is clearly seen by two-dimensional echocardiography. At a mean follow up of 27 ± 10 months there were two late deaths with normal last echocardiography. There were only two children who progressed to severe left AV valve regurgitation needing reoperations.

Conclusions

This modified technique yields good anatomical repair. Allowing reconstruction of both AV valves independent of the other and is in particular helpful in cases of deficient left AVV tissue.     

The impact of mitral stenosis on outcomes of aortic valve stenosis patient undergoing surgical aortic valve replacement or transcatheter aortic valve replacement

Background

The concomitant presence of mitral stenosis (MS) in the setting of symptomatic aortic stenosis represent a clinical challenge. Little is known regarding the outcome of mitral stenosis (MS) patients undergoing transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR). Therefore, we sought to study the outcome of MS patients undergoing aortic valve replacement (AVR).

Method

Using weighted data from the National Inpatient Sample (NIS) database between 2011 and 2014, we identified patients who were diagnosed with MS. Patients who had undergone TAVR as a primary procedure were identified and compared to patients who had SAVR. Univariate and multivariate logistic regression analysis were performed for the outcomes of in‐hospital mortality, length of stay (LOS), blood transfusion, postprocedural hemorrhage, vascular, cardiac and respiratory complications, permanent pacemaker placement (PPM), postprocedural stroke, acute kidney injury (AKI), and discharge to an outside facility.

Results

A total of 4524 patients were diagnosed with MS, of which 552 (12.2%) had TAVR and 3972 (87.8%) had SAVR. TAVR patients were older (79.9 vs 70.0) with more females (67.4% vs 60.0%) and African American patients (7.7% vs 7.1%) (P < 0.001). In addition, the TAVR group had more comorbidities compared to SAVR in term of coronary artery disease (CAD), congestive heart failure (CHF), chronic lung disease, hypertension (HTN), chronic kidney disease (CKD), and peripheral vascular disease (PVD) (P < 0.001 for all). Using Multivariate logistic regression, and after adjusting for potential risk factors, TAVR patients had lower in‐hospital mortality (7.9% vs 8.1% adjusted Odds Ratio [aOR], 0.615; 95% confidence interval [CI], 0.392–0.964, P = 0.034), shorter LOS. Also, TAVR patients had lower rates of cardiac and respiratory complications, PPM, AKI, and discharge to an outside facility compared with the SAVR group.

Conclusion

In patients with severe aortic stenosis and concomitant mitral stenosis, TAVR is a safe and attractive option for patients undergoing AVR with less complications compared with SAVR.

     

Dysfunction of mechanical heart valve prosthesis: experience with surgical management in 48 patients

Background

Dysfunction of mechanical heart valve prostheses is an unusual but potentially lethal complication after mechanical prosthetic valve replacement. We seek to report our experience with mechanical valve dysfunction regarding etiology, surgical techniques and early outcomes.

Methods

Clinical data of 48 patients with mechanical valve dysfunction surgically treated between October 1996 and June 2011 were analyzed.

Results

Mean age was 43.7±10.9 years and 34 were female (70.8%). The median interval from primary valve implantation to dysfunction was 44.5 months (range, 1 hour to 20 years). There were 21 emergent and 27 elective reoperations. The etiology was thrombosis in 19 cases (39.6%), pannus in 12 (25%), thrombosis and pannus in 11 (22.9%), improper disc orientation in 2 (4.1%), missing leaflet in 1 (2.1%), excessively long knot end in 1 (2.1%), endogenous factor in 1 (2.1%) and unidentified in 1 (2.1%). Surgical procedure was mechanical valve replacement in 37 cases (77.1%), bioprosthetic valve replacement in 7 (14.9%), disc rotation in 2 (4.2%) and excision of excessive knot end in 1 (2.1%). Early deaths occurred in 7 patients (14.6%), due to low cardiac output in 3 (6.3%), multi-organ failure in 2 (4.2%) and refractory ventricular fibrillation in 2 (4.2%). Complications occurred in 10 patients (20.8%).

