Littérature scientifique sur le sujet « PROLASSO DELLA VALVOLA MITRALE »

Background and aim of the study: The aim of the present study was to investigate the importance of the modality of pericardial incision (lateral versus anterior) onto postoperative right ventricular systolic function by comparing echocardiographic parameters in patients undergoing minimally invasive or traditional mitral valve repair Materials and methods: 34 patients (mean age 52±12 years; 27 males) with severe mitral regurgitation due to mitral valve prolapse were prospectively and randomly assigned to traditional (sternotomy) operation (Group A, 17 pts) or minimally invasive surgery with right antero-lateral thoracotomy (Group B, 17 pts). The pericardial approach consisted in an anterior reversed T incision for traditional surgery and in a lateral one for mini-invasive surgery. Two-dimensional transthoracic echocardiography was performed pre- and 6 months post surgery to evaluate right ventricular function by tricuspid annular plane systolic excursion (TAPSE). Three-dimensional echocardiography was used for right ventricular volumes, ejection fraction and stroke volume evaluation Results: All patients underwent successful and uncomplicated surgery. Preoperative right ventricular function was normal in all patients. Groups failed to statistically differ in basal right ventricular volumes and function and cross-clamping time. A postoperative TAPSE fall was found in both groups, but mini-invasive patients experienced a statistically significant less marked variation (22.2±4.1 post versus 23.5±3.4 pre, p=0.06) versus traditional surgery (15.2±3.1 post versus 25.8±5.2 pre, p<0.0001), p<0.0001. 3D echocardiography retrieved no significant inter-group differences in postoperative changes of end-systolic and end-diastolic right ventricular volumes. In mini-invasive patients, right ventricular stroke volume and ejection fraction slightly augmented after surgery while in Group A both values faintly decreased, but such difference was not statistically or clinically significant Conclusions: Mini-invasive mitral repair with lateral pericardial opening reduces postoperative right ventricular longitudinal function decrease but fails to have significant effect onto ejection fraction modifications evaluated at 3D echocardiography.

Objectives: to define in patients undergoing surgery for mitral regurgitation (MR) the risk of thrombo-embolic complications, particularly ischemic stroke (IS) compared to that in the general population. Background: MR is frequent, occurs mostly in the elderly and guidelines recommend surgery in asymptomatic patients but IS risks are unknown. Methods: in 1344 patients (65±12 years) consecutively operated for MR (procedures: 897 valve repair, MRep; 447 valve replacement, 231 mechanical, MVRm; 216 biological, MVRb), thrombo-embolic complications particularly IS (diagnosed by a neurologist) during follow-up were assessed early (<30 days), mid-term (30-180 days) and long-term (180 days). Results: IS occurred in 130 patients and IS or transient ischemic attack in 201. IS rates were 1.9±0.4% and 2.7±0.5%, at 30 and 180 days and 8.1±0.8% at 5 years. IS rates were lowest after MRep vs. MVRb and MVRm (6.1±0.9, 8±2.1 and 16.1±2.7% at 5 years, p<0.001). Comparison to IS expected rates in the population showed high risk within 30 days of surgery (Risk-ratio 41[26-60], p<0.001 but p>0.10 between procedures) and moderate risk after 30 days (risk-ratio 1.7 overall, p<0.001; 1.3 for MRep, p=0.07; 0.98 for MVRb, p=0.95; 4.8 for MVRm, p<0.001). Beyond 180 days, IS risk declined further and was not different from the general population for MRep (1.2, p=0.30) and for MVRb (0.9, p=0.72). Risk of IS or transient ischemic attack was higher than the general population in all groups up to 180 days. The risk of bleeding beyond 30 days was lowest in MRep vs. MVRb and MVRm (7±1, 14±4 and 16±3% at 10 years, p<0.001). Conclusion: thrombo-embolic complications after MR surgery are both reason for concern and encouragement. IS risk is notable early, irrespective of the procedure performed, but long-term is not higher than in the general population after MRep and MVRb. Preference for MRep should be emphasized and trials aimed at preventing IS should be conducted to reduce the thrombo-embolic and hemorrhagic risk in patients undergoing surgery for MR.

