Background: Clinical and echocardiographic results of valve repair for mitral regurgitation in the setting of atrial fibrillation are poorly studied. Methods: Between January 2008 and December 2020... Show moreBackground: Clinical and echocardiographic results of valve repair for mitral regurgitation in the setting of atrial fibrillation are poorly studied. Methods: Between January 2008 and December 2020, 89 patients underwent valve repair for mitral regurgitation in the setting of atrial fibrillation. Clinical and echocardiographic follow-up data were collected and studied. The primary composite endpoint consisted of all-cause mortality or hospitalization for heart failure. Results: Valve repair with true-sized annuloplasty was performed in 83 (93 %) and restrictive annuloplasty in 6 (7 %) patients. Early mortality occurred in 3 (3 %) and residual mitral regurgitation in 1 (1 %) patient. During a median follow-up of 5.4 years (interquartile range 3.4–9.5), 25 patients died, 6 due to end-stage heart failure. Ten patients were hospitalized for heart failure. The estimated event-free survival rate at 10 years was 48.2 % (95 % CI 33.5 %–62.9 %). Recurrent mitral regurgitation was observed in 14 patients and most often caused by leaflet tethering. When analyzed as a time-dependent variable, recurrent regurgitation was related to the occurrence of the primary endpoint (hazard ratio 3.192, 95 % CI 1.219–8.359, p = 0.018). On exploratory sub-analyses, no recurrent regurgitation was observed after restrictive annuloplasty or in patients with paroxysmal atrial fibrillation. Moreover, recurrent regurgitation was observed more often when signs of left ventricular impairment were present preoperatively. Conclusions: Despite good initial results, recurrent regurgitation was a frequent observation after valve repair for mitral regurgitation in atrial fibrillation and had an effect on heart failure related morbidity and mortality. Refinements in the timing of surgery and surgical technique might help improve outcomes. Show less
Mathari, S. el; Tomsic, A.; Kharbanda, R.K.; Zappala, P.; Wijnmaalen, A.P.; Klautz, R.J.M.; ... ; Palmen, M. 2024
ObjectivesThis study aims to investigate the occurrence, type and correlation of early and late atrial arrhythmias following mitral valve repair in patients with no preoperative history of atrial... Show moreObjectivesThis study aims to investigate the occurrence, type and correlation of early and late atrial arrhythmias following mitral valve repair in patients with no preoperative history of atrial arrhythmias.MethodsPatients undergoing mitral valve (MV) repair for degenerative disease were included. Early and late postoperative electrocardiograms were evaluated for the incidence and type of atrial arrhythmia (atrial fibrillation [AF] or atrial tachycardia [AT]).ResultsThe 192 patients were included. Early atrial arrhythmias occurred in 100/192 (52.1%) patients; AF in 61 (31.8%) patients, early AT in 15 (7.8%) and both in 24 (12.5%). In total 89% of patients were discharged in sinus rhythm. During a follow-up time of 7.3 years, 14 patients (7.3%) died and 49 (25.5%) patients developed late atrial arrhythmias. At 10 years, the cumulative incidence of any late atrial arrhythmia, with death as competing risk, was 64% (95% confidence interval [CI] = 55%–72%). On Fine-Gray model analysis, only early postoperative AF lasting >24 h was related to the development of late AF (hazard ratio 5.99, 95% CI = 1.78%–20.10%, p = .004). Early postoperative ATs were related to the development of late tachycardias, independent of their duration (<24 h hazard ratio 4.25, 95% CI = 1.89–9.57, p = .001 and >24 h hazard ratio 3.51, 95% CI = 1.65–7.46, p = .001).ConclusionsEarly and late atrial arrhythmias were common after MV repair surgery. Only early postoperative AF lasting >24 h was a risk factor for the occurrence of late AF. Conversely, any postoperative AT was correlated to the development of late ATs. Show less
Tomsic, A.; Weger, A. de; Stoel, M. van der; Klautz, R.J.M.; Palmen, M.; Cardiothoracic Surg Registration 2024