Conclusions

Surgical management of mechanical valve dysfunction is associated with significant mortality and morbidity. Earlier identification and prompt reoperation are vital to achieving better clinical outcomes. The high incidence of thrombosis in this series highlights the need for adequate anticoagulation and regular follow-up after mechanical valve replacement.     

Mitral valve repair with aortic valve replacement in rheumatic heart disease

From 1992 to 2001, 609 patients with rheumatic heart disease underwent aortic valve replacement with either mitral valve repair (n = 201) or mitral valve replacement (n = 408). Follow-up extended to 10 years. Thirty-day mortality was 1.4% for mitral valve repair and 0.7% for mitral valve replacement (p = 0.4). Survival at 9 years was 96.5 +/- 1.4% after mitral valve repair and 89.7 +/- 7.8% after mitral valve replacement (p = 0.73). Freedom from major bleeding at 9 years was 94.8 +/- 2.4% after mitral valve repair and 81 +/- 7.2% after mitral valve replacement (p = 0.03). Freedom from other valve-related complications and from mitral valve re-operation was similar for the two groups. This study showed that in patients with rheumatic heart disease the results of mitral valve repair with aortic valve replacement were comparable to those of double valve replacement. Major bleeding was less frequent after mitral valve repair with aortic valve replacement. Therefore, whenever feasible, mitral valve repair should be attempted in patients with rheumatic heart disease who need concomitant aortic valve replacement.     

Percutaneous management of prosthetic valve thrombosis

Background

Thrombosis of a prosthetic valve is a serious complication in patients with prosthetic heart valves. Thrombolysis is the initial choice of treatment. Patients who do not respond to thrombolysis are subjected to surgery which carries a high risk. We report a case series of 5 patients with prosthetic mitral valve thrombosis who did not respond to thrombolysis and were subjected to percutaneous manipulation of the prosthetic valves successfully and improved.

Methods

Five patients who were diagnosed to have prosthetic mitral valve thrombosis and failed to respond to a minimum of 36 h of thrombolysis (persistent symptoms with increased gradients, abnormal findings on fluoroscopy),were subjected to percutaneous treatment after receiving proper consent. None of them had a visible thrombus on transthoracic echocardiogram. All patients underwent transseptal puncture following which a 6F JR4 guiding catheter was passed into the left atrium. The valve leaflets were repeatedly hit gently under fluoroscopic guidance till they regained their normal mobility.

Results

Mean age was 38.8 years. Average peak and mean gradients prior to the procedure were 38 and 25 and after the procedure were 12 and 6 mm of Hg respectively. All patients had successful recovery of valve motion on fluoroscopy with normalization of gradients and complete resolution of symptoms. None of the patients had any focal neurological deficits, embolic manifestations or bleeding complications.

Conclusions

Percutaneous manipulation of prosthetic valves in selected patients with prosthetic valve thrombosis who do not respond to thrombolytic therapy is feasible and can be used as an alternative to surgery.     

Debranching Solutions in Endografting for Complex Thoracic Aortic Dissections

Background

Conventional surgical repair of thoracic aortic dissections is a challenge due to mortality and morbidity risks.

Objectives

We analyzed our experience in hybrid aortic arch repair for complex dissections of the aortic arch.

Methods

Between 2009 and 2013, 18 patients (the mean age of 67 ± 8 years-old) underwent hybrid aortic arch repair. The procedural strategy was determined on the individual patient.

Results

Thirteen patients had type I repair using trifurcation and another patient with bifurcation graft. Two patients had type II repair with replacement of the ascending aorta. Two patients received extra-anatomic bypass grafting to left carotid artery allowing covering of zone 1. Stent graft deployment rate was 100%. No patients experienced stroke. One patient with total debranching of the aortic arch following an acute dissection of the proximal arch expired 3 months after TEVAR due to heart failure. There were no early to midterm endoleaks. The median follow-up was 20 ± 8 months with patency rate of 100%.

