Littérature scientifique sur le sujet « Mitral prolapse repair »

Background We reviewed the midterm results of our approach for mitral valve repair with the use of standardized loops. Methods In a retrospective single-center study, mitral repairs performed between November 2015 and December 2019 with the standardized loop technique were included. Predefined loops of 15 and 25 mm (Gore-Tex) were implanted for posterior or anterior mitral prolapses, respectively. Isolated or concomitant mitral repairs were performed by either a sternotomy or minithoracotomy. Mean follow-up was 25.3 ± 14.7 months. Results Among 92 patients operated on for mitral repair during this period, 65 had repair with the standardized loop technique. They were mostly men (73.8%) and the mean age was 65.1 ± 9.7 years. Valve prolapse was mainly posterior (87.7%), and cordal rupture was seen in 81.5% of cases. The procedures were carried out by a minithoracotomy in 49.2% of patients. Isolated mitral repairs represented 63.1% of cases. Crossclamp and bypass times were 102 ± 22.8 min and 144.7 ± 34.9 min, respectively. The mean number of loops implanted was 2.7 ± 0.9. No patient left the operating room with moderate or severe mitral regurgitation. Postoperative morbidity was 18.4% (12 patients) and 30-day mortality was 3.1% (2 patients). Overall 4-year survival and freedom from reoperation for mitral repair failure were 84.4% and 91.7%, respectively. Conclusions The standardized loop technique for mitral repair showed good midterm results. This technique can be valuable in the armamentarium of mitral repairs. Further evaluation is needed for long-term follow-up.

A mitral valve prolapse nowadays is the most common cause of mitral insufficiency in the western countries and is associated with high morbidity and mortality. In the last decades repairing the mitral valve has become the operation of choice for treatment of the mitral valve prolapse, thus enabling to improve the geometry and function of the left ventricle and long-term survival. Literature related to mitral valve repair in patients with Barlow disease is reviewed.

Introduction: Mitral valve calcifications are frequent finding in the Barlow disease. This is makinkg mitral repair surgery even more demanding in already complex valve pathology. Case report: Fifty-five year old Barlow disease patient underwent mitral repair surgery due to posterior leaflet prolapse at P2 level and extensive posterior leaflet and annular calcifications as well. Prolapsed scalop was resected, while P1 and P3 scalops were detached from the annulus. After complete posterior annulus decalcification, so formedlarge atrio-ventricular defect was reconstructed with autologous pericardial patch and double suture line technique.P1 and P3 segments were reatched thereafter by sliding technique, and sutured with no strain. Annuloplasty was performed with saddle rigid ring No 36. Patient was discharged nine days after the surgery with just a trace of mitral reguritation. Conclusion: Annular decalcificaion and reconstruction in patients with calcified Barlow mitral disease is neccessary for safe and durable mitral valve repair surgery.

Degenerative mitral regurgitation due to posterior leaflet prolapse is often associated with tissue redundancy in the leaflet height and free margin of the prolapsing segment. The butterfly technique has been introduced for focal resection to precisely control the leaflet height without annular plication. This technique is indicated for a high prolapsing leaflet, greater than 20 mm. With intraoperative measurement of leaflet heights and ink dot marking as a depth indicator, the butterfly technique can be safely performed in most high posterior leaflet prolapse cases, without increasing the risk of systolic anterior motion.

Background: Mitral valve surgery can be challenging for patients with mitral annular calcification (MAC). The prevalence of MAC in patients who undergo mitral valve replacement is 19.9%. The treatment options for MAC include complete decalcification and annular reconstruction with valve repair/replacement or performing a surgical valve repair or replacement without decalcification, accepting the risk of paravalvular leak. We describe three cases of mitral valve prolapse with posterior annular calcification, which were repaired using a unique technique that does not require decalcification. Case reports: The mitral annular calcification was heavy and involved most of the posterior annulus just sparing the commissures in all the three cases. Leaflet prolapse was dealt with by using neochordae, closing any clefts, and leaflet plication. Since the MAC ring was not complete and there was chance of further dilatation of the annulus, a partial annuloplasty was done using a PTFE felt (cut as strip). There was trivial to no mitral regurgitation with this technique in the immediate postoperative and five-year follow-up period echocardiography in all the three cases. Conclusion: This technique can benefit the major subset of pure mitral valve regurgitant lesions associated with MAC, which is limited to the posterior annulus.

