Objectives Mitral annular disjunction (MAD) is a structural abnormality of the mitral annulus fibrosus, associated with myxomatous leaflet degeneration, mitral valve prolapse (MVP), and ventricular arrhythmias. The combination of annular dilatation and abnormal annular motion increases mechanical stress on the mitral leaflets, triggering the degenerative process. Methods This review summarizes the major pathophysiologic, diagnostic and therapeutic measures for the treatment of patients with MAD and an indication for mitral surgery. Results The diagnosis is primarily based on non-invasive imaging techniques. Echocardiography is the first choice due to its ability to assess real-time mitral valve function. Cardiac computed tomography and magnetic resonance imaging provide more detailed information on the extent of MAD and the presence of calcifications. Indications for surgical mitral valve treatment are based on current recommendations. In cases with MAD and moderate mitral regurgitation, early intervention may be advocated in the presence of arrhythmogenic MVP. Long-term outcomes after treatment are assessed through multimodal imaging and electrocardiogram monitoring. A ring annuloplasty is an important cornerstone of treatment. Stabilization of the mitral annulus abolishes functional prolapse and increases the antiarrhythmic effect of mitral surgery. However, postoperative arrhythmic burden may persist in some cases, requiring continuous monitoring and sometimes an additional device therapy. Conclusions MAD represents a complex anatomical and functional entity associated with diagnostic challenges and rhythm abnormalities. Although the current indications for surgical treatment follow the recommendations for treatment of primary mitral regurgitation, early treatment may be important especially in patients with arrhythmias.

Die Verkalkung des Mitralanulus ist die Folge einer atherosklerotischen Grunderkrankung und geht häufig mit einer erhöhten kardiovaskulären Morbidität und Mortalität einher. Ein chirurgischer Eingriff ist erforderlich, wenn Patienten aufgrund einer Herzklappenerkrankung Symptome entwickeln, deren Ursache in der Regel eine aufgetretene Mitralklappeninsuffizienz ist. In diesem Manuskript werden histopathologische Aspekte im Zusammenhang mit der Verkalkung des Mitralanulus erörtert und chirurgische Strategien für das Débridement und die Rekonstruktion des Anulus mit anschließender Reparatur oder Ersatz der Mitralklappe beschrieben. Neben den typischen Strategien werden auch seltene und eher experimentelle chirurgische Techniken diskutiert.

Background: Left ventricular (LV) volume reshaping reduces myocardial wall stress and may induce reverse remodeling in patients with heart failure with reduced ejection fraction. The AccuCinch Transcatheter Left Ventricular Restoration system consists of a series of anchors connected by a cable implanted along the LV base that is cinched to the basal free wall radius. We evaluated the echocardiographic and clinical outcomes following transcatheter left ventricular restoration. Methods and results: We analyzed 51 heart failure patients with a left ventricular ejection fraction between 20% and 40%, with no more than 2+ mitral regurgitation treated with optimal medical therapy, who subsequently underwent transcatheter left ventricular restoration. Serial echocardiograms, Kansas City Cardiomyopathy Questionnaire scores, and 6-minute walk test distances were measured at baseline through 12 months. Primary analysis end point was change in end-diastolic volume at 12 months compared with baseline. Patients (n = 51) were predominantly male (86%) with a mean age of 56.3 +/- 13.1 years. Fluoroscopy showed LV free wall radius decreased by a median of 9.2 mm amounting to a 29.6% decrease in the free wall arc length. At 12 months, the LV end-diastolic volume decreased by 33.6 +/- 34.8 mL (P < .01), with comparable decreases in the LV end-systolic volume. These decreases were associated with significant improvements in the overall Kansas City Cardiomyopathy Questionnaire score (16.4 +/- 18.7 points; P < .01) and 6-minute hall walk test distance (45.9 +/- 83.9 m; P < .01). There were no periprocedural deaths; through the 1-year follow-up, 1 patient died (day 280) and 1 patient received a left ventricular assist device (day 13). Conclusions: In patients with heart failure with reduced ejection fraction without significant mitral regurgitation receiving optimal medical therapy, the AccuCinch System resulted in decreases of LV volume, as well as improved quality of life and exercise endurance. A randomized trial is ongoing (NCT04331769).

