Antonio Bivona

Mitral Valve Surgery for Functional Mitral Regurgitation: Should Moderate-or-More Tricuspid Regurgitation Be Treated? A Propensity Score Analysis

BACKGROUND The aim of this retrospective study was to evaluate the clinical outcome of treating or not treating moderate-or-more functional tricuspid regurgitation in patients with functional mitral regurgitation undergoing mitral valve surgery. METHODS From January 1988 to March 2003, 110 patients with functional mitral regurgitation undergoing mitral valve surgery showed moderate-or-more functional tricuspid regurgitation, which was treated (group T) in 51 and untreated in 59 (group UT) patients. Propensity score was used to adjust midterm results. The tricuspid valve was always repaired using the DeVega technique. The mitral valve was repaired in 84 and replaced in 26 patients; no residual moderate-or-more functional mitral regurgitation was assessed at hospital discharge. RESULTS Thirty-day mortality was 5.5% (8.5% for group UT versus 2% for group T; p= 0.245). Adjusted 5-year survival was 45.0% +/- 6.1% in group UT and 74.5% +/- 5.1% in group T (p= 0.004), whereas the possibility to be alive in New York Heart Association class I or II was 39.8% +/- 6.0% in group UT versus 60.0% +/- 6.5% in group T (p= 0.044). Proportional Cox analysis, forcing propensity score into the model, demonstrated that untreated moderate-or-more tricuspid regurgitation was a risk factor for lower midterm survival (hazard ratio, 2.7; 95% confidence interval, 1.3 to 5.4) and survival in New York Heart Association class I or II (hazard ratio, 1.9; 95% confidence interval, 1.1 to 3.4). Follow-up functional tricuspid regurgitation progression rate (3+/4+) was 5% in group T versus 40% in group UT (p < 0.001). The progression of functional tricuspid regurgitation grade at follow-up was a risk factor for worse survival and the possibility to be alive in New York Heart Association class I or II. CONCLUSIONS Tricuspid annuloplasty is an easy and safe procedure, mandatory in case of at least moderate functional tricuspid regurgitation to achieve better mid-term outcome in patients with functional mitral regurgitation undergoing mitral valve surgery.

Mitral valve surgery for functional mitral regurgitation: prognostic role of tricuspid regurgitation §

BACKGROUND The purpose of this study was to evaluate the impact of untreated moderate-or-more functional tricuspid regurgitation (FTR) on mid-term outcome of patients with functional mitral regurgitation (FMR) undergoing mitral valve surgery (MVS). METHODS From January 1988 to April 2003, 165 patients having FMR underwent MVS with untreated FTR. Patients with organic mitral or tricuspid valve disease were excluded. The entire population was divided into two groups, group A: 102 patients (FTR 0/1+), group B: 63 patients (FTR 2+/3+). No statistical difference was found between two groups concerning preoperative and operative variables. MV was repaired in 137 and replaced in 28 cases; the impact of untreated moderate-or-more FTR was estimated by Cox analysis. RESULTS Thirty-day mortality was 6.7 (5.9% group A vs 7.9% group B, p=0.607). Five-year actuarial survival was 73.5% (66.6-80.4%); 88.2% (83.0-93.4%) group A versus 46.0% (33.7-58.3%) group B, p<0.001; the possibility to be alive in NYHA class I-II was 65.8% (58.4-73.2%); 78.4% (72.3-84.5%) group A versus 41.2% (29.1-53.3%) group B, p<0.001. Cox analysis confirmed the impact of untreated moderate-or-more FTR on 5-year survival (HR=3.1, 95% CI=1.8-5.1, p<0.001) and possibility to be alive in NYHA class I-II (HR=3.0, 95% CI=1.8-4.9, p<0.001). After a median interval time of 28 months (IQR=11-60), TR grade was echocardiographically assessed in 122 (79.2%) of 154 patients surviving the first month. In group A (87 patients), TR grade decreased significantly from 0.7+/-0.5 to 0.3+/-0.5 (p<0.001) in the early postoperative period. Then, it increased again to 0.6+/-0.7 at follow-up (p<0.001); no difference was found between preoperative and follow-up time (p=ns). In group B (35 cases), TR grade decreased significantly from 2.2+/-0.4 to 1.3+/-0.7 in the early postoperative period (p<0.001), but then increased again to 2.2+/-0.9 (p<0.001 vs postoperative value; p=0.838 vs preoperative value). Cox analysis confirmed that the progression of TR grade at follow-up is a risk factor for lower survival and possibility to be alive in NYHA class I-II. CONCLUSIONS Patients with untreated moderate-or-more FTR had survival and survival in NYHA class I-II lower than patients with untreated less-than-moderate FTR at 5-year follow-up.

