Background: Mitral regurgitation due to Barlow's disease remains surgically demanding. Despite widespread experience, consensus is lacking on whether the Alfieri repair can serve as a deliberate and durable rather than a rescue strategy in this complex pathology. Methods: We retrospectively analyzed patients undergoing mitral valve repair due to severe mitral regurgitation resulting from Barlow's disease using either the Alfieri or Neochordae repair techniques. Patients received a uniform semi-rigid annuloplasty ring, while leaflet resection and concomitant coronary or aortic procedures were excluded. Results: Baseline demographics and echocardiography were broadly comparable. Perioperative mortality was 0% in both cohorts, with similarly low rates of major complications. Aortic cross-clamp time was significantly shorter with Alfieri repair (p < 0.001). No relevant postoperative transmitral gradient or systolic anterior motion occurred. At a mean follow-up of 4.2 years, more-than-moderate MR was observed in one patient per group (Alfieri 2.4% vs. Neochordae 1.2%). At 10 years, the cumulative incidence of more-than-moderate mitral regurgitation and redo mitral surgery was similarly low between techniques (p = 0.810 and p = 0.460). Most patients were NYHA class I-II at last follow-up, demonstrating improved functional status. Echocardiography showed left ventricular reverse remodeling without intergroup differences. Conclusions: These data indicate that the Alfieri approach provides durable competence and hemodynamic safety comparable to the Neochordae technique while reducing cross-clamp time, supporting its use as a deliberate strategy rather than a bailout in anatomically suitable valves.

Objective: The available data on long-term durability of mitral valve repair using chordae replacement versus leaflet resection for degenerative mitral regurgitation (MR) is contradictory. Although some studies report equal long-term durability, others demonstrate worse durability for chordae replacement. Methods: All consecutive patients receiving mitral valve repair using chordae replacement versus leaflet resection for degenerative MR from January 2003 to December 2010 at a high-volume single center were analyzed. Long-term survival, cumulative incidence of reoperation, and recurrent MR as well as echocardiographic follow-up were investigated. Results: In total, 658 patients were included. Median follow-up was 13.6 years (interquartile range, 9.5-16.0 years). Chordae replacement and leaflet resection were performed in 72.5% (n = 477) and 24.2% (n = 159) of cases, respectively. At unadjusted analysis, cases of leaflet resection tended to have worse survival when compared with cases of chordae replacement (66.3% ± 4.1% vs 77.2% ± 2.3% at 15 years; P = .053). Patients with chordae replacement had a significantly higher risk for recurrent MR (33.4% ± 3.6% vs 12.1% ± 3.6% at 15 years; P < .001) and reoperation (19.1% ± 2.4% vs 7.1% ± 2.6% at 15 years; P = .013) than patients with leaflet resection. The risk remained significant even after excluding all patients with Barlow's disease and endocarditis. Risk factors for recurrent MR were chordae replacement (hazard ratio, 2.218; 95% CI, 1.237-3.979; P = .008), endocarditis (hazard ratio, 3.382; 95% CI, 1.676-6.825; P < .001), and MR >I at discharge (hazard ratio, 5.602; 95% CI, 3.009-10.441; P < .001). Conclusions: Mitral valve repair using chordae replacement was associated with slightly higher survival rates and significantly higher cumulative incidence of MR recurrence and reoperation when compared with mitral valve repair using leaflet resection.