OBJECTIVES:We evaluate the mid-term results of mitral valve (MV) repair with patch augmentation of the posterior leaflet in secondary mitral regurgitation.METHODS:Patients were included after diagnosis of a severe symptomatic secondary MV insufficiency with grade III and IV according to the Carpentier classification IIIb. Indication for a patch augmentation technique was a dilatation of the left ventricle leading to a displacement of the papillary muscles, causing restricted leaflet motion and a marked leaflet tenting height. Data were collected prospectively between December 2011 and March 2020.RESULTS:In total, 174 patients (mean age: 65 ± 12 years) received an MV repair with patch augmentation of the posterior leaflet and a true-sized remodelling annuloplasty (mean size 30.8 mm). Causes of the MV incompetence were dilatative cardiomyopathy in 126 patients and ischaemic myocardial disease in 48 patients. Concomitant bypass surgery was performed in 28 patients, and the tricuspid valve was repaired in 68 patients. The mean follow-up was 40 ± 28.2 months. There was no 30-day mortality. In-hospital mortality was 1.2% (n = 2); late mortality was 10.9% (n = 19). At 8 years, overall survival was 62.48%, freedom from moderate or severe recurrent mitral regurgitation was 91.9% and freedom from reoperation due to MV insufficiency was 97.1%.CONCLUSIONS:Augmentation of the posterior MV leaflet in addition to remodelling annuloplasty is a safe and reproducible mitral reconstruction technique that renders sustainable MV competence.

‘The ultimate goal of warfare is to win without fighting’ Although, in its early years, cardiac surgery represented one of the most technologically advanced surgical specialties, inertia and lack of agency have struck the profession at its core. Contrary to other surgical specialties, such as general surgery, urology and gynaecology, which were keen to advance towards least-invasive operations, including laparoscopic and robotic procedures, cardiac surgeons have firmly resisted to partake in the hunt for the least-invasive approach to treat cardiac disease. Disheartening as it may be, cardiac surgeons have become notoriously slow to embrace innovation and adopt new techniques and technologies, therefore steadily disengaging from industry, which has directed its focus to catheter-based techniques. Alongside industry’s ample support, interventional cardiology has emerged as the patients' preference. In the span of a decade, transcatheter aortic valve implantation (TAVI) came to be the most disruptive cardiac intervention, rapidly altering the scene in the treatment of the aortic valve disease.

Objectives: Major benefits of minimally invasive mitral valve surgery are the consistent finding of faster rate of recovery, reduction of pain and the speedy return to normal activity. Even in the hands of experienced surgeons the incidence of inguinal seroma is reported to be 2 to 11.3%. In our institution, seroma after minimally invasive mitral valve surgery has an occurrence rate of 2.7%. We have adopted the technique of tapping the seroma and applying a continued closed suction drainage and patients can proceed to rehabilitation.

Objectives: The aim of this study was to evaluate the long-term results of mitral valve repair with augmentation of the posterior leaflet with regard to late recurrence of valve incompetence in functional mitral regurgitation.

