Mitral regurgitation is the most common cardiac valve disease, with high rates of morbidity and mortality. Transcatheter mitral valve replacement (TMVR) is used as a promising intervention in non-surgical patients and in those with unsuitable anatomy for transcatheter edge-to-edge repair. TMVR can also be performed for inoperable or high-risk patients with degenerated or failed bioporstheses or failed repairs, or in patients with severe annular calcifications. The complex anatomy of the mitral valves makes the design of transcatheter mitral valve prostheses extremely challenging, and increases the difficulty of TMVR procedure, thus could led to non-negligible complications including periprocedural and post-procedural long-term complications. This review aims to discuss the potential TMVR-complications and measures implemented to mitigate these complications, in order to improve the prognosis of TMVR patients.
This article reports a case of a 70-year-old female patient who developed bioprosthetic mitral valve deterioration 4 months after her initial valve replacement surgery, manifesting as severe regurgitation and New York Heart Association Class Ⅲ. Due to the high risk of a redo open-heart surgery, she underwent a transapical transcatheter mitral valve-in-valve procedure. Intraoperatively, a J-Valve prosthesis was successfully implanted under echocardiographic and fluoroscopic guidance. Immediate transesophageal echocardiography confirmed an optimal valve position, complete resolution of regurgitation, and no significant paravalvular leak or left ventricular outflow tract obstruction. The patient's postoperative course was uneventful. She was extubated 16 hours post-procedure with significant improvement in cardiac function. Follow-up echocardiography showed normal prosthetic valve function.
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.
Objective To investigate and evaluate the safety and effectiveness of the Chimney technique in mitral valve reoperation. Methods The clinical data of mitral valve reoperation patients who underwent Chimney surgery in Wuhan Asia Heart Hospital from 2019 to 2021 were retrospectively analyzed. Results A total of 26 patients were collected, including 7 males and 19 females, aged 27-67 (53.46±11.18) years. All patients had previous mitral valve surgery, including 23 mitral valve replacements and 3 mitral valve repairs. All patients received Chimney technique using the ideal artificial sized mitral valve, and 1 patient died of neurological complications in hospital. The cardiopulmonary bypass time and the aortic cross-clamping time were 231.11±77.05 min and 148.50±52.70 min, respectively. The mean diameter of the implanted mitral valve prosthesis was 29.08±0.68 mm, which was statistically different from pre-replacement valve prosthesis size of 26.69±0.77 mm (P＜0.001). The mean transvalvular pressure gradient of the prosthetic mitral valve measured on postoperative echocardiography was 14.77±5.34 mm Hg, which was statistically different from preoperative value of 20.92±9.83 mm Hg (P=0.005). Conclusion The Chimney technique is safe and effective for reoperation in patients with small mitral annuli, which can not only reduce the risk of reoperation, but also obtain larger prosthetic valve implants with good hemodynamic characteristics and clinical outcomes.
Thoracoscopic mitral valve replacement is a common minimally invasive cardiac surgery procedure. However, small annulus, severe calcification of the annulus, and severe thickening of the posterior valve leaflet or sub valvular structure are the difficulties of thoracoscopic mitral valve replacement. Improper treatment can easily lead to left ventricular rupture or prosthesis-patient mismatch. This paper reports a thoracoscopic mitral bioprosthesis replacement case using the chimney technique in Guangdong Provincial People's Hospital and summarizes its operating key points. The patient was a 68-year-old female, weighing 36 kg. The preoperative diagnosis was rheumatic mitral stenosis and atrial fibrillation, the preoperative transthoracic echocardiogram showed the left ventricular end-diastolic diameter was 39 mm. The surgical effect was satisfactory. The patient was in good condition at the follow-up 2 months after the operation.
