Abstract： Objective To summarize our experience and clinical outcomes of preservation of posterior leaflet and subvalvular structures in mitral valve replacement（MVR）. Methods We retrospectively analyzed the clinical data of 1 035 patients who underwent MVR in Beijing An Zhen Hospital from January 2006 to March 2011. There were 562 male patients and 473 female patients with their age of 37-78（53.84±13.13）years old. There were 712 patients with rheumatic valvular heart disease and 323 patients with degenerative valve disease, 389 patients with mitral stenosis and 646 patients with mitral regurgitation. No patient had coronary artery disease in this group. For 457 patients in non-preservation group, bothleaflets and corresponding chordal excision was performed, while for 578 patients in preservation group, posterior leafletand subvalvular structures were preserved. There was no statistical difference in demographic and preoperative clinical characteristics between the two groups. Postoperative mortality and morbidity, and left ventricular size and function were compared between the two groups. Results There was no statistical difference in postoperative mortality（2.63% vs. 1.21%, P =0.091）and morbidity （8.53% vs. 7.44%, P=0.519）between the non-preservation group and preservation group, except that the rate of left ventricular rupture of non-preservation group was significantly higher than that of preservation group（1.09% vs. 0.00%, P=0.012）. The average left ventricular end-diastolic dimension （LVEDD）measured by echocardiography 6 months after surgery decreased in both groups, but there was no statistical difference between the two groups. The average left ventricular ejection fraction (LVEF) 6 months after surgery was significantly improved compared with preoperative average LVEF in both groups. The average LVEF 6 months after surgery in patients with mitral regurgitation in the preservation group was significantly higher than that in non-preservation group （56.00%±3.47% vs. 53.00%±3.13%，P =0.000）, and there was no statistical difference in the average LVEF 6 months after surgery in patients with mitral stenosis between the two groups（57.00%±5.58% vs. 56.00%±4.79%，P =0.066）. Conclusion Preservation of posterior leaflet and subvalvular structures in MVR is a safe and effective surgical technique to reduce the risk of left ventricle rupture and improve postoperative left ventricular function．
Mitral valve prolapse (MVP) is a common heart valve disease that affects 2%-3% of the general population. It can be manifested as mitral valve regurgitation and is the main indication for mitral valve surgery. MVP includes two forms of syndrome and non-syndrome. Syndromic MVP is associated with connective tissue diseases, such as Marfan syndrome. Non-syndromic MVP includes diffuse myxomatous mitral valve disease or Barlow’s disease and fibroelastic deficiency. MVP is a common disease in which late systolic clicks or mitral valve leaflets shift upward into the left atrium during ventricular systole, with or without mitral regurgitation. Echocardiography defines MVP as the prolapse of one or two leaflets of the mitral valve into the left atrium during systole, exceeding the level of the annulus line by more than 2 mm. In recent years, the development of genomics and imaging technology has enabled us to better understand the pathogenesis of MVP and provide possibilities for further prevention and treatment. This article reviews the research progress of MVP in epidemiology, etiology, histopathology, diagnosis and genetics.
Objective
To explore the safety and complications of repeated sternotomy after mitral valve repair and prevention strategies.
Methods
We retrospectively analyzed the clinical data of 88 consecutive patients of non-rheumatic mitral valve disease who underwent repeated sternotomy for failure of first-time mitral valve repair in our hospital from January 2009 through June 2015. There were 53 males and 35 females with a mean age of 36.1±17.5 years in the patients who underwent repeated sternotomy. Meanwhile 88 patients who underwent the first-time sternotomy for mitral valve repair simultaneously were randomly recruited as a control group, and there were 57 males and 31 females with a mean age of 39.9±12.6 years. The clinical outcomes were analyzed retrospectively and compared between the two groups.