BACKGROUND:Female patients undergoing mitral valve surgery have worse short- and long-term survival compared with male patients. Less is known about long-term outcomes other than survival. METHODS:All patients who underwent mitral valve repair for primary mitral regurgitation from 2003 to 2012 at a single high-volume center were investigated. The aim of this retrospective, observational study was to investigate long-term survival, cumulative incidence of reoperation and recurrent mitral regurgitation, as well as sex differences in perioperative characteristics and at follow-up. RESULTS:A total of 848 patients were included, of whom 28.4% (n = 241) were female. The mean age was 61.8 ± 13.6 years for women and 56.9 ± 11.4 years for men (P < .001). Median follow-up was 13.0 (interquartile range, 8.8-15.5) years. Women were more often affected by anterior leaflet prolapse (P = .018) and calcification of the mitral valve (P = .022) than men. In unadjusted analysis, survival differed significantly for women and men: 10-year survival was 77.3% and 85.8%; 20-year survival was 57.6% and 59.5%, respectively (P = .010). However, female sex was not identified as risk factor for death (hazard ratio [HR], 0.989, P = .947), but age (HR, 1.101; P < .001), atrial fibrillation (HR, 2.109, P = .007), and reduced left ventricular ejection fraction <55% (HR, 2.937, P < .001) were. Cumulative incidence of reoperation at 10 and 20 years after mitral valve repair was 12.5% and 20.7% for women, and 11.5% and 22.3% for men (P = .859). CONCLUSIONS:Long-term survival was significantly worse for women, which can be attributed to higher age at baseline. Reoperation rates were comparable for all patients, although female patients presented with more complex mitral valve pathology.

Background and Clinical Significance: Papillary Fibroelastoma is a benign primary cardiac tumor, commonly located in a valvular position, predominantly on the aortic valve. Case Presentation: We present a 73-year-old male patient with a medical history of chronic lymphatic leukemia, kidney failure, diabetes, and obstructive sleep apnea. In a routinely performed echocardiogram an abnormal structure in the left ventricle was found. The patient presented completely asymptomatically at the time of examination. A cardiac magnetic resonance-scan provided further information about the size and localization of the tumor in the left ventricle, which seemed to be attached to a papillary muscle and was about 1.6 cm in diameter. Due to visible scarring of the myocardia, which was identified in the scan, a cardiac catheter examination was performed. A coronary artery disease was detected with a severe stenosis in three vessels. During an elective bypass-operation, the removal of the structure was performed with an approach through the left atrium, passing the mitral valve using a valve sizer for better exposure. The tumor of 1 cm presented macroscopically with an anemone-like shape. The histopathological examination confirmed the intraoperative assumption of a papillary fibroelastoma, found in an aberrant location. Conclusions: Unexpectedly challenging surgical removals of structures in the left ventricle require innovative techniques with available instruments for better exposure.

BACKGROUND:Mechanisms of repair failure after mitral valve repair (MVr) using chordal replacement and annuloplasty for degenerative mitral regurgitation were analyzed. METHODS:All mitral valve reoperations after isolated MVr using solely chordal replacement and annuloplasty for degenerative mitral regurgitation at the German Heart Center Munich (Munich, Germany) were reviewed. This retrospective observational study aimed to analyze mechanisms of repair failure leading to reoperations. RESULTS:Between 2003 and 2010, a total of 344 patients underwent MVr with chordal replacement and annuloplasty. During a mean follow-up of 9.7 years (range, 0-15.9 years), reoperation on the mitral valve was necessary in 38 (11.0%) cases. Reoperations were performed after a mean of 6.8 years (range, 0-14.1 years). The mechanisms of MVr failure were disease progression (39.5%), technical failure (36.8%), and endocarditis (18.4%). Re-repair was performed in 28.9% and was accomplished using redo annuloplasty (90.9%), chordal replacement (90.9%), resection techniques (27.3%), and leaflet patch reconstruction (9.1%). One patient (2.6%) underwent transcatheter edge-to-edge repair for reoperation. Mitral valve replacement (MVR) was necessary in 63.2%. Redo MVr was mainly performed in cases of technical failure, and MVR was more frequently performed in patients with mitral valve sclerosis. Repeat reoperation was necessary in 3 of 24 cases of MVR and in 2 of 11 cases of redo MVr after a median of 3.8 years (range, 0.01-10.04 years). CONCLUSIONS:MVr using chordal replacement allows a variety of methods for re-repair, including transcatheter solutions. Redo MVr is more often feasible in cases of technical failure, whereas MVR for reoperation is more frequently necessary in patients with mitral valve sclerosis.