BackgroundReal-world evidence supporting the reproducibility and superiority of valve repair over replacement in active mitral valve infective endocarditis is lacking.MethodsData from a prospective... Show moreBackgroundReal-world evidence supporting the reproducibility and superiority of valve repair over replacement in active mitral valve infective endocarditis is lacking.MethodsData from a prospective nationwide database, including all cardiac surgical procedures in The Netherlands, were used. Adult patients undergoing primary mitral valve intervention who had a diagnosis of active infective endocarditis and who underwent surgery between 2013 and 2020 were included. Survival analysis was performed for the whole follow-up period as well as after applying the landmark of 90 days.ResultsOf 715 patients who met the inclusion criteria, 294 (41.1%) underwent valve repair. Mitral valve repair rates decreased slightly over the course of the study. The early mortality rate was 13.0%, and a trend of steadily declining early mortality rates over the course of the study, despite a steady increase in patient complexity, was observed. On risk-adjusted analysis, mitral valve replacement demonstrated inferior results when compared with valve repair (adjusted hazard ratio, 2.216; 95% CI, 1.425-3.448; P < .001), even after a landmark analysis was performed (adjusted hazard ratio 2.489; 95% CI, 1.124-5.516; P = .025). These results were confirmed by a propensity score–adjusted analysis (adjusted hazard ratio 2.251; 95% CI, 1.029-4.21; P = .042).ConclusionsContemporary trends in mitral valve surgery for active infective endocarditis suggest growing patient complexity but slightly declining early mortality rates. A trend of decreasing mitral valve repair rates was seen. The results of this study suggest improved late outcomes of valve repair compared with valve replacement. Show less
Surgical mitral valve repair through median sternotomy has long presented the treatment of choice for degenerative mitral valve disease. In recent decades, minimal invasive surgical techniques have... Show moreSurgical mitral valve repair through median sternotomy has long presented the treatment of choice for degenerative mitral valve disease. In recent decades, minimal invasive surgical techniques have been developed and are now gaining widespread popularity. Robotic cardiac surgery presents an emerging field, initially adopted only by selected centres, mostly in the United States. In recent years, the number of centers interested in robotic mitral valve surgery has grown with an increasing adoption in Europe as well. Increasing interest and surgical experience gained are stimulating further developments in the field and the full potential of robotic mitral valve surgery remains to be developed. Show less
BACKGROUND The effect of an "aggressive" approach on the aortic root in acute type A aortic dissection (ATAAD) remains insufficiently explored. METHODS Retrospective analysis was conducted between... Show moreBACKGROUND The effect of an "aggressive" approach on the aortic root in acute type A aortic dissection (ATAAD) remains insufficiently explored. METHODS Retrospective analysis was conducted between 1992 and 2020 of a single-center, prospective cohort of consecutive patients aged double dagger 18 years diagnosed with ATAAD. Patients were divided into 2 groups: aortic root replacement (ARR; prosthetic or valve-sparing root replacement, n = 141) and conservative root approach (CRA; root sparing of partially dissected root, n = 90; and supracoronary ascending replacement in nondissected root, n = 68). Inverse probability weighting was used to compare patients with different preoperative characteristics. Mean follow-up was 5.1 (0-21) years in ARR and 7.1 (0-25) years in CRA. RESULTS The frequency of ARR increased over the years, with 19% and 78% of patients undergoing ARR in the earliest and most recent periods, respectively. Early mortality decreased over the years, despite a more aggressive approach, and remained lower in ARR. CRA was associated with a higher hazard of late mortality (hazard ratio, 1.38; 95% CI, 1.12-1.68; P = .001) and reintervention (hazard ratio, 2.08; 95% CI, 1.44-3.56; P = .001). After CRA, new-onset aortic valve insufficiency was a common cause of reintervention. CONCLUSIONS Over the years, there was a gradual increase in the root replacement approach in ATAAD. Root replacement was associated with better long-term survival and fewer reinterventions compared with the conservative approach, whereas the in-hospital mortality decreased during these years. Hence, aggressive root replacement is safe and may be applied in ATAAD with good long-term clinical results, without increased hospital mortality.(Ann Thorac Surg 2023;115:1396-402)(c) 2023 by The Society of Thoracic Surgeons Show less
Tomsic, A.; Klautz, R.J.M.; Borger, M.A.; Palmen, M. 2023