Objective To evaluate the clinical efficacy of valve-in-valve transcatheter mitral valve replacement for the management of degenerated bioprosthetic mitral valves. Methods This study retrospectively analyzed the clinical data of patients who underwent transcatheter mitral valve replacement due to degenerated bioprosthetic mitral valves at the First Affiliated Hospital of Zhengzhou University from 2020 to 2023. The analysis included baseline characteristics, surgical details, perioperative complications, and hemodynamic changes during the early postoperative period and subsequent follow-up. Results A total of 31 patients were included in the study, comprising 7 males and 24 females, with an average age of (66.57±9.32) years. The average duration since the initial surgical placement of the bioprosthetic valves was (9.92±3.71) years. The procedures included 7 patients utilizing the transfemoral venous-atrial septal approach and 24 patients employing the transapical approach. All patients exhibited significant improvement in cardiac function postoperatively, with a reduction in the number of patients classified as New York Heart Association (NYHA) grade Ⅲ or Ⅳ and those with moderate to severe tricuspid valve regurgitation. Echocardiographic assessments revealed a decrease in peak flow velocity across the mitral valve and a reduction in the average transvalvular pressure gradient, while left ventricular ejection fraction remained unchanged. One patient experienced a recurrent stroke and died on the fifth postoperative day; however, the remaining patients were discharged without complications, including cardiac death, all-cause mortality, or outflow tract obstruction. During a median follow-up period of 12 months, no adverse events were reported, and hemodynamic stability was maintained. Conclusion Valve-in-valve transcatheter mitral valve replacement is a safe and effective option for patients with degenerated bioprosthetic mitral valves, demonstrating favorable hemodynamic outcomes and satisfactory short-term clinical results.
ObjectiveTo investigate the feasibility, safety and effectiveness of radiofrequency ablation of atrial fibrillation with mitral valve replacement under totally thoracoscopic surgery.MethodsThe clinical data of 107 patients with rheumatic mitral disease and atrial fibrillation who underwent mitral valve replacement and radiofrequency ablation at the same time in our hospital from January 2014 to October 2018 were retrospectively analyzed. The patients were divided into two groups: a totally thoracoscopic surgery group (n=51, including 20 males and 31 females, aged 50.57±5.24 years) and a median sternotomy group (n=56, including 21 males and 35 females, aged 52.12±5.59 years) according to the surgical methods. The preoperative, intraoperative and postoperative data of the patients were compared.ResultsAll operations were successfully completed without death. In terms of bleeding volume, drainage volume, ventilator-assisted breathing time, hospital stay and incision length, the totally thoracoscopic surgery group was better than the median sternotomy group, and the difference was statistically significant (P<0.05). The cardiopulmonary bypass time and radiofrequency ablation time in the totally thoracoscopic surgery group were longer than those in the median sternotomy group (P<0.05). There was no significant difference in the operation time, aortic occlusion time, postoperative complications, left ventricular ejection fraction, left atrial diameter and sinus rhythm maintenance between the two groups (P>0.05). There was no atrioventricular block, pulmonary vein stenosis, atrioesophageal fistula, coronary artery injury, stroke or hemorrhage during the follow-up.ConclusionRadiofrequency ablation of atrial fibrillation with mitral valve replacement under totally thoracoscopic surgery is safe and effective, and it is worthy of clinical application.
ObjectiveTo systematically evaluate the therapeutic effects of different surgical procedures for ischemic mitral regurgitation (IMR). MethodsComputer searches were conducted in CNKI, Wanfang, VIP, CBM, PubMed, The Cochrane Library, EMbase, and Web of Science, with the search time limit from the inception of the databases to February 2024. Two researchers independently screened the literature, extracted data, used the Cochrane bias risk assessment tool to evaluate the quality of the included studies, and used Stata 17.0 software to analyze the data. ResultsA total of 19 randomized controlled trials involving 6139 patients were finally included, involving six surgical procedures, and the overall quality of the included studies was relatively high. The results of the network Meta-analysis showed that the 30-day all-cause mortality rate of mitral valve repair (MVr) was significantly lower than that of coronary artery bypass grafting (CABG) [OR=0.24, 95%CI (0.07, 0.87)], mitral valve replacement (MVR) [OR=0.43, 95%CI (0.23, 0.79)], CABG+MVR [OR=0.21, 95%CI (0.04, 0.95)] and transcatheter mitral valve edge-to-edge repair (TEER) using MitraClip [OR=0.13, 95%CI (0.02, 0.87)]. The 30-day all-cause mortality rate of CABG+MVr was significantly lower than that of CABG [OR=0.56, 95%CI (0.33, 0.93)] and CABG+MVR [OR=0.48, 95%CI (0.24, 0.94)], and the best probability ranking results showed that MVR might be the most effective in reducing the 30-day all-cause mortality rate. The incidence of renal complications in CABG+MVr was significantly lower than that in CABG+MVR [OR=0.42, 95%CI (0.21, 0.83)]; the best probability ranking results showed that CABG+MVr might be the most effective in reducing renal complications. ConclusionThe current limited evidence suggests that CABG+MVr and MVR may be the best surgical intervention methods for IMR patients at present. Due to the limitations of the number and quality of included studies, the above conclusions still need to be verified by more high-quality studies.