Background. Despite the guideline recommendation, implementation of the Cox‐maze (CM) IV procedure has been variable and current data are limited. Methods. We reviewed patients with concomitant CM IV procedure (05/2019−05/2020). The primary endpoints of the study were the success rate of surgical ablation and continuity of sinus rhythm (SR) 1 year after surgery. Secondary endpoints included permanent pacemaker (PPM) implantation, postoperative mortality, and identification of predictors for postoperative SR. Results. The concomitant CM IV procedure was performed in 92 patients. Indications were persistent atrial fibrillation (AF) in 40 patients (43.5%), paroxysmal AF in 36 (39.1%), and long‐standing persistent AF in 16 (17.4%). At hospital discharge, SR was achieved in 49 patients (63.6%) and PPM implantation was necessary in 12 patients (13%). At 1 year after surgical ablation, SR was seen in 31 patients (59.6%) and PPM implantation was required in six further patients (6.5%). Patients with long‐standing persistent AF were significantly less likely to achieve SR (odds ratio (OR): 0.18, p = 0.003), and postoperative mortality was significantly increased in this subgroup (hazard ratio (HR): 5.4, p = 0.02). In patients with enlarged left atrial (LA) diameter, the probability of achieving SR was significantly decreased (OR: 0.48, p = 0.045). Need for postoperative dialysis (HR: 12.9, p = 0.02) and prolonged stay in the intensive care unit (HR: 2.2, p = 0.01) were independently associated with increased mortality after CM IV. Conclusions. The cryothermal CM IV procedure has an overall 1‐year success rate of 60% with increased rates of PPM implantation. Patients with long‐standing persistent AF and increased LA diameter were significantly less likely to achieve SR.

Objectives: The optimal surgical approach for the treatment of functional mitral regurgitation (FMR) remains controversial. Current guidelines suggest that the surgical approach has to be tailored to the individual patient. The aim of the present study was to clarify further aspects of this tailored treatment. Methods: From 01/2006 to 12/2015, 390 patients underwent mitral valve (MV) surgery for FMR (ischemic n = 241, non-ischemic n = 149) at our institution. A regression analysis was used to determine the effect of MV repair or replacement on survival. The patients were analyzed according to the etiology of the MR (ischemic or non-ischemic), different age groups (<65 years, 65–75 years, and >75 years), LV function, and LV dimensions, as well as the underlying heart rhythm. Results: The overall survival rates for the repair group at 1, 5, and 8 years were 86.1 ± 1.9%, 70.6 ± 2.6%, and 55.1 ± 3.1%, respectively. For the same intervals, the survival rates in patients who underwent MV replacement were 75.9 ± 4.5%, 58.6 ± 5.4%, and 40.9 ± 6.4%, respectively (p = 0.003). Patients younger than 65 years, with an ischemic etiology of FMR, poor ejection fraction (<30%), severe dilatation of left ventricle (LVEDD > 60mm), and presence of atrial fibrillation had significantly higher mortality rates after MV replacement (HR, 3.0; CI, 1.3–6.9; p = 0.007). Patients between 65 and 75 years of age had a higher risk of death when undergoing mitral valve replacement (HR, 1.7; CI, 1.0–2.8; p = 0.04). In patients older than 75 years, the surgical approach (MV repair or replacement) had no effect on postoperative survival (HR, 0.8; CI, 0.4–1.3; p = 0.003). Conclusions: Our data demonstrate that, in patients younger than 65 years, the treatment of choice for FMR should be MV repair. This advantage was even more evident in patients with an ischemic origin of MR, a poor ejection fraction, a severe LV dilatation, and atrial fibrillation.