Results
No major injury was observed in the patients who underwent repeated sternotomy. Eight patients (9.1%) in the repeated sternotomy group required femoral artery cannulation. Cardiopulmonary bypass (CPB) time was longer in the femoral artery cannulation group than that in the aortic cannulation group (155.5±59.0 minvs. 119.5±39.9 min,P=0.023). While there was no statistical difference in aortic cross-clamp time (P=0.786). Eight patients (9.1%) in the repeated sternotomy group used extra-pericardium approach. There was no significant difference in CPB time (P=0.255) or aortic cross-clamp time (P=0.360) between the patients who used extra-pericardium approach and those used routine approach. There was no statistical difference in post-operative complications between the patients who used different sternotomy strategies. Although CPB time (123.0±3.0 minvs. 95.4±37.1 min,P=0.000) or aortic cross-clamp time (79.0±36.3 minvs. 67.5±29.1 min,P=0.026) was longer in the repeated sternotmy group, the major outcomes were similar between the repeated sternotmy group and the first-time sternotmy group (P＞0.05).
Conclusion
Repeated sternotomy after mitral valve repair is relatively safe. With appropriate strategies, repeated sternotomy is not associated with increased risk of operative morbidity.
Abstract: Objective To explore whether clinically mild functional tricuspid regurgitation should be addressed at the time of mitral valve repair (MVP) for moderate or severe mitral regurgitation due to myxomatous degeneration. Methods We retrospectively analyzed the outcomes of 135 patients with moderate or severemitral regurgitation due to myxomatous degeneration with mild functional tricuspid regurgitation. All patients were treated between January 1993 and March 2008 in the Department of Cardiothoracic Surgery of Changhai Hospital, the Second Military Medical University. We divided the patients into a MVP group (n=76) and a MVP+tricuspid valvuloplasty (TVP) group(n=59) according to whether they underwent combined TVP, and observed the perioperative mortality rate, degree of tricuspid regurgitation, and compared survival rate, and freedom from longterm moderate or severe tricuspid regurgitation after operation. Cox regression was used to analyzethe risk factors for longterm moderate or severe tricuspid regurgitation after operations. Results (1) There were no deaths during the perioperative period, and postoperative transthoracic echocardiography of all patients indicated that tricuspid regurgitation was mild or less. (2) Survival rate at 5 years, 10 years after operations in MVP group was 98.4%, 95.0%, respectively, and survival rate at 5 years, 10 years after operations in MVP+TVP group was 100.0%, 93.7%, respectively, and there was no significant difference in the survival rate after operations between the two groups(P=0.311), butthere was a significant difference in the freedom from longterm moderate or severe tricuspid regurgitation after operations between the two groups (P=0.040). Multivariate Cox regression showed that preoperative pulmonary artery pressure gt;30 mm Hg (95%CI 1.127 to 137.487, P=0.040 )and atrial fibrillation (95%CI 1.177 to 23.378, P=0.030) wereindependent risk factors for longterm moderate or severe tricuspid regurgitation afteroperations.Conclusion TVP is necessary for most patients undergoing MVP for moderate or severe mitral regurgitation due to myxomatous degeneration who have coexistent mild functional tricuspid regurgitation, especially those patients with preoperative pulmonary artery pressure gt;30 mm Hg or atrial fibrillation.
Objective To investigate the feasibility and effect of stentedpulmonary autograft replacement and find out the best way to treat mitral valve diseases. Methods From August 2006 to October 2007, 20 male sheep at the age of about 1 year old underwent mitral valves replacement operation in Anzhen Hospital. Weight of these sheep was 50.0±6.0 kg. They were randomly divided into two groups. Ten sheep in the experimental group underwent RossⅡsurgery in which we first sutured pulmonary valve onto a pulmonary valve stent, transferred the valve to the mitral valve annulus and then reestablished the outflow tract of the right ventricle. The other 10 sheep in the control group underwent bioprosthetic valve replacement routinely. Ultrasonic cardiogram (UCG) was employed 6 hour after operation to measure the effective orifice area (EOA) of the mitral valve, mitral peak velocity of early filling, the peak pressure gradient (PPG), the extent of regurgitation, left ventricular enddiastolic dimension (LVEDD) and ejection fraction (EF). Results One sheep in the experimental group died of low cardiac output syndrome; one in the control group died of unmanageable bleeding during operation, and the others all survived. Six hours after operation, UCG of the experimental group showed that the heart valves were well fixed, valve echo was clear, and there was no perivalvular leakage or mitral valve stricture or regurgitation, but moderate pulmonary valve regurgitation occurred in 1 case and mild in 2. There was no significant difference between the two groups in PPG (11.86±1.28 mm Hg vs. 10.98±0.98 mm Hg,t= 1.670,P=0.110) and the mitral peak velocity of early filling (1.72±0.09 m/s vs. 1.65±0.07 m/s, t=1.680,P=0.110). However, EOA of the experimental group was smaller than the control group (2.23±0.09 cm2 vs. 2.39±0.08 cm2, t= 4.240,P= 0.001). Conclusion The experimental result of sheep mitral valves replacement with stentedpulmonary autograft is satisfying. The new mitral valves work well and the surgery method is feasible.
