Study Objectives: Surgical valve repair for mitral regurgitation has significant advantages over valve replacement. In this study, we aimed to investigate the early and mid-term results of mitral valve repair using current techniques in order to find out independent risk factors affecting the early and mid-term outcomes. Methods: We retrospectively studied firstly 192 consecutive adult patients (mean age: 43.2±12.3; 120 females and 72 males) who underwent primary mitral valve repair between January 2012 and July 2018. Risk factors affecting the need for re-operations and late survival were determined via univariate and multivariate analyses. Actuarial survival and event-free curves were compared by linear regression analysis. Results: Operative mortality was 2.6% (5 deaths 0–30th. postoperative day (POD). Late mortality was 3.7% (7/187). Reoperation was required in 16 (8.3%) patients. Kaplan–Meier actuarial survival was 95.8%±2.3% at a mean of 43 months. Survival free from reoperation was 92.8%± 4.2% at 60 months. Multivariate analysis demonstrated that residual NYHA class III and IV, low preoperative ejection fraction, and ischemic MR were independent predictors of mortality. Conclusion: We concluded that mitral valve repair showed excellent survival (except ischemic MR), acceptable re-operation rate with satisfactory valve function in a mid-term follow-up period

Deniz, Hayati

Uygur, Feragat

Mardin Artuklu University Institutional Repository

cases are successfully repaired (1-4, 8). Several stud-ies showed excellent rates of freedom from reoperation after MV repair (3-5, 9).  The purpose of this study was to review our results of MV repair, particularly with respect to the recur-rence of severe regurgitation, the re-operation, and survival rates. MethodsOur study was designed as a retrospective study, including 192 consecutive patients, who underwent MV repair surgery, between January 2012 and July Progress in Nutrition 2022; Vol. 24, Supplement 1: e2022058  DOI 10.23751/pn.v23iS1.11879 © Mattioli 1885O r i g i n a l  a r t i c l eEvaluation of Early and Midterm Mitral Valve Repair Results in Consecutive Severe Mitral Regurgitation PatientsFeragat Uygur1, Hayati Deniz21Sanko University, Faculty of Medicine, Education and Research Hospital, Department of Cardiovascular Surgery Gaziantep, Turkey 2Mardin Artuklu University, Faculty of Medicine, Education and Research Hospital, Department of Cardiovascular Surgery Mardin, TurkeyAbstract. Study Objectives: Surgical valve repair for mitral regurgitation has significant advantages over valve replacement. In this study, we aimed to investigate the early and mid-term results of mitral valve repair using current techniques in order to find out independent risk factors affecting the early and mid-term outcomes. Methods: We retrospectively studied firstly 192 consecutive adult patients (mean age: 43.2±12.3; 120 females and 72 males) who underwent primary mitral valve repair between January 2012 and July 2018. Risk factors affecting the need for re-operations and late survival were determined via univariate and multivariate analy-ses. Actuarial survival and event-free curves were compared by linear regression analysis. Results: Operative mortality was 2.6% (5 deaths 0–30th. postoperative day (POD). Late mortality was 3.7% (7/187). Reop-eration was required in 16 (8.3%) patients. Kaplan–Meier actuarial survival was 95.8%±2.3% at a mean of 43 months. Survival free from reoperation was 92.8%± 4.2% at 60 months. Multivariate analysis demonstrated that residual NYHA class III and IV, low preoperative ejection fraction, and ischemic MR were independent predictors of mortality. Conclusion: We concluded that mitral valve repair showed excellent survival (except ischemic MR), acceptable re-operation rate with satisfactory valve function in a mid-term follow-up periodKey words: Mitral valve repair, regurgitation, repair techniquesIntroductionMitral valve (MV) repair in patients with mitral valve insufficiency (MVI) has been discussed exten-sively in the literature and the results of repair pro-cedures are conflicting among different publications. Except for ischemic mitral regurgitation (MR), MV repair is preferred over replacement to treat MVI with improved short and long-term survival (1-5).Moreover, repair rates seem to be increasing with time, as newer techniques such as artificial chordal re-placement and autologous pericardial leaflet augmen-tations are being increasingly used  (6,7).  