Conclusion

Various debranching solutions for different complex scenarios of the aortic arch serve as less invasive procedures than conventional open surgery enabling safe and effective treatment of this highly selected subgroup of patients with complex aortic pathologies.     

Robotic mitral valve repair in infective endocarditis

Background

Robotic mitral surgery is the most common robotic cardiac procedures. However, in mitral endocarditis the repair become more challenging especially in minimally approach. We applied robotic surgery in mitral endocarditis repair and reviewed our surgical methods and results.

Patients

From January 2012 to December 2013, 12 patients with mitral endocarditis in National Taiwan University Hospital were operated via robotic assisted repair. Age of them was among 21 to 65 years old, mean 43.

Results

The vegetation involves anterior leaflet in 3, posterior leaflet in 8 and commissural leaflet in 4. Mean cardiopulmonary bypass time is 124 minutes and cross clamp time is 89 minutes. There was no stroke and no operation death. Mitral valve repair technique including anterior leaflet patch augmentation in 2, direct closure of rupture hole on anterior leaflet in one, plication commissural leaflet in 2, and artificial chordae in 10. There was no mitral regurgitation detected immediately after weaning of cardiopulmonary bypass. All of them got free-from-regurgitation or -stenosis rate was 100% at one-year follow.

Conclusions

Although mitral infective endocarditis is complex and difficult to repair, robotic mitral repair in infective endocarditis is feasible. Even in the complex repair group, the cardiopulmonary bypass time is not prolonged and the result is good.     

Patient profile and results of percutaneous transvenous mitral commissurotomy in mitral restenosis following prior percutaneous transvenous mitral commissurotomy vs surgical commissurotomy

Background

Patients with mitral restenosis who have undergone prior PTMC or surgical commissurotomy have increased. Predictors of outcome of repeat PTMC in either subgroup of patients may be different.

Aims and objectives

Aim was to assess and compare the immediate results of PTMC in patients who had undergone a prior PTMC or surgical commissurotomy.

Methods and results

This is a single center, prospective, open label study. Of 70 patients in study, 44 (62.85%) patients had prior history of PTMC and 26 (37.15%) had prior surgical commissurotomy (closed/open). Average time from the initial procedure was 8.88 ± 5.36 years overall, 6.75 ± 3.38 for patients with prior PTMC and 16.73 ± 3.67 for patients with prior surgical commissurotomy. Prior PTMC group had 75% female, patients with prior surgical commissurotomy were older (44 ± 7 vs 33.57 ± 9.1 years, p = 0.001), had higher NYHA class (III/IV in100% vs 86.36%, p = 0.006.), higher atrial fibrillation (73.1% vs 25% p < 0.0001) and higher Wilkins'' score (>8 in 88.46% vs 68.18%, p = 0.05). Successful PTMC was lower (65.4% vs 84.1%) in patients with prior surgical commissurotomy, though statistically not significant (p = 0.07). After PTMC, mitral valve area, PA systolic pressure, LA mean pressure and trans-mitral gradient were similar. Post procedure complications were not different in both the groups.

Conclusion

PTMC for mitral restenosis in patients with prior surgical valvotomy is as effective as in patients with prior PTMC despite older age, higher NYHA class, higher Wilkins score and atrial fibrillation and can be considered in all patients with restenosis irrespective of the type of past procedures done.     

Midterm results of left atrial bipolar radiofrequency ablation combined with a mitral valve procedure in persistent atrial fibrillation

Introduction

The aim of the study was to assess the midterm results of left atrial bipolar radiofrequency ablation combined with a mitral valve procedure in patients with mitral valve disease and persistent atrial fibrillation.

Methods

Between October 2006 and July 2009, 95 patients with mitral valve disease and persistent atrial fibrillation underwent a mitral valve procedure and left atrial bipolar radiofrequency ablation. The postoperative data of the combined procedure were collected at the time of discharge and at one, three, six and 12 months after the operation.