Objectives: to define in patients undergoing surgery for mitral regurgitation (MR) the risk of thrombo-embolic complications, particularly ischemic stroke (IS) compared to that in the general population. Background: MR is frequent, occurs mostly in the elderly and guidelines recommend surgery in asymptomatic patients but IS risks are unknown. Methods: in 1344 patients (65±12 years) consecutively operated for MR (procedures: 897 valve repair, MRep; 447 valve replacement, 231 mechanical, MVRm; 216 biological, MVRb), thrombo-embolic complications particularly IS (diagnosed by a neurologist) during follow-up were assessed early (<30 days), mid-term (30-180 days) and long-term (180 days). Results: IS occurred in 130 patients and IS or transient ischemic attack in 201. IS rates were 1.9±0.4% and 2.7±0.5%, at 30 and 180 days and 8.1±0.8% at 5 years. IS rates were lowest after MRep vs. MVRb and MVRm (6.1±0.9, 8±2.1 and 16.1±2.7% at 5 years, p<0.001). Comparison to IS expected rates in the population showed high risk within 30 days of surgery (Risk-ratio 41[26-60], p<0.001 but p>0.10 between procedures) and moderate risk after 30 days (risk-ratio 1.7 overall, p<0.001; 1.3 for MRep, p=0.07; 0.98 for MVRb, p=0.95; 4.8 for MVRm, p<0.001). Beyond 180 days, IS risk declined further and was not different from the general population for MRep (1.2, p=0.30) and for MVRb (0.9, p=0.72). Risk of IS or transient ischemic attack was higher than the general population in all groups up to 180 days. The risk of bleeding beyond 30 days was lowest in MRep vs. MVRb and MVRm (7±1, 14±4 and 16±3% at 10 years, p<0.001). Conclusion: thrombo-embolic complications after MR surgery are both reason for concern and encouragement. IS risk is notable early, irrespective of the procedure performed, but long-term is not higher than in the general population after MRep and MVRb. Preference for MRep should be emphasized and trials aimed at preventing IS should be conducted to reduce the thrombo-embolic and hemorrhagic risk in patients undergoing surgery for MR.

I più recenti sviluppi tecnologici hanno permesso l'applicazione dell'Imaging di Risonanza Magnetica in ambito cardiaco. La Risonanza Magnetica Cardiaca fornisce in modo non invasivo e riproducibile informazioni di tipo morfologico, qualitativo e quantitativo; l’utilizzo del mezzo di contrasto a base di gadolinio permette di ottenere informazioni su impregnazione, perfusione e vitalità miocardica. Tecniche di mappatura parametrica dei tempi di rilassamento T1 e T2 consentono rispettivamente una quantificazione della fibrosi miocardica, sia focale che diffusa, e dell’edema miocardico tipico della patologia miocardica acuta, ischemica ed infiammatoria. Tra le possibili applicazioni il dottorando ha in particolare valutato il ruolo della Risonanza Magnetica Cardiaca con LGE (late gadolinium enhancement) e sequenze T1 mapping in pazienti con prolasso della valvola mitrale, comune valvulopatia associata ad un aumentato rischio di complicanza aritmiche e morte cardiaca improvvisa. The most recent technological developments have allowed the application of Magnetic Resonance Imaging in the cardiac environment. Cardiac Magnetic Resonance provides morphological, qualitative and quantitative information in a non-invasive and reproducible way; the use of gadolinium-based contrast agent allows obtaining information on enhancement, perfusion and myocardial vitality. Parametric mapping techniques of relaxation times T1 and T2 respectively allow a quantification of myocardial fibrosis, both focal and diffuse, and of myocardial edema typical of acute myocardial pathology, ischemic and inflammatory. Among the possible applications the student has evaluated the role of Cardiac Magnetic Resonance with LGE (late gadolinium enhancement) and T1 mapping sequences in patients with mitral valve prolapse, a common valvular disease associated with an increased risk of arrhythmic complication and sudden cardiac death.