Objective To compare the mid- and long-term clinical results of mitral valve plasty (MVP) and mitral valve replacement (MVR) in the treatment of functional mitral regurgitation (FMR). MethodsPatients with FMR who underwent surgical treatment in the Department of Cardiovascular Surgery of the General Hospital of Northern Theater Command from 2012 to 2021 were collected. The patients who underwent MVP were divided into a MVP group, and those who underwent MVR into a MVR group. The clinical data and mid-term follow-up efficacy of two groups were compared. Results Finally 236 patients were included. There were 100 patients in the MVP group, including 53 males and 47 females, with an average age of (61.80±8.03) years. There were 136 patients in the MVR group, including 72 males and 64 females, with an average age of (61.29±8.97) years. There was no statistical difference in baseline data between the two groups (P＞0.05). There was no statistical difference between the two groups in the extracorporeal circulation time, aortic occlusion time, postoperative hospital and ICU stay, intraoperative blood loss, or hospitalization death (P＞0.05), but the time of mechanical ventilation in the MVP group was significantly shorter than that in the MVR group (P=0.022). The total follow-up rate was 100.0%, the longest follow-up was 10 years, and the average follow-up time was (3.60±2.55) years. There were statistical differences in the left atrial diameter, left ventricular end-diastolic diameter, left ventricular end-systolic diameter and cardiac function between the two groups compared with those before surgery (P<0.05). The postoperative left ventricular ejection fraction in the MVP group was statistically higher than that before surgery (P=0.002), but there was no statistical difference in the MVR group before and after surgery (P=0.658). The left atrial diameter in the MVP group was reduced compared with the MVR group (P=0.026). The recurrence rate of mitral regurgitation in the MVP group was higher than that in the MVR group, and the difference was statistically significant (10.0% vs. 1.5%, P=0.003). There were 14 deaths in the MVP group and 19 in the MVR group. The cumulative survival rate (P=0.605) and cardiovascular events-free survival rate (P=0.875) were not statistically significant between the two groups by Kaplan-Meier survival analysis. Conclusion The safety, and mid- and long-term clinical efficacy of MVP in the treatment of FMR patients are better than MVR, and the left atrial and left ventricular diameters are statistically reduced, and cardiac function is statistically improved. However, the surgeon needs to be well aware of the indications for the MVP procedure to reduce the rate of mitral regurgitation recurrence.
Objective To analyze the clinical efficacy and survival outcome of totally thoracoscopic redo mitral valve replacement and evaluate its efficiency and safety. Methods The clinical data of patients with totally thoracoscopic redo mitral valve replacement in Guangdong Provincial People’s Hospital between 2013 and 2019 were retrospectively analyzed. Survival analysis was performed using the Kaplan-Meier method. Univariate and multivariate Cox regression analyses were used to determine the risk factors for postoperative death. Results There were 48 patients including 29 females and 19 males with a median age of 53 (44, 66) years. All the procedures were performed successfully with no conversion to median sternotomy. A total of 15, 10 and 23 patients received surgeries under non-beating heart, beating heart and ventricular fibrillation, respectively. The in-hospital mortality rate was 6.25% (3/48), and the incidence of early postoperative complications was 18.75% (9/48). Thirty-five (72.92%) patients had their tracheal intubation removed within 24 hours after the operation. The 1- and 6-year survival rates were 89.50% (95%CI 81.30%-98.70%) and 82.90% (95%CI 71.50%-96.20%), respectively. Age>65 years was an independent risk factor for postoperative death (P=0.04). Conclusion Totally thoracoscopic redo mitral valve replacement is safe and reliable, with advantages of rapid recovery, reducing blood transfusion rate, reducing postoperative complications and acceptable long-term survival rate. It is worthy of being widely popularized in the clinic.