BACKGROUND:The long-term outcomes of mitral valve repair by nonresection techniques, such as annuloplasty and chordal replacement, for degenerative mitral valve regurgitation were investigated.METHODS:All consecutive patients with degenerative mitral regurgitation who received solely chordal replacement and annuloplasty for mitral valve repair between 2003 and 2010 at the German Heart Center Munich were reviewed. The endpoints of this retrospective study were survival, cumulative incidence of reoperation on the mitral valve, and cumulative incidence of significant recurrent mitral regurgitation.RESULTS:A total of 346 patients were evaluated. The median follow-up period was 10.86 (range, 0.01-15.86) years. The 30-day mortality rate was 0.58% (n = 2 of 346), whereas the 5-year survival was 92.97% ± 1.41%. At 5 years, cumulative incidence of recurrent mitral regurgitation was 6.87% ± 1.57% and cumulative incidence of reoperation on the mitral valve was 3.69% ± 1.05%. Survival at 10 years was 83.35% ± 2.15%. At 10 years, cumulative incidence of recurrent mitral regurgitation was 13.31% ± 2.22% and cumulative incidence of reoperation was 7.84% ± 1.55%. Cox regression analysis identified age, diabetes mellitus, and reduced left ventricular ejection fraction <55% as independent risk factors for death. Left ventricular ejection fraction <55% was revealed as independent risk factor for significant recurrent mitral regurgitation.CONCLUSIONS:This study demonstrated excellent long-term outcomes with low incidence of reoperation after mitral valve repair using chordal replacement in a highly selected patient cohort. Our findings emphasized the importance of early intervention in severe degenerative mitral regurgitation, especially in patients with reduced left ventricular ejection fraction.

OBJECTIVES:Minimally invasive mitral valve repair (MVR) promises major advantages over median sternotomy regarding cosmetic results and faster recovery. However, the long-term functional outcome of minimally invasive MVR has been questioned by critics because the limited access may not exclusively promise high-quality repair. This study examines the long-term outcome regarding survival and reoperation rate. METHODS:All patients undergoing minimally invasive MVR from February 2000 until March 2020 were included in this study. Baseline clinical and surgical characteristics were summarized from the internal database. Primary end points were survival and freedom from reoperation, analysed via Kaplan-Meier curves. Secondary end points were periprocedural complications after minimally invasive MVR and incidence for recurrent mitral regurgitation &gt;II°. RESULTS:A total of 1194 patients underwent minimally invasive MVR, in 17 cases mitral valve replacement was required. The mean age was 55.1 years [47.6; 62.7]. The successful minimally invasive repair rate was 97%. The 30-day mortality was 0.6%. Survival was 96.7% [standard deviation (SD): 5.8%], 91.6% (SD: 1.1%) and 80.0% (SD: 11.2%) at 5, 10 and 20 years. The incidence of reoperation was 4.4% (SD: 3.2%), 10.3% (SD: 7.4%) and 16.7% (SD : 7.4%) at 5, 10 and 20 years, respectively. Concomitant procedures such as tricuspid valve repair and modified Cryo-maze procedure were performed in 263 cases. CONCLUSIONS:Minimally invasive MVR for degenerative mitral regurgitation is safe, shows excellent functional long-term results and is associated with low perioperative and late mortality.

BACKROUND:Mitral valve (MV) repair in the case of a large anterior-posterior diameter and redundant valve tissue remains challenging and favors repair with a ring that exhibits a large anterior-posterior diameter. Compared to other available rings, the Medtronic Simulus annuloplasty ring shows the largest anterior-posterior diameter. This study reports for the first time mid-term results using this annuloplasty ring.METHODS:Between 11/2015 and 12/2019, a total of 378 patients underwent MV repair for degenerative mitral regurgitation using the Medtronic Simulus ring, according to the following selection criteria: large MV annuli, abundant leaflet tissue (i.e., Barlow disease), and risk for SAM.RESULTS:Overall survival after 5 years was 90.8 ± 4.6%. Five patients required valve-related reoperations because of ring dehiscence (n = 1), progression of native valve disease (n = 2), dehiscence of quadrangular resection suture (n = 1), and endocarditis (n = 1). The cumulative incidence of valve-related reoperation at 5 years was 1.3 ± 0.5%. At latest follow-up, echocardiography demonstrated excellent valve function with no/mild MR in 299 patients (94.6%). Two patients (0.6%) had more than moderate MR. No patient developed SAM after repair.CONCLUSION:Repair of MV with large annuli and abundant leaflet tissue with the Medtronic Simulus annuloplasty ring shows excellent mid-term results regarding reoperation rates and recurrent MR.