With the use of these techniques, up to 95% of degenerative MVI Progress in Nutrition 2022; Vol. 24, Supplement 1: e202205822018 in Gaziantep Dr. Ersin Arslan Education and Research Hospital, Cardiovascular Surgery Clinic. Af-ter approval from the Institutional Review Board had been taken, all data were collected by reviewing medi-cal records. Operative TechniqueAll procedures were performed through a me-dian sternotomy under cardiopulmonary bypass. Antegrade and retrograde cold blood cardioplegia was used for myocardial protection. When coronary artery bypass surgery was necessitated, and distal anastomosis was performed before the mitral pro-cedure, tricuspid and aortic valve procedures were necessitated, carried out after the mitral procedure. The annulus, leaflets, and subvalvular apparatus were carefully evaluated with the aid of a saline injection test to determine the precise anatomy of the lesion and to choose the optimal method of repair. TEE was also used before CPB to evaluate the regurgi-tation mechanism to choose the right repair tech-nique and to detect the regurgitation degree after cross-clamp. Follow-UpClinical and echocardiographic follow-up was performed shortly before hospital discharge, at 1 month, and then every 6 months by the referring cardiologist. Survival, reoperation, cerebrovascular accidents, bleeding complications, anticoagulation therapy, NYHA functional class, and cardiac rhythm were recorded. On echocardiography, mitral regurgita-tion was classified from 1 to 4.Statistical AnalysisThe preoperative presence and severity of mitral insufficiency were determined by transthoracic and transesophageal echocardiography (TEE) according to current guidelines. Survival curves and event-free survival curves free from events were calculated by using the Kaplan-Meier method (10). Survival rates are presented as percentages of patients per year (% patient/year). ResultsThe mean age of patients was 43.2±12.3 years (18-67 years), 62.5% (n=120) of them were female and %37.5 (n=72) were male. Demographic data and clini-cal characteristics of the patients are shown in Table 1.Among the 192 patients, there were 5 in-hospi-tal deaths and the operative mortality rate was 2.6%. Three patients died due to low cardiac output syn-drome, 1 patient died from malign arrhythmias and 1 patient died from multi-organ failure. All patients who died in the early postoperative period had un-dergone re-operation with suspicion of acute mitral regurgitation clinic.Multivariate analysis demonstrated that residual NYHA class III and IV (p=0.023, OR 2.53, 95% CI: 1.93–4.88), low preoperative ejection fraction (p=0.001, 0R 3.11, 95% CI: 1.82–5.66), and ischemic MR (p=0.01, OR 3.39, 95% CI: 1.29–4.37) were all independent predictors of mortality. Persistent mitral regurgitation at a third POD (p=0.001, OR 3.55, 95% CI: 1.55–5.5), and absence of prosthetic ring or band (p=0.001, OR 4.55, 95% CI: 1.58–7.18) were all inde-pendent risk factors for reoperation.  Table 1. Demographic variables and clinical characteristics of the patientsAssociated techniques Patients (n)   Patients (%)            Female 120 62.5Male 72 37.5Age (Mean±SD) 43.2±12.3 yearsComorbid factorsHypertension 72 37.5Atrial fibrillation 50 26Diabetes 23 11.9Coronary artery disease18 9.3Chronic renal failure 18 9.3Chronic obstructivePulmonary disease8 4.1Peripheral vascular disease6 3.1Progress in Nutrition 2022; Vol. 24, Supplement 1: e2022058 3The rates of comorbid conditions were as follows; atrial fibrillation 26% (n=50), hypertension 37.5% (n=72), diabetes 11.9% (n=23), chronic renal failure 9.3% (n=18), chronic obstructive pulmonary disease 4.1% (n=8) and peripheral vascular disease 3.1% (n=6). The cause of mitral regurgitation was primer in %90.6 (n=174) patients; (96 (50%) rheumatic, 54 (28.1%) myxomatous and 24 (12.5%) infective) and secondary to coronary artery disease in %9.3 (n=18) patients. Seventeen patients (8.8%) had coronary le-sions requiring surgical correction. The most common non-mitral concomitant cardiac procedure was tricus-pid valve repair (27.6%, n=53).Various repair techniques (ring or band annulo-plasty insertion, triangular or quadrangular resection, edge-to-edge repair) were used according to the func-tional and pathologic findings of MV (Table 2).The preoperative clinical status of 157 patients (82%) were in NYHA functional class III-IV. At the end of the observation period, almost all 165/187 (88%) of the patients were