Bilateral internal thoracic artery on the left side: a propensity score-matched study of impact of the third conduit on the right side.

OBJECTIVE This study was undertaken to evaluate long-term results of bilateral internal thoracic artery grafting with saphenous vein or another arterial conduit as the third conduit. METHODS From September 1991 to December 2002, a total of 1015 patients underwent first isolated coronary artery bypass grafting for triple-vessel disease, with bilateral internal thoracic artery plus saphenous vein in 643 cases and bilateral internal thoracic artery plus arterial conduit in 372. A nonparsimonious regression model was built to determine propensity score, then sample matching (saphenous vein vs arterial conduit) was performed to select 885 patients (590 with saphenous vein, 295 with arterial conduit). Groups had similar preoperative and operative characteristics. RESULTS Eight-year freedoms from cardiac death were significantly higher when saphenous vein was used (98.6% +/- 0.5% with saphenous vein vs 95.3% +/- 1.3% with arterial conduit, P = .009), but this difference was related exclusively to right gastroepiploic artery grafting (94.5% +/- 1.6% vs saphenous vein, P = .004). This difference disappeared for radial artery grafting (97.6% +/- 1.6% vs saphenous vein, P = .492). Cox analysis confirmed that supplementary gastroepiploic artery was an independent variable for lower freedoms from all-cause mortality and from cardiac death. Presence of high-degree stenosis (80%) appeared to influence this result. CONCLUSIONS In patients with triple-vessel disease undergoing first isolated coronary artery bypass grafting, supplementary venous grafts seem to provide more stability than gastroepiploic artery, which may even impair long-term outcome.

Impact of Ischemic Mitral Regurgitation on Long-Term Outcome of Patients With Ejection Fraction Above 0.30 Undergoing First Isolated Myocardial Revascularization

BACKGROUND We evaluated the impact of ischemic mitral regurgitation (IMR) on long-term outcome of patients with an ejection fraction (EF) exceeding 0.30 undergoing isolated coronary artery bypass grafting (CABG). METHODS From November 1994 to December 2002, 4226 patients (EF > 0.30) underwent a first isolated CABG. Preoperative IMR was present in 1421 (33.6%, group IMR), of which 1254 had mild (1/4) and 167 had moderate (2/4). The remaining 2805 patients (66.4%, group no-IMR) showed no IMR. A nonparsimonious regression model was built to determine the propensity score. Ten-year freedom from death from any cause, cardiac death, and cardiac events was evaluated by the Kaplan-Meier method. Results of Cox analysis were adjusted by entering the propensity score as an independent variable. RESULTS All patients had similar early mortality (2.1% no-IMR vs 2.5% IMR, p = 0.502) and morbidity (6.5% no-IMR vs 6.6% IMR, p = 0.840). In patients with EF of 0.31 to 0.40, but not in those ones with EF exceeding 0.40, IMR grade was an independent variable for worse long-term freedom from cardiac death (82.8 +/- 3.2 vs 91.4 +/- 2.4; Cox hazard ratio [HR], 2.1 [95% confidence interval (CI), 1.1 to 4.1]; p = 0.0324) and cardiac events (78.6 +/- 3.5 vs 88.5 +/- 2.7; Cox HR, 2.0 [95% CI, 1.1 to 3.7]; p = 0.0174). CONCLUSIONS Mild or moderate IMR in patients with an EF exceeding 0.30 undergoing first isolated CABG influences long-term outcome when EF is 0.31 to 0.40, but not when it exceeds 0.40.