MITRAL REGURGITATION (MR) presents as a consequence of a primary pathology of the mitral valve apparatus or secondary to ventricular dysfunction and remodeling. Most common etiology for primary MR is degenerative, with a prevalence of 1%-to-2%. 1 Freed LA Levy D Levine RA et al. Prevalence and clinical outcome of mitral valve prolapse. N Engl J Med. 1999; 341: 1-7 Crossref PubMed Scopus (798) Google Scholar Degenerative mitral valve disease is a progressive, noninflammatory, structural distortion of the valve apparatus, culminating in leaflet prolapse and regurgitation. Some of these patients present acutely due to rupture of the abnormal chordae, whereas most others present with chronic progressive MR. The spectrum of this disease is wide, ranging from fibroelastic degeneration, through forme-fruste, to Barlow's. Pathogenesis of mitral valve prolapse (MVP) has been shifting from a degenerative process involving the leaflets to an intrinsic annular abnormality. The subset in which this abnormal annular anatomy and kinetics have been demonstrated is now categorized as mitral annular disjunction (MAD). Although, primarily, MVP is characterized by leaflet and chordal involvement with secondary changes in the annulus, MAD is found to have a primary annular involvement with secondary changes in leaflets and myocardium. Typically, MAD presents as a discontinuation of the annuloatrial junction from the ventricular myocardium. It is more commonly associated with myxomatous MVP than the fibroelastic variant. 2 Essayagh B Iacuzio L Civaia F et al. Mitral annular disjunction in mitral valve prolapse: A cardiac magnetic resonance study. Arch Cardiovasc Dis Suppl. 2019; 11: 62-63 Google Scholar Similar to MVP, it has a female preponderance. 3 Putnam AJ Kebed K Mor-Avi V et al. Prevalence of mitral annular disjunction in patients with mitral valve prolapse and severe regurgitation. Int J Cardiovasc Imaging. 2020; 36: 1363-1370 Crossref PubMed Scopus (27) Google Scholar It still is unclear whether it is MAD or MVP that is the initiating trigger for MR.

Corresponding Author: Joseph Zacharias, Department of Cardiothoracic Surgery, Blackpool Teaching Hospitals NHS Foundation Trust, 83 Whinney Heys Road, Blackpool FY3 8NR, UK. Email: drjzacharias@ gmail. com Innovations 2020, Vol. 15(1) 11–16 © The Author(s) 2020 Article reuse guidelines: sagepub. com/ journalspermissions DOI: 10.1177/1556984519888456 journals. sagepub. com/ home/ inv Seven Habits of Highly Effective Endoscopic Mitral Surgeons

In industrialized countries, the most common etiology of mitral regurgitation (MR) is degenerative mitral valve (MV) disease. The natural history of severe degenerative MR is poor. However, its appropriate and timely correction is associated with a life expectancy similar to that of the normal population. Surgical MVrepair is the gold-standard treatment. This review will focus on the most recent evidence with a specific emphasis on surgical indications, timing of treatment, contemporary surgical techniques, Heart Teams, and Centers of Excellence.

BackgroundA clinically effective treatment for functional mitral regurgitation (fMR) due to left ventricular (LV) remodeling may need to address both annular and LV dilation to improve symptoms of heart failure (HF). Here we describe the effects of a device intended to reduce mitral annular dimensions and also reduce the radius of curvature of the LV to improve function.MethodsPatient 202–051 is a 79-year-old man with ischemic cardiomyopathy and 3-to-4+ fMR treated with guideline recommended HF therapies. Echocardiography showed an effective regurgitant orifice (ERO) of 0.36 cm2, a regurgitant stroke volume of 69 ml, an LVEF of 14% and an LV diastolic diameter of 6.2 cm. The patient underwent percutaneous implantation of the Ancora Heart device which consists of a series of intramyocardial anchors connected via a cinching cable implanted into the LV free wall below the mitral annulus and behind the papillary muscles. Tension applied to the cable resulted in an acute ~15% decrease of the circumferential distance between the first and last anchors. Cinching was maintained with a locking mechanism placed at the end of the cable.ResultsEchocardiographic follow up performed over the course of 1 year showed that ERO decreased to 0.12 cm2, regurgitant stroke volume to 23 ml, LV dimension to 5.6 cm and EF improved to 34%. ntPro-BNP decreased from 3440 to 1450 pg/ml.ConclusionThese findings provide proof-of-concept that a percutaneously deployable, sub-valvular intramyocardial implant that cinches the myocardial wall below the mitral annulus has the potential to reduce the severity of fMR and improve LV function.