Objective Robotic mitral valve (MV) repairs are performed at many institutions. Repair failures have been attributed to the challenging technology and potentially to the use of annuloplasty band anchoring U-clips. The purpose of this study was to characterize causes of robotic MV repair failure. Methods A total of 300 patients underwent a da Vinci robotic MV repair between May 2000 and November 2006 by a single operating console surgeon. Standard repair techniques and a Cosgrove annuloplasty band were used in every case. Clinical data in patients requiring a reoperation, as well as videos of their original operation, were reviewed. MV pathology, repair methods, and findings at reoperation were determined. Results Sixteen (5.3%) patients required reoperation. Seven (7%) failures occurred in the first 100 cases and 9 (4.5%) in the last 200 cases. Initial MV pathology included isolated anterior (n = 4) or posterior leaflet prolapse (n = 6), bileaflet prolapse (n = 3), and annular dilation (n = 3). Reoperations after their initial operation were required early (<6 months) in 8 patients and later in 8 patients. Reasons for reoperation included CHF (n = 9), hemolysis (n = 4), systolic anterior leaflet motion (n = 2), and endocarditis (n = 1). At reoperation, 7 patients had partial dehiscence of the annuloplasty band. The incidence of band dehiscence was not associated with the use of U-clips and decreased with experience. Conclusions Reoperative rates seemed to decrease with increased case volume and surgeon's experience. Repair results using robotic techniques are similar to conventional techniques. The use of U-clips is not associated with a higher reoperation rate.