Echocardiographically based treatment of chronic ischemic mitral regurgitation

OBJECTIVES We evaluated results of an echocardiographically based strategy combining mitral annuloplasty with other procedures to treat chronic ischemic mitral regurgitation. METHODS From March 2006 to February 2009, 147 patients underwent mitral valve surgery for chronic ischemic mitral regurgitation. Mean effective regurgitant orifice was 36 ± 11 mm(2), and ejection fraction was 35% ± 9%. On the basis of echocardiographic findings, in 10 cases a prosthesis was inserted and mitral annuloplasty was performed in 137 cases, isolated in 83, associated with chordal cutting in 12 cases (in 5 anterior leaflet was augmented with pericardial patch), and with exclusion of anteroseptal (n = 35) or inferior (n = 7) scars in 42. RESULTS Thirty-day mortality was 4.8%; 3-year survival was 86% ± 3%. None of the 126 survivors were in New York Heart Association functional class III or IV. Among 117 survivors of mitral valve repair, after 18 ± 6 months mean effective regurgitant orifice reduced from 34.1 ± 10.2 mm(2) to 2.3 ± 0.4 mm(2) (P < .001). Nine patients showed residual effective regurgitant orifice 10 to 19 mm(2). Reverse remodeling was present in 69 patients (59.0%), no remodeling in 40 (34.1%), and continuous remodeling in 8 (6.9%). Ejection fraction changed from 37% ± 10% to 43% ± 10% (P < .001), improving in 47, remaining unchanged in 63, and worsening in 7. CONCLUSIONS Echocardiographically based strategy contributed to reduced postoperative mitral regurgitation persistence (effective regurgitant orifice ≥ 10 mm(2) in 7.7% of cases, with no patients showing effective regurgitant orifice ≥ 20 mm(2)). All patients remained in New York Heart Association functional class I or II, but more than mitral annuloplasty was performed in close to 40%.

Left ventricular surgical restoration for anteroseptal scars: Volume versus shape

OBJECTIVE We report the long-term results of left ventricular surgical restoration in which 2 different strategies were used, which had restoration of ventricular volume or ventricular shape as their target. METHODS From 1988 to 2008, 308 patients with anterior scars underwent elective left ventricular surgical restoration. Before 2002, a Dor procedure was performed in 107 cases to reduce left ventricular volume (group V); from 1998 to 2001, a Guilmet procedure was performed in 32 patients to rebuild a left ventricular conical shape (group S). From 2002, 169 patients (group S) underwent left ventricular surgical restoration to reshape a conical left ventricle by means of the Dor procedure (n = 29, septoapical scars) or septal reshaping (n = 140, when the septum was more involved than the anterior wall). The 2 groups were similar for all features but age, mitral regurgitation grade, mitral valve surgery rate (higher in group S), and ejection fraction (higher in group V). RESULTS Early mortality was 7.8% (11.2% in group V vs 6.0% in group S, P = .102). Logistic regression showed that volume reduction was significantly related to higher early mortality. Five-year cardiac survival, cardiac event-free survival, and event-free survival were higher in group S. Cox analysis showed that the choice of volume reduction provided lower survival (hazard ratio, 2.1), cardiac survival (hazard ratio, 3.0), cardiac event-free survival (hazard ratio, 2.7), and event-free survival (hazard ratio, 2.2). When 30-day events were excluded, volume reduction was still a risk factor for cardiac event-free survival (hazard ratio, 2.2). CONCLUSIONS When the main target of left ventricular surgical restoration is left ventricular reshaping rather than left ventricular volume reduction, early and late outcomes seem to improve.