Surgical mitral valve repair, performed either through median sternotomy or minimal invasive approach, presents the gold standard treatment for degenerative mitral valve disease. In dedicated... Show moreSurgical mitral valve repair, performed either through median sternotomy or minimal invasive approach, presents the gold standard treatment for degenerative mitral valve disease. In dedicated centres, high repair and low complication rates have been established with excellent valve repair durability. Recently, new techniques have been introduced, that allow mitral valve repair to be performed through small surgical incisions and while avoiding cardio-pulmonary bypass. These new techniques, however, conceptually differ significantly when compared to surgical repair and it remains questionable whether they are capable of reproducing the results of surgical treatment. Show less
Growing interest in minimalizing surgical trauma during heart procedures stimulated the development of robotic mitral valve surgery in the late 1990s. Initially, the new technology was slowly... Show moreGrowing interest in minimalizing surgical trauma during heart procedures stimulated the development of robotic mitral valve surgery in the late 1990s. Initially, the new technology was slowly adopted in clinical practice. However, following encouraging results by teams that adopted robotic heart surgery early on, a growing interest in implementation of robotic mitral valve surgery has emerged. Of importance are the technical developments and possibilities that accompany robotic surgery.Robotic arms feature unique characteristics, allowing unparalleled range of motion and allowing complex mitral valve repair techniques to be performed without limitations related to limited surgical incisions. High-quality three-dimensional vision effectively compensates for the lack of tactile feedback.Several technical solutions have been developed to facilitate mitral valve repair in minimal invasive setting, including chordal guiding systems, now available with various annuloplasty rings. On the other hand, precise vision and movements allows accurate determination of the length of implanted neochordae, facilitating precise determination of the length of implanted neochords even without the use of chordal-guiding systems. With robotic mitral valve surgery, leaflet resection techniques can be performed without limitations, ensuring that no compromises of the surgical strategy are made. Nevertheless, careful preoperative planning with appropriate work-up and imaging is of utmost importance to prevent complications. Moreover, the drawbacks of the initial learning curve and higher procedural costs are counterbalanced by less surgical trauma, lower utilization of blood products, and faster patient recovery. Robotic mitral valve surgery is still a young field and evolving technology that is bound to become an important tool in the toolbox of surgical mitral valve approaches. Show less
Palmen, M.; Navarra, E.; Bonatti, J.; Franke, U.; Cerny, S.; Musumeci, F.; ... ; Pereda, D. 2022
Objective: Posterior mitral valve leaflet prolapse repair can be performed by leaflet resection or chordal replacement techniques. The impact of these techniques on left ventricular function... Show moreObjective: Posterior mitral valve leaflet prolapse repair can be performed by leaflet resection or chordal replacement techniques. The impact of these techniques on left ventricular function remains a topic of debate, considering the presumed better preservation of mitral-ventricular continuity when leaflet resection is avoided. We explored the effect of different posterior mitral valve leaflet repair techniques on postoperative left ventricular function. Methods: In total, 125 patients were included and divided into 2 groups: leaflet resection (n=82) and isolated chordal replacement (n=43). Standard and advanced echocardiographic assessments were performed preoperatively, directly postoperatively, and at late follow-up. In addition, left ventricular global longitudinal strain was measured and corrected for left ventricular end-diastolic volume to adjust for the significant changes in left ventricular volumes. Results: At baseline, no significant intergroup difference in left ventricular function was observed measured with the corrected left ventricular global longitudinal strain (resect: 1.76% +/- 0.58%/10 mL vs respect: 1.70% +/- 0.57%/10 mL, P=.560). Postoperatively, corrected left ventricular global longitudinal strain worsened in both groups but improved significantly during late follow-up, returning to preoperative values (resect: 1.39% +/- 0.49% to 1.71% +/- 0.56%/10 mL, P<.001 and respect: 1.30% +/- 0.45% to 1.70% +/- 0.54%/10 mL, P<.001). Mixed model analysis showed no significant effect on the corrected left ventricular global longitudinal strain when comparing the 2 different surgical repair techniques over time (P=.943). Conclusions: Our study showed that both leaflet resection and chordal replacement repair techniques are effective at preserving postoperative left ventricular function in patients with posterior mitral valve leaflet prolapse and significant regurgitation. Show less
