Mitral valve disease is one of the most popular heart valve diseases. Precise positioning and displaying of the valve characteristics is necessary for the minimally invasive mitral valve repairing procedures. This paper presents a multi-resolution elastic registration method to compute the deformation functions constructed from cubic B-splines in three dimensional ultrasound images, in which the objective functional to be optimized was generated by maximum likelihood method based on the probabilistic distribution of the ultrasound speckle noise. The algorithm was then applied to register the mitral valve voxels. Numerical results proved the effectiveness of the algorithm.
With the expanding indications for transcatheter aortic valve replacement (TAVR) guidelines, combined valvular disease is often encountered in the clinic, and existing relevant studies have shown that preoperative moderate to severe mitral regurgitation is associated with higher mortality. In these patients, the optimal treatment strategy for TAVR with evidence-based heart failure, TAVR with transcatheter mitral intervention, or staging transcatheter therapy are unclear. Therefore, a comprehensive assessment of the anatomy and function of the aortic and mitral valves, as well as an in-depth assessment of the patient’s baseline risk profile, are the basis for an individualized approach to treatment. This article will review the results of the relevant research to better help clinicians diagnose and treat relevant patients.
Objective
To evaluate the safety and efficacy of biatrial Cox Maze Ⅳ cryoablation for concomitant atrial fibrillation (AF) during minimally invasive valve surgery.
Methods
A total of 47 patients (26 males, 21 females, age of 42-69 years) with mitral valve disease and long-standing persistent AF received minimally invasive biatrial Cox Maze Ⅳ cryoablation procedure combined with mitral valve surgery through right minithoracotomy from January 2014 to September 2015. The etiology of mitral valve disease was rheumatic (n=31) and degenerative (n=16). AF duration ranged from 2 to 11 years. Diameter of the left atrium ranged from 43 to 60 mm. Concomitant biatrial Cox Maze Ⅳ cryoablation procedure was performed through right lateral minithoracotomy.
Results
All 47 patients successfully underwent this minimally invasive concomitant biatrial Cox Maze Ⅳ cryoablation procedure and valve surgery. No patient needed conversion to sternotomy during the surgery. The mean cardiopulmonary bypass time, aortic cross-clamp time and cryoablation time was 95-146 (120.3±12.3) min, 82-115 (93.3±7.7) min and 32-48 (38.6±4.5) min, respectively. There was no death perioperatively. The average postoperative length of hospital stay was 5-16 (7.9±1.9) d. At discharge, 44 patients (44/47, 93.6%) maintained sinus rhythm. At a mean follow-up of 6-26 (14.4±5.4) months, sinus rhythm was maintained in 41 patients (41/47, 87.2%). Cumulative maintenance rate of normal sinus rhythm without AF recurrence at one year postoperatively was 86.3%±5.8%.
Conclusion
Biatrial Cox Maze Ⅳ cryoablation procedure is safe, feasible and effective for AF during concomitant minimally invasive valve surgery.
Objective To investigate the effect of edgetoedge mitral valve plasty on left ventricular diastolic function and in order to find the validity and safety of this procedure. Methods From Feb. 2006 to Dec. 2007, thirty cases with mitral regurgitation were divided into two groups. Quadrangular resection was performed on fifteen cases with posterior proplapse in control group, and edgetoedge mitral valve plasty was performed on fifteen cases with anterior or bileaflet proplapse in experimental group, and ring annuloplasty(Medtronic ring) was used in both groups. The hemodynamics were monitored and recorded with SwanGanz catheter at the time of postoperation，2 h, 4 h, 6 h and 12 h after operation. Left ventricular diastolic function was also evaluated with echocardiography using color Doppler and tissue Doppler imaging in the patients with sinus rhythm. The ratio of the peak E velocity and A velocity(E/A), the ratio of the early diastolic peak flow velocity to the early diastolic mitral valve annular movement velocity(E/Em), and the ratio of early diastolic mitral valve annular movement velocity to late diastolic mitral valve annular movement velocity（Em/Am）were measured before operation and 1 week after operation respectively. Results Mitralvalve area were significantly reduced at 1 week after operation compared with that before operation in both groups (control group 3.63±1.06 cm2 vs. 7.18±2.41 cm2, experimental group 3.44±1.02 cm2 vs. 6.51±3.06 cm2, Plt;0.05）; and mitral regurgitant grade were significantly reduced at 1 week after operation in both groups as well(control group 0.53±0.64 cm2 vs.3.60±0.51 cm2, experimental group 0.67±0.82 cm2 vs.3.40±0.63 cm2, Plt;0.05). However, there was no significant difference for mitral valve area and mitral regurgitant grade between two groups before and after operation（Pgt;0.05）. In experimental group, there were no significant change of evaluations of E/A,E/Em and Em/Am before and after operation（E/A 1.28±0.36 vs. 1.95±1.06,E/Em 8.79±2.16 vs. 8.13±3.02, Em/Am 1.39±0.38 vs. 1.31±041，Pgt;0.05). There was no significant change of pulmonary artery wedge pressure (PAWP) before and after operation between two groups（13.60±4.37 mm Hg vs.12.20±3.53 mm Hg, Pgt;0.05）. Conclusion Edgetoedge mitral valve plasty technique is available and has no significant influence on left ventricular diastolic function, and a doubleorifice mitral valve has similar hemodynamic change compared with a physiological mitral valve.
