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      A Surgical Technique to Preserve the Subvalvular Apparatus in Patients Undergoing Mitral Valve Replacement for Severe Ischemic Regurgitation

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          Abstract

          Severe functional mitral valve regurgitation should be treated in patients undergoing myocardial revascularization. When replacement is considered the best therapeutic option, preservation of the mitral subvalvular apparatus is crucial, especially in the emergency setting, because of its primary role in preserving geometry and function of left and right ventricles. Here we present a simple and quick technique, where subvalvular apparatus is preserved in toto in patients undergoing mitral valve replacement with a bioprosthesis.

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          Mitral-Valve Repair versus Replacement for Severe Ischemic Mitral Regurgitation

          Michael A Acker, Michael K Parides, Louis P Perrault … (2014)
          Ischemic mitral regurgitation is associated with a substantial risk of death. Practice guidelines recommend surgery for patients with a severe form of this condition but acknowledge that the supporting evidence for repair or replacement is limited. We randomly assigned 251 patients with severe ischemic mitral regurgitation to undergo either mitral-valve repair or chordal-sparing replacement in order to evaluate efficacy and safety. The primary end point was the left ventricular end-systolic volume index (LVESVI) at 12 months, as assessed with the use of a Wilcoxon rank-sum test in which deaths were categorized below the lowest LVESVI rank. At 12 months, the mean LVESVI among surviving patients was 54.6±25.0 ml per square meter of body-surface area in the repair group and 60.7±31.5 ml per square meter in the replacement group (mean change from baseline, -6.6 and -6.8 ml per square meter, respectively). The rate of death was 14.3% in the repair group and 17.6% in the replacement group (hazard ratio with repair, 0.79; 95% confidence interval, 0.42 to 1.47; P=0.45 by the log-rank test). There was no significant between-group difference in LVESVI after adjustment for death (z score, 1.33; P=0.18). The rate of moderate or severe recurrence of mitral regurgitation at 12 months was higher in the repair group than in the replacement group (32.6% vs. 2.3%, P<0.001). There were no significant between-group differences in the rate of a composite of major adverse cardiac or cerebrovascular events, in functional status, or in quality of life at 12 months. We observed no significant difference in left ventricular reverse remodeling or survival at 12 months between patients who underwent mitral-valve repair and those who underwent mitral-valve replacement. Replacement provided a more durable correction of mitral regurgitation, but there was no significant between-group difference in clinical outcomes. (Funded by the National Institutes of Health and the Canadian Institutes of Health; ClinicalTrials.gov number, NCT00807040.).
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            Randomized trial comparing partial versus complete chordal-sparing mitral valve replacement: effects on left ventricular volume and function.

            David S Miller, C Sintek, G S Kochamba … (2002)
            The merits of retaining the subvalvular apparatus during mitral valve replacement for chronic mitral regurgitation have been demonstrated in numerous retrospective clinical investigations but not in a randomized study. In this report we analyzed the early and late effects of complete versus partial chordal preservation on left ventricular mechanics. Forty-seven patients undergoing isolated surgical correction of mitral insufficiency were prospectively randomized to either total or partial chordal-sparing mitral valve replacement. Complete data from 36 patients were available for analysis. Of these individuals, 15 had preservation of the posterior leaflet only (P-MVR group), and 21 had complete preservation of all chordal structures (C-MVR group). Echocardiography was performed preoperatively, at the time of discharge, and after 1 year to determine dimensions, wall stress, left ventricular mass, and ejection function. End-diastolic volume decreased in both groups initially but continued to decline only in the C-MVR cohort. Similarly, although end-systolic volume decreased over time with total chordal preservation, no notable changes were observed in the P-MVR group. In the C-MVR group, end-systolic stress decreased initially but rose slightly by 1 year. In contrast, end-systolic stress remained unchanged at discharge in the P-MVR group and increased at 1 year. In terms of systolic performance, ejection fraction declined after surgical intervention with partial chordal-sparing techniques and did not improve by 1 year. Ejection fraction returned to the preoperative level after an initial decrease in the C-MVR group. Finally, left ventricular mass was reduced in the C-MVR cohort versus no change in the P-MVR group. Complete retention of the mitral subvalvular apparatus during mitral valve replacement confers a significant early advantage by reducing left ventricular chamber size and systolic afterload compared with partial chordal preservation. Furthermore, left ventricular ejection performance continues to improve over time, probably because of more favorable left ventricular remodeling.
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              Outcomes and Hospital Utilization in Patients with Papillary Muscle Rupture Associated with Acute Myocardial Infarction

              Bhaskar Bhardwaj, Gurusukhmandeep Sidhu, Sudarshan Balla … (2020)
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                Author and article information

                Journal
                Journal ID (nlm-ta): Braz J Cardiovasc Surg
                Journal ID (iso-abbrev): Braz J Cardiovasc Surg
                Journal ID (publisher-id): rbccv
                Title: Brazilian Journal of Cardiovascular Surgery
                Publisher: Sociedade Brasileira de Cirurgia Cardiovascular
                ISSN (Print): 0102-7638
                ISSN (Electronic): 1678-9741
                Publication date (Print and electronic): Nov-Dec 2022
                Publication date (Print): Nov-Dec 2022
                Volume: 37
                Issue: 6
                Pages: 932-936
                Affiliations
                [1 ] Department of Neuroscience and Rehabilitation, University of Ferrara, Ferrara, Italy.
                [2 ] Department of Cardiac Surgery, University Hospital Center “Mother Teresa”, Tirana, Albania.
                [3 ] Department of Cardiac Surgery, University of Rome Tor Vergata, Rome, Italy.
                Author notes
                Correspondence Address: Jacob Zeitani Department of Neuroscience and Rehabilitation, University of Ferrara, Via Ariosto 35, Ferrara, Italy, Zip Code: 44121, E-mail: zeitani@ 123456hotmail.com
                Author information
                http://orcid.org/0000-0001-6107-591X
                Article
                DOI: 10.21470/1678-9741-2021-0320
                PMC ID: 9713662
                PubMed ID: 35657306
                SO-VID: 684286ce-fdf2-4ed5-ab86-f1dca877526e
                License:

                This is an Open Access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

                History
                Date received : 15 February 2021
                Date accepted : 28 July 2021
                Categories
                Subject: How I Do It

                Keywords: bioprosthesis,emergencies,heart ventricles,mitral valve insufficiency,myocardial revascularization
                Data availability:
                Keywords: bioprosthesis, emergencies, heart ventricles, mitral valve insufficiency, myocardial revascularization

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