Meucci, M.C.; Stassen, J.; Tomsic, A.; Palmen, M.; Crea, F.; Bax, J.J.; ... ; Delgado, V. 2022
Objective Left atrial (LA) and left ventricular (LV) mechanics are impaired in patients with atrial functional mitral regurgitation (AFMR), but their prognostic value in this subset of patients... Show moreObjective Left atrial (LA) and left ventricular (LV) mechanics are impaired in patients with atrial functional mitral regurgitation (AFMR), but their prognostic value in this subset of patients remains unknown. The present study aimed to evaluate the association between LA and LV longitudinal strain and clinical outcomes in patients with AFMR. Methods A total of 197 patients (mean age 73 +/- 10 years, 44% men) with at least moderate AFMR were retrospectively identified. LV global longitudinal strain (GLS) and left atrial reservoir strain (LAS) were calculated by two-dimensional speckle tracking echocardiography. All-cause mortality was the primary endpoint of the study. The threshold value of LV GLS (<= 16.3%) to identify impaired LV mechanics was defined based on the risk excess of the primary endpoint described with a spline curve analysis. Results Impaired LV GLS (<= 16.3%) was found in 89 (45%) patients. During a median follow-up of 69 months, 45 (23%) subjects experienced the primary endpoint. Patients with impaired LV GLS (<= 16.3%) had a significantly lower cumulative survival rate at 5 years, as compared with patients with LV GLS (>16.3%) (74% vs 93%, p<0.001). On multivariable Cox regression analysis, LV GLS expressed as continuous variable was independently associated with the occurrence of all-cause mortality (HR 0.856, 95% CI 0.763 to 0.960; p=0.008) after adjustment for age, LAS, pulmonary artery systolic pressure and severe tricuspid regurgitation. Conversely, LAS was not significantly associated with patients' outcome. Conclusions In patients with significant AFMR, the impairment of LV GLS was independently associated with worse outcomes. Show less
ObjectivePosterior mitral valve leaflet prolapse repair can be performed by leaflet resection or chordal replacement techniques. The impact of these techniques on left ventricular function remains... Show moreObjectivePosterior mitral valve leaflet prolapse repair can be performed by leaflet resection or chordal replacement techniques. The impact of these techniques on left ventricular function remains a topic of debate, considering the presumed better preservation of mitral-ventricular continuity when leaflet resection is avoided. We explored the effect of different posterior mitral valve leaflet repair techniques on postoperative left ventricular function.MethodsIn total, 125 patients were included and divided into 2 groups: leaflet resection (n = 82) and isolated chordal replacement (n = 43). Standard and advanced echocardiographic assessments were performed preoperatively, directly postoperatively, and at late follow-up. In addition, left ventricular global longitudinal strain was measured and corrected for left ventricular end-diastolic volume to adjust for the significant changes in left ventricular volumes.ResultsAt baseline, no significant intergroup difference in left ventricular function was observed measured with the corrected left ventricular global longitudinal strain (resect: 1.76% ± 0.58%/10 mL vs respect: 1.70% ± 0.57%/10 mL, P = .560). Postoperatively, corrected left ventricular global longitudinal strain worsened in both groups but improved significantly during late follow-up, returning to preoperative values (resect: 1.39% ± 0.49% to 1.71% ± 0.56%/10 mL, P < .001 and respect: 1.30% ± 0.45% to 1.70% ± 0.54%/10 mL, P < .001). Mixed model analysis showed no significant effect on the corrected left ventricular global longitudinal strain when comparing the 2 different surgical repair techniques over time (P = .943).ConclusionsOur study showed that both leaflet resection and chordal replacement repair techniques are effective at preserving postoperative left ventricular function in patients with posterior mitral valve leaflet prolapse and significant regurgitation. Show less