Results

Hospital mortality rate was 6.3% (six patients). Normal sinus rhythm was achieved in 77.2% of patients during the early postoperative period in hospital, and in 73.3, 72.0 and 75% of patients at three, six and 12 months postoperatively, respectively. Patients were followed up for a mean duration of 14.02 ± 5.71 months (range: 6–19 months). During this midterm follow-up period, nine patients had late recurrence of atrial fibrillation. No risk factor was identified for late recurrence of atrial fibrillation.

Conclusion

Our midterm follow-up results suggest that the addition of left atrial bipolar radiofrequency ablation to mitral valve surgery is an effective and safe procedure to restore sinus rhythm in patients with chronic atrial fibrillation.     

Change in quality of life after transcatheter aortic valve implantation and aortic valve replacement surgery in Australian patients aged ≥ 75 years: the effects of EuroSCORE and patient operability

Objective To determine the extent to which differences in generic quality of life (QOL) between transcatheter aortic valve implantation (TAVI) and surgical aortic valve replacement (AVR) patients explained by EuroSCORE and heart-team operability assessment. Methods A total of 146 high-risk patients with EuroSCORE > 6 and aged ≥ 75 years underwent TAVI (n = 80) or aortic valve replacement (n = 66) between February 2010 and July 2013. A total of 75 patients also completed preoperative and six month SF-12 QOL measures. Analyses examined incident major morbidity, compared six month QOL between groups adjusted for EuroSCORE and operability, and quantified rates of clinically significant QOL improvement and deterioration. Results The AVR group required longer ventilation (> 24 h) (TAVI 5.0% vs. AVR 20.6%, P = 0.004) and more units of red blood cells [TAVI 0 (0–1) vs. AVR 2 (0–3), P = 0.01]. New renal failure was higher in TAVI (TAVI 5.0% vs. AVR 0%, P = 0.06). TAVI patients reported significantly lower vitality (P = 0.01) by comparison to AVR patients, however these findings were no longer significant after adjustment for operability. In both procedures, clinically significant QOL improvement was common [range 25.0% (general health) – 62.9% (physical role)] whereas deterioration in QOL occurred less frequently [range 9.3% (physical role) – 33.3% (mental health)]. Conclusions Clinically significant improvement and deterioration in QOL was evident at six months in high risk elderly aortic valve replacement patients. Overall QOL did not differ between TAVI and AVR once operability was taken into consideration.     

Defective recovery of QT dispersion following transcatheter aortic valve implantation: frequency, predictors and prognosis

Background Corrected QT dispersion (cQTD) has been correlated with non-uniform ventricular repolarisation and increased mortality. In patients with aortic stenosis, cQTD has been shown improved after surgical valve replacement, but the effects of transcatheter aortic valve implantation (TAVI) are unknown. Therefore, we sought to explore the frequency, predictors and prognostic effects of defective cQTD recovery at 6 months after TAVI. Methods A total of 222 patients underwent TAVI with the Medtronic-CoreValve System between November 2005 and January 2012. Patients who were on classⅠor Ⅲ antiarrhythmics or on chronic haemodialysis or who developed atrial fibrillation, a new bundle branch block or became pacemaker dependent after TAVI were excluded. As a result, pre-, post- and follow-up ECG (median: 6 months) analysis was available in 45 eligible patients. Defective cQTD recovery was defined as any progression beyond the baseline cQTD at 6 months. Results In the 45 patients, the mean cQTD was 47 ± 23 ms at baseline, 45 ± 17 ms immediately after TAVI and 40 ± 16 ms at 6 months (15% reduction, P = 0.049). Compared to baseline, cQTD at 6 months was improved in 60% of the patients whereas defective cQTD recovery was present in 40%. cQTD increase immediately after TAVI was an independent predictor of defective cQTD recovery at 6 months (per 10 ms increase; OR: 1.89, 95% CI: 1.15–3.12). By univariable analysis, defective cQTD recovery was associated with late mortality (HR: 1.52, 95% CI: 1.05–2.17). Conclusions Despite a gradual reduction of cQTD after TAVI, 40% of the patients had defective recovery at 6 months which was associated with late mortality. More detailed ECG analysis after TAVI may help to avoid late death.