in the NYHA functional class I. None of the patients were lost to follow-up. The mean follow-up period for the 187 discharged patients was 41±18 months. Sixteen patients (8.5%) required reoperation (Table 3) at a mean interval of 26.2±3.6 months, nine of whom (4.8%) were required MV re-placement. The mortality rate in the re-operated group was 32% (5/16). Causes of most deaths were congestive heart failure. Diagnosis of mitral stenosis and persis-tent MVR on discharge (Mitral regurgitation grade≥3 or mitral stenosis with mean gradient ≥10mmHg) Table 2. Techniques associated with mitral valve repair (more than one procedure was applied in near all operations)Associated techniques Patients (n) Patients (%) Annuloplasty ring insertion 51 25.5Annuloplasty band insertion 141 73.4Edge-to-edge repair 45 23.4Quadrangular resection 25 13Triangular resection 15 7.8Neochord insertion 14 7.3Shortening of the chordea tendineae14 7.3Sliding of the posterior leaflet 13 23.4Table 3. Causes of failed mitral valve repairCause of failed repair (n=16) (n) %Valve related 10 62.5Progressive disease 7 43.75Endocarditis 3 18.75Procedure-related 4 25Ruptured chordae 3 18.75Incomplete repair 1 6.25Unknown 2 12.5were significant risk factors for re-operation (p<0.05). The late mortality rate was 3.7% (7/187). The actuarial survival was 95.8%±2.3% at a mean follow-up of 43 months (Figure 1). Survival free from re-operation was 92.8%± 4.2% at 60 months. Discussion and ConclusionRecurrence of MVI after MV reconstruction surgery is one of the major concerns of the surgeon. Doubts about repair exist as the advantage from the lesser requirement for anticoagulation may be over-whelmed by the shorter durability regarding the re-placement. It has been shown that survival benefits of repair may be age-related, and elderly patients could benefit less from valve repair (11, 12).Tissue valves are not suitable for the mitral posi-tion, but mechanical valves require life-long anticoag-ulation which is associated with the certain degree of morbidity and mortality. In addition, prosthetic heart valves have a higher risk of endocarditis compared to repair (13).Repair and replacement may be much more con-venient to different subsets of patients, however, the factors affecting the correct clinical decision are dif-ficult to be found out from clinical experience alone. Especially in degenerative disease, it is unclear whether repair or replacement provides the best long-term out-comes in different patient subsets. Mitral valve repair is becoming the preferred ap-proach for most causes of MR. There are increasing data showing in-hospital and long-term survival ad-vantages exist for MV repair over replacement (1-4)Progress in Nutrition 2022; Vol. 24, Supplement 1: e20220584mortality (16). Similarly, we also found that ischemic mitral regurgitation is an independent risk factor as-sociated with mortality.The techniques used for MV repair in our popula-tion include almost always (more than %95) full ring or band annuloplasty (Edwards Physio, Carpentier classic) along with appropriate leaflet or chordal pro-cedures. Various combinations of leaflet and chordal procedures were used, depending on surgeons’ prefer-ence, patho-anatomical variations, and evolution of techniques with time. Recent advances in surgical technique allow re-pair of most mitral valves with degenerative disease. However, few long-term data exist to support the su-periority of repair versus prosthetic valve replacement, and repair could be limited by late durability or other problems.The durability of mitral repair also depends on the technique. After we learned that annular remodeling is very important in MV reconstruction, and prosthetic ring insertion became had excellent results, several sur-geons think that a prosthetic ring should be applied to Enriquez-Sarano and associates reported signifi-cantly less hospital mortality with repair over replace-ment (2.6% versus 10.3%) (3). Ten year survival rate was better for repair than replacement (68%±6% versus 52%±4%; p=0.0001). Gillinov and colleagues supported long-term durability of MV repair for degenerative dis-ease with ten year freedom from reoperation of %93 (2). Patients with ischemic MR have also seen benefits from valve repair (14). Our findings in regard to re-operation rates are similar to the literature (1-4, 8). The concept of superiority of MV repair over re-placement in ischemic MV regurgitation is controver-sial. The report by