Objectives: To assess the impact of valve pathology on the outcome of the modified preservation of the mitral valve apparatus during mitral valve replacement.Hypothesis: Preservation of mitral valve apparatus will improve outcomes of prosthetic mitral valve replacement for severe mitral valve regurgitation. Methods: This prospective analytic cohort study included 100 patients in two main groups: 50 patients with rheumatic mitral valve disease (group A) and non-rheumatic (group B): B1:25 patients with ischemic mitral lesions and B2:25patients with selected degenerative valve lesions admitted between 1st March 2022 and 28th Feb. 2024 at one but a good flow rate-center. All patients had modified preservation of the mitral apparatus during prosthetic mitral replacement. Additionally, Group B1 had bypass grafts to diseased coronary arteries. Group B2 had chordal transposition, folding or reattachment. Results: Pre-operative data did not show significant differences between groups (p > 0.05) but the smoking index was much higher in group B. Intraoperative Trans-Esophageal Echocardiography showed free mobility of prosthetic leaflets, left ventricular outflow tract free of any obstruction and freedom from any valve-related complications in the groups. Cross-clamp and recovery times were shorter in group A (p = 0.0001) & early mortality of 2patients. Group B: post-operative inotrope requirements were significantly larger; three died after failure of weaning from the intra-aortic balloon pump. Three others needed a coronary angiogram and stenting due to the occlusion of one of the grafts 3 and 7 months after surgery. One in group A and another in group B died after thrombo-embolic events. Improved left ventricular functions were reported 6, 12 and 24 months after surgery. Left ventricular and atrial dimensions were reduced among all patients. Mean follow-up period = 34 + 7.5 months. Conclusions: This technique is feasible and reproducible for rheumatic and selected cases of non-rheumatic valve lesions due to freedom from mid-term reoperation, preserved ventricular functions and acceptable value-related complication rates.
References
[1]
Binder, R.K., Dweck, M. and Prendergast, B. (2020) The Year in Cardiology: Valvular Heart Disease. EuropeanHeartJournal, 41, 912-920. https://doi.org/10.1093/eurheartj/ehz948
[2]
Dalen, J.E., Alpert, J.S., Goldberg, R.J. and Weinstein, R.S. (2014) The Epidemic of the 20th Century: Coronary Heart Disease. TheAmericanJournalofMedicine, 127, 807-812. https://doi.org/10.1016/j.amjmed.2014.04.015
[3]
Carpentier, A., et al. (2010) Carpentier’s Reconstructive Valve Surgery: From Valve Analysis to Valve Reconstruction. The Annals of Thoracic Surgery, 90, 2092.
[4]
Chan, V., Levac-Martinho, O., Sohmer, B., Elmistekawy, E., Ruel, M. and Mesana, T.G. (2017) When Should the Mitral Valve Be Repaired or Replaced in Patients with Ischemic Mitral Regurgitation? TheAnnalsofThoracicSurgery, 103, 742-747. https://doi.org/10.1016/j.athoracsur.2016.07.002
[5]
Lorosso, R. and Gelsomino, S. (2013) Mitral Valve Repair or Replacement for Ischemic Mitral Regurgitation? The Italian Study on the Treatment of Ischemic Mitral Regurgitation (ISTLMLR). The Journal ofThoracicandCardiovascular Surgery, 145, 128-139.
[6]
Otto, C.M., Nishimura, R.A., Bonow, R.O., Carabello, B.A., Erwin, J.P., Gentile, F., et al. (2021) 2020 ACC/AHA Guideline for the Management of Patients with Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 143, e72-e227. https://doi.org/10.1161/cir.0000000000000923
[7]
Nappi, F., Cristiano, S., Nenna, A. and Chello, M. (2016) Ischemic Mitral Valve Prolapse. JournalofThoracicDisease, 8, 3752-3761. https://doi.org/10.21037/jtd.2016.12.33
[8]
Lancellotti, P., Tribouilloy, C., Hagendorff, A., Popescu, B.A., Edvardsen, T., Pierard, L.A., et al. (2013) Recommendations for the Echocardiographic Assessment of Native Valvular Regurgitation: An Executive Summary from the European Association of Cardiovascular Imaging. EuropeanHeartJournal—CardiovascularImaging, 14, 611-644. https://doi.org/10.1093/ehjci/jet105
[9]
Baumgartner, H., Falk, V., Bax, J.J., De Bonis, M., Hamm, C., Holm, P.J., et al. (2017) ESC/EACTS Guidelines for the Management of Valvular Heart Disease. European Heart Journal, 38, 2739-2791.