Study objective: The added value of computed tomography (CT) follow-up after elective proximal aortic surgery is unclear. We evaluated the benefit of CT follow-up by assessing the incidence of... Show moreStudy objective: The added value of computed tomography (CT) follow-up after elective proximal aortic surgery is unclear. We evaluated the benefit of CT follow-up by assessing the incidence of aorta-related complications and reinterventions detected during routine CT follow-up. Methods: Data on 314 patients undergoing first time elective proximal aortic surgery between 2000 and 2015 were collected. The primary study end points were aorta-related complications and reinterventions, detected during routine CT follow-up. Secondary study endpoints included all aorta-related complications and reinterventions, irrespective of the mode of detection and survival. Results: Median CT follow-up time was 6.8 (IQR 4.1-9.8) years, during which a total of 1303 routine follow-up CT-scans (median 4, IQR 3-5) were performed. During CT follow-up, aorta-related complications were detected in 18 (5.7%) patients, of which 6 (1.6%) underwent reintervention. In total, 28 aorta-related complications were observed in 23 (7.3%) patients, of which 9 led to reintervention. In order to detect 1 aorta-related complication leading to reintervention, 218 routine followup CT-scans were required. The unadjusted and EuroSCORE II adjusted hazard ratios of not undergoing CT follow-up on mortality were 1.260 (95% CI 0.705-2.251) and 0.830 (95% CI 0.430-1.605), respectively. Conclusions: Following first time elective proximal aor tic surgery, aor ta-related complications are uncommon, are not always detected during CT follow-up and, if detected, often do not result in reintervention. Therefore, a more conservative CT follow-up protocol could be considered in selected patients to reduce lifetime radiation burden and health care costs. Show less
The optimal choice of graft material in patients >= 70 years of age undergoing coronary artery bypass grafting remains unknown. A systematic review of literature was conducted by searching... Show moreThe optimal choice of graft material in patients >= 70 years of age undergoing coronary artery bypass grafting remains unknown. A systematic review of literature was conducted by searching PubMed, Embase, Web of Science, and Cochrane Library databases for original publications that compared bilateral internal thoracic artery (BITA) grafting with single internal thoracic artery grafting in patients >= 70 years of age. Data were extracted by 2 independent investigators and meta-analyzed with the use of random effects. A total of 10 studies, including 11,185 patients, met the inclusion criteria. No differences in early mortality and morbidity, with the exemption of sternal wound complications which were more frequently observed in the BITA group (odds ratio 1.72, 95% 1.00 to 2.96 confidence interval [CI], p = 0.05; propensity score-matched population odds ratio 1.58, 95% CI 1.09 to 2.29, p = 0.02), were observed. Overall survival was superior in the overall patient popu-lation (hazard ratio [HR] 0.76, 95% CI 0.66 to 0.86, p < 0.001), after applying a blanking period of 3 months to the overall patient population (HR 0.77, 95% CI 0.64 to 0.92, p = 0.005) as well as in the matched population (HR 0.72, 95% CI 0.58 to 0.89, p = 0.002); in all cases, a benefit was readily seen within a few years after surgery. The difference in freedom from major adverse cardiac and cerebrovascular events failed to reach statistical significance (overall patient population HR 0.55, 95% CI 0.27 to 1.13, p = 0.10; matched population HR 0.52, 95% CI 0.23 to 1.16, p = 0.11). In conclusion, BITA grafting can be safely performed in patients >= 70 years of age as late clinical benefits are expected to mani-fest themselves readily within a few years after surgery. (C) 2022 The Author(s). Published by Elsevier Inc. Show less