The heart has four heart valves (HV), and correct HV function is the main prerogative for the vital of cardiovascular health. The mitral valve (MV), the largest valve of the heart, regulates unidirectional flow between the left atrium and left ventricle. During the systolic phase the MV function is to sustain the maximum ventricle pressure and prevent the reversal flow; during the diastole, the MV is open allowing the blood flow from the atrium and the ventricle filling. The physiological function of the left heart is partly guaranteed by the perfect sealing of the mitral valve in the systole. In presence of disease due to the prolapse of the valve leaflets, instead, there is a persistent regurgitation from the ventricle to the atrium. The degenerative mitral valve regurgitation (DMR) is one of the most common valvular heart diseases that affects about 4% of the population over 70; the natural history of severe MR is adverse, leading to worsening of left ventricle (LV) function, pulmonary hypertension, atrial fibrillation, and death. A variety of less invasive treatment for degenerative MV has been developed. Among these, the NeoChord procedure has emerged as the most promising intervention to repair MV. In NeoChord technique, artificial chords are placed through percutaneous access to restore the proper closure of the leaflets and consequently mitigate the regurge. The present work focuses on the numerical investigation of the Neochord procedure by means of a finite element model, which firstly analyses an idealized anatomy of prolapsing MV and, subsequently, investigates the procedure on three patient-specific MV anatomies. For the first time, the intraoperative phase of the procedure was studied considering two modes of chords tensioning. In additions, we studied on the patients-specific domains the role of both the access site correlated to the suture trajectories inside the left ventricle and the different stitching points on the prolapsed leaflet, by performing a consistent number of simulations. Numerical simulations are commonly used to assess the effectiveness and capability of surgical procedures. For this reason, the proposed study get an insight also on the commonly reported procedural complications, such as i) the leaflet rupture, ii) the interference of the artificial suture with the MV structures, and iii) the neochords overloading/unloading. The present model lays the basis for the realization of a numerical tool dedicated for the surgical planning, which would like to support the surgeons to point out the potential critical issues due to the patient-specific features of the MV undergoing treatment, making it possible the optimum design of the procedure.
Il cuore è composto da quattro valvole cardiache. La loro corretta funzione è necessaria per garantire costantemente un adeguato apporto di sangue all’intero sistema cardiocircolatorio. Tra le quattro valvole la più grande è la valvola mitrale, che è posta a presidio tra l'atrio e il ventricolo sinistro. Durante la fase sistolica la valvola mitrale si chiude impedendo il flusso tra le due camere e sostenendo la pressione massima che si sviluppa nel ventricolo sinistro; durante la diastole, invece, la valvola mitrale si apre permettendo il flusso del sangue dall’atrio verso il ventricolo. La fisiologica funzionalità del cuore sinistro è in parte garantita soprattutto dalla perfetta tenuta della valvola mitrale in fase sistolica. Quando ciò non avviene, spesso a causa del prolasso dei lembi della valvola stessa, si assiste al persistere di un flusso di rigurgito dal ventricolo verso l’atrio. Il rigurgito della valvola mitrale, di tipo degenerativo, è una tra le più comuni patologie cardiache e colpisce circa il 4% della popolazione oltre i 70 anni d’età. L’indesiderato sviluppo di questa patologia, con conseguente peggioramento della funzionalità del ventricolo sinistro, porta ad una serie di complicanze, quali l’ipertensione polmonare e la fibrillazione atriale, e nelle condizioni più gravi alla morte. Negli ultimi anni sono state maturate una varietà di terapie chirurgiche per trattare efficacemente questa patologia, soprattutto grazie allo sviluppo di nuove metodologie di tipo mini-invasivo. Una delle tecniche più recenti e promettenti è l’impianto di corde artificiali all’interno del ventricolo a supporto dell’esistente struttura valvolare, il cosiddetto impianto di neocorde. In questo tipo di intervento le corde artificiali sono posizionate attraverso un accesso transapicale allo scopo di ripristinale la struttura valvolare originaria e, conseguentemente, la chiusura corretta della valvola. Il seguente lavoro di tesi si concentra sull'indagine numerica della procedura di riparo Neochord. A questo scopo, è stato sviluppato un modello agli elementi finiti per indagare l’interazione tra le corde artificiali e la valvola mitrale, inizialmente su un modello idealizzato di valvola prolassata e, successivamente, su dei modelli “paziente specifico” ricavati dall’analisi di immagini cliniche (Echo e CT-scan). È stata studiata per la prima volta il ripristino della valvola mitrale nella fase intraoperatoria della procedura e sono state analizzate due modalità di tensionamento delle suture impiantate. Inoltre, per tre diverse tipologie di prolasso sono stati indagati vari scenari di possibili impianti che tenessero conto dei possibili punti di inserimento delle corde e della traiettoria finale delle stesse. Parallelamente si è cercato di indagare alcune delle complicanze procedurali comunemente riportate dai cardiochirurghi. Nello specifico, i) la rottura dei lembi nel punto di attacco delle corde, dovuta principalmente agli eccessivi stress sul lembo dovuti all’attacco delle suture e al successivo tiro, ii) l’eventuale interferenza della sutura artificiale con le strutture della valvola, in particolare con le corde native e i lembi, e iii) il sovraccarico/scarico delle suture impiantate. Il presente modello rappresenta il primo passo verso la realizzazione di uno strumento numerico per la pianificazione chirurgica, che permetta di mettere in evidenza, in fase pre-operatoria, le potenziali criticità legate alle caratteristiche individuali del prolasso trattato, rendendo possibile la messa a punto di una procedura ad hoc ottimale.

Mitral valve repair is the preferred surgical option for nearly all patients with mitral regurgitation (MR) as its durability is widely recognized to be excellent. Advantages of mitral valve repair over mitral valve replacement include better preservation of left ventricular function, greater freedom from endocarditis and anticoagulant-related hemorrhage, and, in some cases, improved survival. Mitral valve repair has particular advantages in younger patients, who require lifelong anticoagulation if they receive mechanical prostheses. Mitral valve repair can be achieved in more than 90% of patients who have MR caused by prolapse. The forthcoming account includes an overview of the various techniques used in current practice.