[10]
Kron, I.L., Acker, M.A., Adams, D.H., Ailawadi, G., Bolling, S.F., Hung, J.W., et al. (2016) 2015 the American Association for Thoracic Surgery Consensus Guidelines: Ischemic Mitral Valve Regurgitation. The Journal of Thoracic and Cardiovascular Surgery, 151, 940-956. https://doi.org/10.1016/j.jtcvs.2015.08.127
[11]
Lancellotti, P., Troisfontaines, P., Toussaint, A. and Pierard, L.A. (2003) Prognostic Importance of Exercise-Induced Changes in Mitral Regurgitation in Patients with Chronic Ischemic Left Ventricular Dysfunction. Circulation, 108, 1713-1717. https://doi.org/10.1161/01.cir.0000087599.49332.05
[12]
Praz, F., Borger, M.A., Lanz, J., Marin-Cuartas, M., Abreu, A., Adamo, M., et al. (2025) 2025 ESC/EACTS Guidelines for the Management of Valvular Heart Disease. EuropeanHeartJournal, 46, 4635-4736. https://doi.org/10.1093/eurheartj/ehaf194
[13]
Gentry III, J.L., Phelan, D., Desai, M.Y. and Griffin, B.P. (2017) The Role of Stress Echocardiography in Valvular Heart Disease: A Current Appraisal. Cardiology, 137, 137-150. https://doi.org/10.1159/000460274
[14]
Lang, R.M., Tsang, W., Weinert, L., Mor-Avi, V. and Chandra, S. (2011) Valvular Heart Disease: The Value of 3-Dimensional Echocardiography. Journal of the American CollegeofCardiology, 58, 1933-1944. https://doi.org/10.1016/j.jacc.2011.07.035
[15]
Acker, M.A., Parides, M.K., Perrault, L.P., Moskowitz, A.J., Gelijns, A.C., Voisine, P., et al. (2014) Mitral-Valve Repair versus Replacement for Severe Ischemic Mitral Regurgitation. NewEnglandJournalofMedicine, 370, 23-32. https://doi.org/10.1056/nejmoa1312808
[16]
Bonow, R.O., Carabello, B.A., Kanu, C., et al. (2010) ACC/AHA 2006 Guidelines for the Management of Patients with Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients with Valvular Heart Disease): Developed in Collaboration with the Society of Cardiovascular Anesthesiologists: Endorsed by the Society for Cardiovascular Angiography and Interventions and the Society of Thoracic Surgeons. Circulation, 121, e443.
[17]
The Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology and the European Association for Cardio-Thoracic Surgery (2012) Guidelines on the Management of Valvular Heart Disease. European Heart Journal, 33, 2451-2496.
[18]
Lang, R.M., Badano, L.P., Tsang, W., et al. (2012) EAE/ASE Recommendations for Image Acquisition and Display Using Three-Dimensional Echocardiography. Journal of the American Society of Echocardiography, 25, 3-46.
[19]
Habib, G., Hoen, B., Tornos, P., et al. (2009) Guidelines on the Prevention, Diagnosis, and Treatment of Infective Endocarditis (New Version 2009): The Task Force on the Prevention, Diagnosis, and Treatment of Infective Endocarditis of the European Society of Cardiology (ESC). European Heart Journal, 30, 2369-2413.
[20]
Calafiore, A.M., Gallina, S., Di Mauro, M., Gaeta, F., Iacò, A.L., D’Alessandro, S., et al. (2001) Mitral Valve Procedure in Dilated Cardiomyopathy: Repair or Replacement? TheAnnalsofThoracicSurgery, 71, 1146-1152. https://doi.org/10.1016/s0003-4975(00)02650-3
[21]
Yu, H., Su, M., Liao, T., Peng, H., Lin, F. and Tseng, W.I. (2004) Functional Mitral Regurgitation in Chronic Ischemic Coronary Artery Disease: Analysis of Geometric Alterations of Mitral Apparatus with Magnetic Resonance Imaging. TheJournalofThoracicandCardiovascularSurgery, 128, 543-551. https://doi.org/10.1016/j.jtcvs.2004.04.015
[22]
Ahmad, R.M., Gillinov, A.M., McCarthy, P.M., Blackstone, E.H., Apperson-Hansen, C., Qin, J.X., et al. (2004) Annular Geometry and Motion in Human Ischemic Mitral Regurgitation: Novel Assessment with Three-Dimensional Echocardiography and Computer Reconstruction. TheAnnalsofThoracicSurgery, 78, 2063-2068. https://doi.org/10.1016/j.athoracsur.2004.06.016
[23]
Athanasiou, T., Chow, A., Rao, C., Aziz, O., Siannis, F., Ali, A., et al. (2008) Preservation of the Mitral Valve Apparatus: Evidence Synthesis and Critical Reappraisal of Surgical Techniques. EuropeanJournalofCardio-ThoracicSurgery, 33, 391-401. https://doi.org/10.1016/j.ejcts.2007.12.006
[24]
Kisho, M. (2020) Complete Preservation of Mitral Valve Apparatus versus Posterior Leaflet Preservation Only during Mitral Valve Replacement for Rheumatic Mitral Regurgitation. JournalofMedicineinScientificResearch, 3, Article No. 196. https://doi.org/10.4103/jmisr.jmisr_80_19
[25]
Lillehei, C.W., Levy, M.J. and Bonnabeau, R.C. (1964) Mitral Valve Replacement with Preservation of Papillary Muscles and Chordae Tendineae. TheJournalofThoracicandCardiovascularSurgery, 47, 532-543. https://doi.org/10.1016/s0022-5223(19)33587-1