Purpose The Sentinel Cerebral Protection System (Sentinel-CPS) is increasingly used in transcatheter aortic valve replacement (TAVR). However, the impact of inserting the Sentinel-CPS inside the brain-supplying arteries on cerebral perfusion and oxygenation is unknown. Methods Twenty patients undergoing transfemoral TAVR with (n = 10) and without (n = 10) cerebral embolic protection using the Sentinel-CPS were prospectively observed. All patients received conscious sedation and cerebral oxygen saturation (rSO2) was continuously measured with near-infrared spectroscopy (NIRS). The cumulative perioperative cerebral desaturation was calculated for each patient by multiplying rSO2 below an individualized desaturation threshold by time. In addition, rSO2 values at the time of Sentinel-CPS insertion, filter positioning, and device retraction were analyzed. Results There was no significant difference in cumulative cerebral desaturation in patients with Sentinel-CPS (median [IQR]) (0 [0/81] s%) and without (median [IQR]) (0 [0/23] s%), p = .762. A total of 6 patients (33.3%) experienced a perioperative decrease in rSO2 below the individualized desaturation threshold (n = 3 with Sentinel-CPS, n = 3 without Sentinel-CPS; p = 1.000). Cerebral desaturation was detected during valve deployment (n = 5) and after postdilatation (n = 1). No desaturation events occurred during Sentinel-CPS insertion, filter positioning, or retraction. Conclusion Our pilot study revealed no difference in cumulative perioperative cerebral desaturation between TAVR with and without Sentinel-CPS. Catheter- and filter-based manipulations in the brain-supplying arteries for Sentinel-CPS application were not associated with a decrease of cerebral perfusion and oxygenation.

Background: Tricuspid valve (TV) repair is the recommended treatment for severe functional tricuspid regurgitation (fTR) in patients undergoing left-sided surgery. For this purpose, a wide range of annuloplasty devices differing in form and flexibility are available. This study reports the results using a three-dimensional annuloplasty ring (Medtronic, Contour 3D Ring) for TV repair and analysis of risk factors. Methods: A cohort of 468 patients who underwent TV repair (TVr) with a concomitant cardiac procedure from December 2010 to January 2017 was retrospectively analyzed. Results: At follow-up, 96.1% of patients had no/trivial or mild TR. The 30-day mortality was 4.7%; it significantly differed between electively performed operations (2.7%) and urgent/emergent operations (11.7%). Risk factors for recurrent moderate and severe TR were LVEF < 50%, TAPSE < 16 mm, and moderate mitral valve (MV) regurgitation at follow-up. Preoperatively reduced renal function lead to a higher 30-day and overall mortality. Reoperation of the TV was required in six patients (1.6%). Risk factors for TV related reoperations were preoperative TV annulus over 50 mm and an implanted permanent pacemaker. Conclusions: TVr with the Contour 3D annuloplasty ring shows low TR recurrence and reoperation rates. Risk-factor analysis for the recurrence of TR revealed the importance of left- and right-ventricular function.

Objectives: The long-term results of mitral valve repair using “non-resection” techniques (annuloplasty ring and chordal replacement) for degenerative mitral valve regurgitation (DMR) were investigated.

For tailored treatment of primary mitral regurgitation (MR), surgeons developed different repair techniques. One of them, the edge‐to‐edge repair has recently seen a revival, especially for Barlow's disease.

Objectives: Ring annuloplasty is the preferred procedure in patients with tricuspid regurgitation or annular dilatation of the valve. New 3D annuloplasty rings promise to improve leaflet coaptation, hereby improving durability and long-term survival. We present our data on using the 3D Contour annuloplasty ring in a large patients' cohort.