ObjectiveTo investigate heart rhythm outcomes of radiofrequency ablation (RFA)of atrial fibrillation (AF)during mitral valve replacement (MVR)for patients with rheumatic heart disease (RHD), and explore clinical results of radiofrequency catheter ablation (RFCA)for postoperative atrial tachycardia (AT).
MethodsEleven RHD patients who developed AT after RFA of AF during MVR were enrolled in this study. There were 4 males and 7 females with their age of 49±8 years. Electroanatomic mapping of the left or right atrium was conducted with three-dimensional electroana-tomic mapping system during continuous AT. RFCA was performed at the key areas of AT.
ResultsFor MVR, operation time was 149±18 minutes, postoperative hospital stay was 9.5±2.9 days, and length of ICU stay was 1.8±0.4 days. During electroanatomic mapping, 17 ATs were recorded in 11 patients. Six ATs (35%)of 5 patients originated from the right atrium and 11 ATs (65%)of 6 patients originated from the left atrium (LA). Among them, AT of 2 patients was related to the mitral valve ring. Immediate success of RFCA was obtained in 91% (10/11). After a mean follow-up of 17±4 months, 2 patients whose AT originated from LA had AT recurrence.
ConclusionsMajority of postoperative ATs originate from LA, and majority of ATs are not mitral-dependent. RFCA is an effective and safe procedure for AT in patients after RFA of AF during MVR.
Abstract： Objective To determine the influence of preoperative atrial fibrillation （AF） on midterm and longterm clinical outcomes of patients after mitral valve replacement （MVR）. Methods We retrospectively analyzed clinical data of 1 029 patients who underwent MVR with or without tricuspid valve repair in Changhai Hospital， Second Military Medical University， from January 2000 to December 2005. According to the exclusion criteria， 621 patients were selected and divided into two groups depending on presence of preoperative AF. Those 395 patients with preoperative AF belonged to the AF group， including 134 males and 261 females with their average age of 51.1±11.5 years. Those 226 patients with preoperative sinus rhythm （SR） were in the SR group， including 82 males and 144 females with their average age of 48.2±14.1 years. Early postoperative outcomes， midterm and longterm mortality and morbidity of the two groups were compared. Results During 10 years of follow-up， there was no statistical difference in early postoperative mortality and morbidity between the two groups， but the incidence of late thromboembolism was significantly higher in AF group than that in SR group ［0.9‰ （31 patients/33 984 patient-months） vs. 0.4‰ （9 patients/21 151 patient-months）， χ2=4.26， P=0.039］. Ten-year survival rate in patients in AF group was significantly lower than that in SR group （83.2% vs. 92.7%， χ2=10.26， P=0.002）. Multivariate analysis identified preoperative AF ［HR=2.878， 95% CI （1.166，4.129）］， low left ventricular ejection fraction ［HR=0.948， 95% CI （0.917，0.981）］ ， and old age ［HR=1.073， 95% CI （1.038，1.109）］ as independent risk factors for late mortality after MVR. Apart from its influence on patient survival rate and incidence of thromboembolism， preoperative AF also had an adverse effect on left ventricular function， right ventricular function and tricuspid regurgitation. Conclusion AF is an independent risk factor for poor prognosis after MVR. Prognosis after MVR might be improved if surgery could be performed early when patients have predictive signs of AF such as multiple premature atrial contractions or left atrium enlargement.