OBJECTIVES: Barlow's disease (BD) is characterized by thick, redundant mitral valve (MV) leaflets, which can lead to prolapse and significant mitral regurgitation (MR). MV annular abnormalities are... Show moreOBJECTIVES: Barlow's disease (BD) is characterized by thick, redundant mitral valve (MV) leaflets, which can lead to prolapse and significant mitral regurgitation (MR). MV annular abnormalities are also commonly observed and increasingly recognized as possible primary pathology, with leaflet thickening being secondary to increased stress on the MV apparatus. To provide more insights into this hypothesis, the evolution of MV abnormalities over time in patients with BD was assessed.METHODS: A total of 64 patients (54 +/- 12 years, 72% male) with BD who underwent MV surgery and had multiple transthoracic echocardiograms (HE) before surgery were included. In total, 186 TTE were analysed (median time interval 4.2, interquartile range 2.2-6.5 years) including specific MV characteristics.RESULTS: At baseline, MV leaflet length, thickness, billowing height and annular diameter were larger in patients with BD compared to 59 healthy subjects. Systolic outward motion (curling) of the annulus was observed in 77% and severe mitral annular disjunction (>= 5 mm) in 38% of patients with BD. Forty (63%) patients had MR grade I-Il and 24 (37%) MR grade III-IV; at baseline, the 2 groups only differed in left atrial volume and in thickness and billowing height of the posterior leaflet, showing comparable MV annular abnormalities and dilatation despite different grades of MR. Over time, MV annulus diameter, leaflet length and billowing height increased significantly along with MR grade.CONCLUSIONS: In patients with BD, MV annulus abnormalities are present at an early stage and precede the development of significant MR, suggesting their substantial role in the pathophysiology of this disease and as an important target for surgical treatment. Show less
The aim of the thesis is to assess the current status of reconstructive mitral valve surgery. The thesis focuses on the technical aspects of mitral valve surgery as well as the perioperative care... Show moreThe aim of the thesis is to assess the current status of reconstructive mitral valve surgery. The thesis focuses on the technical aspects of mitral valve surgery as well as the perioperative care related hereto. The timing of surgery plays a vital role in ensuring optimal clinical results and unnecessary delay of surgical intervention results in a higher risk of operation. The presented results, characterized by low morbidity and mortality rates, need to be taken into account when a treatment strategy is formed. The described systematic approach to various types of mitral valve disease and technical aspects of surgical correction offer the opportunity to apply a truly patient-tailored approach in these patients. Moreover, the pathophysiological concepts and the effect hereof on the surgical strategy of mitral valve repair are studied. The results presented will hopefully stimulate further research in this field, contributing to further improvements in the field of reconstructive mitral valve surgery. Show less
Objective The hemodynamic effect and early and late survival impact of prosthesis-patient mismatch (PPM) after mitral valve replacement remains insufficiently explored. Methods Pubmed, Embase, Web... Show moreObjective The hemodynamic effect and early and late survival impact of prosthesis-patient mismatch (PPM) after mitral valve replacement remains insufficiently explored. Methods Pubmed, Embase, Web of Science, and Cochrane Library databases were searched for English language original publications. The search yielded 791 potentially relevant studies. The final review and analysis included 19 studies compromising 11,675 patients. Results Prosthetic effective orifice area was calculated with the continuity equation method in 7 (37%), pressure half-time method in 2 (10%), and partially or fully obtained from referenced values in 10 (53%) studies. Risk factors for PPM included gender (male), diabetes mellitus, chronic renal disease, and the use of bioprostheses. When pooling unadjusted data, PPM was associated with higher perioperative (odds ratio [OR]: 1.66; 95% confidence interval [CI]: 1.32-2.10;p < .001) and late mortality (hazard ratio [HR]: 1.46; 95% CI: 1.21-1.77;p < .001). Moreover, PPM was associated with higher late mortality when Cox proportional-hazards regression (HR: 1.97; 95% CI: 1.57-2.47;p < .001) and propensity score (HR: 1.99; 95% CI: 1.34-2.95;p < .001) adjusted data were pooled. Contrarily, moderate (HR: 1.01; 95% CI: 0.84-1.22;p = .88) or severe (HR: 1.19; 95% CI: 0.89-1.58;p = .24) PPM were not related to higher late mortality when adjusted data were pooled individually. PPM was associated with higher systolic pulmonary pressures (mean difference: 7.88 mmHg; 95% CI: 4.72-11.05;p < .001) and less pulmonary hypertension regression (OR: 5.78; 95% CI: 3.33-10.05;p < .001) late after surgery. Conclusions Mitral valve PPM is associated with higher postoperative pulmonary artery pressure and might impair perioperative and overall survival. The relation should be further assessed in properly designed studies. Show less