Edge-to-edge repair (ETER) was introduced to correct mitral valve (MV) regurgitation and has demonstrated efficacy in a spectrum of MV diseases [1], especially MV prolapse. This technique changes MV geometric configuration by suturing the anterior and posterior leaflets at central or commissural edges (depending on lesion), and consequently alters MV mechanics. MV prolapse is the most common heart valve abnormality in the United States. It is mainly caused by chordal rupture or elongation in which imbalanced chordal lengths protrude MV anterior and/or posterior leaflets. Chordal repair or leaflet resection are common surgical procedures in an open heart surgery. ETER is also effective in treatment of MV prolapse and preferred because of potential percutaneous application of the similar procedure. However, ETER restore leaflet coaptation from a prolapsed MV and may alter leaflet stress and chordal tension distribution. Our hypothesis is that ETER changes leaflet and chord special configuration of a prolapsed MV and thus chordal tensions as compared with normal and prolapsed MVs. The aim of the current study was to investigate tensions of marginal, strut chordae of anterior leaflet, and of marginal, intermediate chordae of posterior leaflet during systole before and after ETER on the MV with a prolapsed posterior leaflet. Hypothesis is tested by comparison of chordal tension change.

The edge-to-edge repair (ETER) technique is a mitral valve (MV) repair procedure. It approximates the leading edges of the mitral leaflets by use of sutures, exhibits promising predictable repair results and offers the advantage of being performed pericutaneously without the need for open heart surgery. The technique is becoming a popular surgical procedure to correct MV prolapse caused by abnormal chordal elongation. MV prolapse leads to mitral regurgitation (MR). Generally the ETER technique is performed as a secondary procedure to ring annuloplasty. Although some groups have performed ETER without the ring annuloplasty, recent studies have shown that ETER technique alone leads to substandard results [1]. It is necessary to define the MV annulus mechanics in ETER condition during valve closure or mid-systole as it directly affects the annulus tension (AT) in the annulus plane. AT in the annulus plane is an important force component which balances the myocardium force and contributes to maintaining the annulus shape and size. This AT change caused by the ETER can lead to annulus dilation, reoccurrence of MR and impact reintervention. The objective of the current study is to understand this AT change in the MV annulus tension during the mid-systole in the ETER condition in order to improve the long term efficacy of the ETER procedure on MV annulus tension, after the technique has been applied with both anterior leaflet prolapse and posterior leaflet prolapse.

Percutaneous approaches to mitral valve (MV) repair have received a great deal of interest, as they avoid open-chest surgery and are often the only option for patients with significant co-morbidities [1]. One technique currently in development is a combined radiofrequency (RF) ablation and cryo-anchoring catheter, and we recently demonstrated that reduction of MV leaflet surface area due to RF ablation is feasible in the proximity of cryo-anchoring [2]. This reduction of enlarged, diseased MV leaflets is designed to improve leaflet coaptation and reduce mitral regurgitation. However, myocardial infarcts treated with RF ablation re-dilated in 20–30 days without the application of a retaining patch [3]. Additionally, joint capsular tissues treated with RF ablation reduced in stiffness and ultimate strength over the first six weeks before regaining strength and stiffness [4]. Re-dilation of MV tissues treated with combined RF ablation and cryo-anchoring would reverse the effects of the treatment strategy. Therefore, we hypothesized that excised porcine MV leaflets treated with combined RF ablation and cryo-anchoring would undergo little to no re-dilation over four weeks. Biaxial mechanical testing at 0 and 4 week time points and picrosirius red (PSR) staining was used to assess the degree of re-dilation and collagen morphological changes following 4 week bioreactor treatment of cyclic uniaxial tension.