ObjectiveTo compare the outcomes of concomitant mitral valve surgery and tricuspid valve surgery through right minithoracotomy and conventional median sternotomy approaches.
MethodsWe retrospectively analyzed clinical data of 475 patients underwent mitral valve surgery combined with tricuspid valve surgery through right minithoracotomy or conventional median sternotomy in Xinhua Hospital between June 2006 and June 2013. The patients were divided into two groups including a minimally invasive group(116 patients) and a conventional group (359 patients).
ResultsAll the patients successfully underwent mitral valve and tricuspid valve surgery. During operation, there were 426 patients with no trivial mitral regurgitation (MR) and 49 patients with trivial MR. There were 282 patients with no tricuspid regurgitation (TR) and 193 patients with trivil TR. At discharge, transesophageal echocardiography showed that trivial MR in 38 patients, mild MR in 5 patients, trivial tricuspid regurgitation (TR) in 150 patients and mild TR in 7 patients. There was no significant difference between the two groups in complications.
ConclusionRight minithoracotomy can achieve the similar therapeutic effect to conventional median sternotomy for patients with mitral valve disease and concomitant tricuspid valve disease. In addition, patients through right minithoracotomy had better cosmetic outcomes.
ObjectiveTo conclude the outcomes of mitral valve repair for mitral bileaflet prolapse.
MethodsWe retrospectively analyzed the clinical data of 14 patients with mitral bileaflet prolapse in our hospital between June 2010 and March 2013. There were 10 males and 4 females with at age of 46.9±12.0 years. We used one technique in 4 patients, two techniques in 9 patients, three techniques in 1 patient.
ResultsMean follow-up time was 13.1±7.2 months. There was no perioperative death. No reoperation occurred. No or trace mitral regurgitation (MR) was found in 13 patients. Slight MR was found in one patient.
ConclusionThe early metaphase results of mitral valve repair for mitral bileaflet prolapse are satisfactory if the appropriate surgery method is chosen.
Abstract: Objective To summarize the clinical results of homemade flexible annuloplasty ring in mitral valve repair, in order to discuss the appropriate ring size. Methods Sixtysix patients (55 males,and 11 females with a mean age of 44.62±15.94 years) with mitral insufficiency underwent mitral valve repair with homemade flexible annuloplasty ring from April 2002 to November 2009 in Fu Wai Hospital. In order to choose the ring with an appropriate size, we made and kept to the following principles: if the intercommissural distance was bigger than size 30, we chose a ring 2size smaller; if the measured distance was smaller than size 30, 1size smaller ring would be chosen. Patients were followed by echocardiography to observe the mitral valve function. Results All patients were cured and discharged from the hospital. The results of echocardiography showed mild to moderate regurgitation in 1 patient, mild regurgitation in 11 patients, and normal mitral function or trace regurgitation in the rest 54 patients. Mitral valve forward velocity was 1.40±0.30 m/s with no mitral stenosis or systolic anterior motion (SAM) of the anterior mitral leaflet. Fiftyone patients were followed up from 2 months to 7 years(24.60±25.90 months). The results of echocardiography on 38 patients showed that 1 patient had moderate regurgitation, 5 patients had mild to moderate regurgitation, 9 patients had mild regurgitation and others had normal mitral function or trace regurgitation. For these 38 patients included in the followup study, mitral valve forward velocity was 1.50±0.40 m/s with no mitral stenosis, SAM or left ventricular outlet tract obstruction. During the followup, the left atrium size (43.19±10.48 mm vs. 48.59±9.40 mm, t=4.524, P=0.000) and left ventricular end diastolic diameter (52.64±7.35 mm vs. 6269±8.77 mm, t=7.607, P=0.000) decreased significantly than the preoperative size and diameter respectively. The application of restrictive homemade flexible annuloplasty ring in mitral valve annuloplasty had satisfactory, durable and stable clinical results.