Mitral valve repair for degenerative mitral regurgitation.

Mitral valve repair for degenerative mitral regurgitation is nowadays one of the most common valvular procedures. Different technical modifications were added to the original Carpentiers method, trying to maximise the stability of the results and to reduce the incidence of immediate complications and of late failure of the correction. Survival is good, even if recent reports showed that recurrence of mitral regurgitation can be higher than expected. Prolapse of the anterior leaflet remains challenging and is related to higher reintervention rates. Nevertheless, the overall success rate is high, and the increasing experience of the different surgical teams approaching this procedure will help maintain satisfactory and stable long-term results.

Minimally Invasive Coronary Artery Bypass Grafting on the Beating Heart: The European Experience

The prospect of grafting the internal mammary artery (IMA) to the left anterior descending (LAD) artery via a thoracotomy without the aid of cardiopulmonary bypass (CPB) was first explored by Kolessov in 1967 (1), and further applied by Favaloro (2), Garrett (3), Trapp (4), and others. The early wave of enthusiasm for this technique soon wavered with the widespread availability of CPB and cardioplegia, which allowed for a motionless and bloodless operative field. The unequivocal and widespread success of conventional coronary artery bypass grafting (CABG) limited the use of unsupported bypass grafting. Two developments in the early 1990s revived the technique of myocardial revascularization without CPB: (1) the emergence of minimally invasive technology applicable to the chest, and (2) the promising results of “pumpless” bypass grafting reported by a number of authors (5–7). In our opinion, the definition of minimally invasive cardiac surgery encompasses all approaches that avoid cardiopulmonary bypass, regardless of mode of surgical access

Mitral Valve Repair for Ischemic Mitral Regurgitation

Our aim was to evaluate midterm results in patients who underwent mitral valve repair (MVR) for ischermic mitral regurgitation (IMR) in our most recent experience. From March 2006 to March 2008, 105 patients underwent MVR for IMR. Mean IMR grade was 2.6 ± 1.1, with 46 patients having ≤2/4 and 59 ≥3/4. Five patients (4.8%) died within first month; Two-year freedom from death any cause was 85.5% ± 3.8, freedom from cardiac death was 88.7% ± 3.4. NYHA Class of the survivors was 1.3 ± 0.6, with 3 patients in NYHA Class III. Freedom from death any cause and NYHA Class III-IV was 78.6% ± 4.6. IMR grade decreased from 2.6 ± 1.1 to 0.1 ± 0.3 at the discharge and to 0.5 ± 0.3 after a mean of 7 ± 4 months, with no patient with IMR grade 3/4 or 4/4. MVR for IMR should be performed in patients with moderate-or-more IMR grade or when the MV is excessively dilated, to achieve good midterm results.

Mitral valve repair in ischemic mitral regurgitation

Ischemic mitral regurgitation (IMR) is a common complication after acute myocardial infarction due to annulus dilatation and papillary muscles displacement. In our opinion 3/4 and 4/4 IMR have always to be indicated for MV surgery. In presence of low EF and dilated LV, moderate (2/4) IMR has to be corrected. The end-systolic distance between the coaptation point of mitral leaflets and the plane of mitral valve annulus is the key point to decide repair (≦10 mm) or replacement (≫10 mm). MV annuloplasty has always been addressed to the posterior annulus, whose size can be easily reduced. A specially designed 40 mm long ring has been used to achieve a posterior overreductive annuloplasty. For MV repair thirty-day mortality was 2.4%. Five-year survival and the possibility of being alive and in NYHA class I-II were 75.6±4.7 and 59.8±5.4, respectively. After a mean of 38±35 months, the NYHA class decreases from 3.2±0.5 to 2.1±0.6 (P≪0.001). Most patients (77.4%) have an improvement of its own functional class. MR decreases from 3.2±0.8 to 1.2±1.1 (P≪0.001). 97.5% of the survivors have MR equal to or less than moderate.