Background Despite advances in surgical techniques, aortic reoperation is still associated with a high risk of mortality due to possible injury of the myocardium or great vessels during resternotomy. Materials & Methods We report the case of a giant aortic pseudoaneurysm, 17 years after the Bentall procedure in a 76-year-old male patient. Results Successful pseudoaneurysm resection after the Bentall procedure using the ThruPort IntraClude intra-aortic occlusion device (Edwards Lifesciences) was achieved. Discussion The IntraClude catheter can be used effectively to provide endovascular clamping of the ascending aorta during challenging cardiac reoperations.

Background. Mitral valve (MV) repair in children is challenging because of the broad spectrum of lesions and anticipated patient growth. The purpose of the study was to evaluate the outcome of MV repair in children below 10 years of age. Methods. We reviewed all MV repair procedures performed in children below 10 years of age. Endpoints of the study were survival after MV repair and cumulative incidence of reoperation. Results. MV repair was performed in 40 patients with congenital MV disease (MVD) and in 10 patients with acquired MVD. Median age at time of repair for congenital MVD was 1.2 years (range, 14 days to 9.8 years) and for acquired MVD 1.9 years (range, 10 days to 9.9 years). Indication for MV repair was mitral regurgitation in 31 congenital MVD patients (77.5%) and in all acquired MVD patients. In patients with congenital MVD operative mortality was 5% and late mortality was 10%. No deaths occurred in patients with acquired MVD. Patients with congenital mitral regurgitation showed a better, yet not significant, 6-year survival than patients with congenital mitral stenosis (85.3% +/- 8.2% vs 60% +/- 18.2%, P = .1). In patients with congenital MVD cumulative incidence of reoperation at 6 years was 38.6% +/- 8.3%. Conclusions. In children below 10 years of age, MV repair is an effective treatment option for MVD. However it often just delays the time to valve replacement. (C) 2020 by The Society of Thoracic Surgeons

Objectives: Different sophisticated repair techniques have been established for the tailored treatment of primary mitral regurgitation. The Edge-to-Edge mitral valve repair has been somehow discredited in the past but has seen a revival recently for complicated Barlow disease. The aim of the present study was to assess the long-term results of this repair technique.

Background Three-dimensional saddle-shaped annuloplasty rings have been shown to create a larger surface of leaflet coaptation in mitral valve repair (MVR) for functional mitral regurgitation (FMR) and degenerative mitral regurgitation (DMR) which may increase repair durability. For the first time, this study reports mid-term results after MVR for DMR and FMR using a rigid three-dimensional ring (Profile 3D, Medtronic). Methods Between June 2009 and June 2012, 369 patients with DMR (n = 326) or FMR (n = 43) underwent MVR (mean age 62.3 +/- 12.6 years). A total of 205 patients (55.6%) underwent isolated MVR and 164 patients (44.4%) a combined procedure. Follow-up examinations were performed in 94.9% (mean 4.9 +/- 0.9 years). Echocardiographic assessment was complete in 93.2% (mean 4.3 +/- 1.2 years). Results The 30-daymortality was 1.5% (5/326) for DMR (1.5% for isolated and 1.6% for combined procedures) and 9.3% (4/43) for FMR (0% for isolated and 10.5% for combined procedures). Survival at 6 years was 92.1 +/- 1.9% for DMR (92.9 +/- 2.6% for isolated and 90.7 +/- 2.7% for combined procedures) and 66.4 +/- 7.9% for FMR (80.0 +/- 17.9% for isolated and 63.7 +/- 8.9% for combined procedures). Cumulative risk for mitral valve-related reoperation at 6 years was 0% for FMR and 7.1 +/- 1.5% for DMR. At echocardiographic follow-up, one patient presented with mitral regurgitation (MR) more than moderate. The only predictor of recurrent MR after MVR for DMR was residual mild MR at discharge. Conclusion Repair of FMR with the three-dimensional Profile 3D annuloplasty ring shows excellent mid-term results with regard to recurrence of MR. In cases of DMR, the results are conforming to the current literature.