ObjectiveTo evaluate the changes of left ventricular structure and function by echocardiography and its grading of left ventricular diastolic function in patients with mitral valve prolapse treated by minimally invasive mitral valve repair.MethodsBy retrospective analysis, 37 patients including 25 males and 12 females aged 53.49±11.02 years with mitral valve prolapse who underwent minimally invasive mitral valve repair were as an operation group, and 34 healthy persons including 19 males and 15 females aged 54.26±8.33 years matched by age and sex were selected as a control group. Ultrasound parameters of every participant were routinely collected before operation, 1 month, 3 months, 6 months and 1 year after operation, and left ventricular diastolic function was graded. The ultrasound parameters between the two groups were compared.ResultsThe diameters of left ventricular end systolic and diastolic phase, left atrial diameter and left ventricular volume in the operation group were significantly smaller than those before operation. The diameters of left ventricle and left atrium after operation were significantly shorter than those before operation, but they were still larger than those of the control group. The ejection fraction value decreased significantly at one month after the operation and then returned to normal level. The incidence of left ventricular diastolic dysfunction at 6 months and 1 year after operation was significantly lower than that before operation (P<0.05).ConclusionMinimally invasive repair for patients with mitral valve prolapse can significantly improve systolic and diastolic functions of left ventricle while reconstructing left atrial and left ventricular structures.
In recent years, transcatheter mitral valve replacement is a focused issue in the field of valve intervention, which brings hope to mitral regurgitation patients who are not suitable for surgical thoracotomy. This paper presents the case of echocardiography-guided transseptal mitral valve replacement with the HighLife system in an elderly female patient with severe mitral regurgitation who failed to respond to standard medical therapy. During the procedure, echocardiography was used to guide the wire looping, cinching, atrial septal puncture, ring closure, atrial septal balloon dilatation, prosthetic valve implantation and immediate postoperative evaluation. Echocardiography plays an important role in transseptal mitral valve replacement, which can help the procedural process and improve the safety of the procedure.
ObjectiveTo monitor surgical quality and analyze learning curve of minimally invasive mitral valve replacement (MVR)through right minithoracotomy with cumulative sum analysis (CUSUM analysis).
MethodsClinical data of 60 consecutive patients who underwent minimally invasive MVR through right minithoracotomy in the Fourth Affiliated Hospital of Guangxi Medical University from June 2011 to April 2013 were retrospectively analyzed. There were 32 male and 28 female patients with their age of 28-53 (34.67±7.11)years and their heart function ranging from NYHA class Ⅱ to Ⅳ. There were 31 patients with mitral stenosis (MS), 19 patients with mitral regurgitation (MR), and 10 patients with MS and MR. According to the surgical sequence, all the patients were divided into 3 groups (group A, B and C)with 20 patients in each group. Surgical outcomes were compared among the 3 groups, and surgical quality was analyzed with descriptive statistics and CUSUM curves.
ResultsAortic cross-clamp time, cardiopulmonary bypass time and operation time of group C were significantly shorter than those of group A and group B (aortic cross-clamp time of group C vs. group A:50.35±2.30 minutes vs. 66.15±8.38 minutes; operation time of group C vs. group B:167.50±4.63 minutes vs. 178.60±4.49 minutes, P < 0.05). In-hospital mortality was 3.3% (2/60). CUSUM analysis showed a significant learning curve effect, although surgical quality remained in control during the study period. Surgical failure rate was lower than 80% after about 45 operations, indicating that failure rate was 10% lower than expectation.
ConclusionMinimally invasive MVR is safe and reliable, and CUSUM analysis is a simple statistical method to monitor surgical quality.
ObjectiveTo investigate the effect of concomitant tricuspid valve repair during mitral valve surgery on the early and mid-term prognosis of the tricuspid valve and right heart function in the patients with moderate or less tricuspid regurgitation. MethodsA retrospective study of 461 patients with mitral valve disease requiring cardiac surgery combined with moderate or less tricuspid regurgitation in our hospital from 2011 to 2014 was done. They were 309 males and 152 females with a median age of 53.00 (44.00, 60.00) years. According to whether they received tricuspid valve repair (Kay’s annuloplasty, DeVega’s annuloplasty or annular ring implantation), the patients were divided into a mitral valve surgery only group (a nTAP group, n=289) and a concomitant tricuspid valve repair group (a TAP group, n=172). At the same time, 43 patients whose tricuspid valve annulus diameter was less than 40 mm in the TAP group were analyzed in subgroups. ResultsThe median follow-up duration was 3.00 years (range from 0.10 to 9.30 years). There was no perioperative death. Three months after surgery, the anteroposterior diameter of the right ventricle in the TAP group was significantly improved compared with that in the nTAP group [–1.00 (–3.00, 1.00) mm vs. 0.00 (–0.20, 2.00) mm, P=0.048]. Three years after surgery, the improvement of right ventricular anteroposterior diameter in the TAP group was still significant compared with the nTAP group [–1.00 (–2.75, 2.00) mm vs. 2.00 (–0.75, 4.00) mm, P=0.014], and the patients in the TAP group were less likely to develop moderate or more tricuspid regurgitation (3.64% vs. 35.64%, P<0.001). Annuloplasty ring implantation was more effective in preventing regurgitation progression (P=0.044). For patients with a tricuspid annulus diameter less than 40 mm, concomitant tricuspid valve repair was still effective in improving the anteroposterior diameter of the right ventricle in the early follow-up (P=0.036). Conclusion Concomitant tricuspid valve repair for patients with moderate or less tricuspid regurgitation during mitral valve surgery can effectively improve the tricuspid valve and right heart function in the early and mid-term after surgery. Annuloplasty ring implantation is more effective in preventing regurgitation progression. Patients whose tricuspid annulus diameter is less than 40 mm can also benefit from concomitant tricuspid repair.
ObjectiveTo investigate the risk or protective factors for systemic embolism (SE) in patients undergoing bioprosthetic mitral valve replacement (MVR).
Methods Between October 2002 and March 2013, a total of 146 patients underwent bioprosthetic MVR. There were 78 females and 68 males with mean age of 66.23±5.17 years. The primary reason of mitral valve disease was mitral valve degeneration or mitral valve leaflet prolapse in 40 patients, rheumatic heart valve disease in 101 patients, ischemic heart disease in 3 patients, infectious endocarditis in 1 patient, and mechanical peri-valvular leak in 1 patient. All patients were given anticoagulation therapy with warfarin for 3 months. Thereafter, antithrombotic medication was prescribed according to the surgeon's preference. The patients were followed up by telephone or mail for postoperative condition and SE events.
ResultsSixteen (10.96%) patients developed SE events, including cerebral infarction in 13 cases, transient ischemic attack (TIA) in 2 cases and spleen infarction in 1 case. A total of 16 patients died during follow-up. The 1-year, 3-year, 5-year and 10-year cumulative survival rate after surgery was 95.2%, 93.6%, 92.5% and 88.3% respectively. Patients with SE events had lower rate of left atrial appendage obliteration than those without SE events (25.0% vs. 78.6%, P=0.015). Multivariate analysis showed that left atrial appendage obliteration was an independent protective factor for SE in patients undergoing bioprosthetic MVR (P=0.041).
ConclusionLeft atrial appendage obliteration is a major protective factor for systemic embolism in patients undergoing bioprosthetic MVR no matter what antithrombotic medication is taken.
Objective
To evaluate the short-term outcome and influence of atrial fibrillation ablation and mitral valve replacement for patients with mitral valve stenosis and atrial fibrillation.
Methods
Retrospective analysis was conducted for 44 patients with rheumatic mitral valve stenosis and atrial fibrillation who experienced mitral valve replacement with or without surgical atrial fibrillation ablation procedure in our hospital from January 2016 to June 2017. Eighteen patients experienced mitral valve replacement and surgical atrial fibrillation ablation procedure (a group 1), and the other 26 patients experienced mitral valve replacement without surgical atrial fibrillation ablation procedure (a group 2). In th group 1, there were 4 males and 14 females, aged 43-67 (55.67±7.56) years, and in the group 2 there were 6 males and 20 females, aged 40-72 (54.81±8.81) years. The patients’ data, preoperative echocardiography, surgery procedures, perioperative events, echocardiography and electrocardiogram at postoperative three months were collected to evaluate the short-term outcome and influence of surgical atrial fibrillation ablation procedure for those patients.
Results
There was no statistical difference in the operation duration (P=0.867) and ICU stay (P=0.550) between the two groups. But the group 1 had longer extracorporeal circulation duration (P=0.006) and aorta arrest duration (P=0.001) than the group 2. No patient died perioperatively and one patient from the group 1 experienced reoperation because of too much chest tube drainage. At three months after operation, echocardiography and electrocardiogram examination showed that 16 patients in the group 1 and 2 patients in the group 2 had sinus rhythm. There was no statistical difference between postoperative and preoperative examination about variation in left ventricle ejection fraction, pulmonary arterial systolic pressure, left atrial diameter and left ventricular end diastolic diameter between the two groups (all P>0.05).
Conclusion
Atrial fibrillation ablation does not increase the risk of mitral valve replacement for patients who have mitral valve stenosis and atrial fibrillation. The rate of converting to sinus rhythm is high, but additional atrial fibrillation ablation procedure does not have positive or negative influence on short-term recovery of cardiac structure and function after operation.