Thourani and associates documented equivalent survival with MV repair and replacement in patients requiring coronary bypass surgery (15). This finding is also supported by Gogbashian and col-leagues (9). In contrast, Enriquez–Sarano and associ-ates documented a survival benefit with MV repair over replacement in patients requiring concomitant CABG at 6 years (74%± 6% versus 34% ± 8%) (3). In multivariate analysis, Nagendran and coworkers documented CABG as an independent risk factor for Figure 1. Survival actuarial curve during a 60-month follow-upProgress in Nutrition 2022; Vol. 24, Supplement 1: e2022058 55. Gillinov AM, Wierup PN, Blackstone EH, et al. Is repair preferable to replacement for ischemic mitral regurgitation? J Thorac Cardiovasc Surg 2001; 122:1125-1141.6. Vetter HO, Burack JH, Factor SM, et al. Replacement of chordae tendineae of the mitral valve using the new ex-panded PTFE suture in sheep. In: Bodnar E, Yacoub M, eds. Biologic bioprosthetic valves. New York:Yorke Medical Books, 1986: 772-784.7. Seeburger J, Kuntze T, Mohr FW. Gore-Tex chordoplasty in degenerative mitral valve repair. Semin Thorac Cardiovasc Surg 2007; 19: 111-118. 8. Savage EB, Ferguson TB Jr, DiSesa VJ. Use of mitral valve repair: analysis of contemporary United States experience reported to the Society of Thoracic Surgeons National Car-diac Database. Ann Thorac Surg 2003; 75: 820-825.9. Gogbashian A, Sepic J, Soltesz EG, Nascimben L, Cohn LH. Operative and long-term survival of elderly is signifi-cantly improved by mitral valve repair. Am Heart J 2006; 151: 1325-1333.10. Kaplan EL, Meier P. Nonparametric estimation from in-complete observations. J Am Stat Assoc 1958; 53: 457-481. 11. Ailwadi G, Swenson BR, Girotti ME, et al. Is mitral valve repair superior to replacement in elderly patients? Ann Thorac Surg 2008; 86: 77-86. 12. Gilinov AM, Blackstone EH, Nowicki ER, et al. Valve re-pair versus valve replacement for degenerative mitral valve disease. J Thorac Cardiovasc Surg 2008; 135: 885-893.13. Habib G, Thuny F, Avierinos JF. Prosthetic valve endocardi-tis: current approach and therapeutic options. Prog Cardio-vasc Dis 2008; 50: 274-281.14. Gazoni LM, Kern JA, Swenson BR, et al. A change in per-spective: results for ischemic mitral valve repair are similar to mitral valve repair for degenerative disease. Ann Thorac Surg 2007; 84: 750-757.15. Thourani VH, Weintraub WS, Guyton RA, et al. Outcomes and long-term survival for patients undergoing mitral valve repair versus replacement: effect of age and concomitant cor-onary artery bypass grafting. Circulation 2003; 108: 298-304.16. Nagendran J, Norris C, Maitland A, et al. Is mitral valve surgery safe in ocrogenarians? Eur J Cardiothorac Surg 2005; 28: 83-87.17. Deloche A, Jebara VA, Relland JYM, et al. Valve repair with Carpentier techniques. The second decade. J Thorac Cardio-vasc Surg 1990; 99: 990-1002.   18. Lessana A, Viet TT, Ades F, et al. Mitral reconstructive op-erations. A series of 130 consecutive cases. J Thorac Cardio-vasc Surg 1983; 86: 553-561.19. Cosgrove DM 3rd, Arcidi JM, Rodriquez L, Stewart WJ, Powell K, Thomas JD. Initial experience with the Cosgrove-Edwards Annuloplasty System Ann Thorac Cardiovasc Surg 1995; 60: 499-504.20. Gillinov AM, Cosgrove DM, Lytle BW, et al. Reoperation for failure of mitral valve repair. J Thorac Cardiovasc Surg 1997; 113: 467-475. 21. Orszulak TA, Schaff HV, Danielson GK, et al. Mitral re-gurgitation due to ruptured chordae tendineae. Early and all MV repairs (17-19). However; these rings may be associated with systolic anterior movement (SAM) of the MV (20, 21) which causes left ventricular outflow obstruction and residual mitral regurgitation. Selec-tion of the correct ring size is necessary to avoid SAM, which usually appears when the ring is too small, a good correlation between the implanted ring size and body surface area (17, 22). Our results indicated that our choices of ring sizes were appropriate as there were no cases of SAM observed in our study population during follow-up.Our study showed that the type of annuloplasty (Cosgrove-Edwards, Carpentier-Edwards, posterior pericardial plication) did not influence repair durabil-ity. We conclude that mitral valve repair, using current techniques, showed excellent survival, acceptable re-operation rate with satisfactory valve function at early and mid-term follow-up.  Because it conserves the subvalvular apparatus and ventricular geometry which preserves left ventricular function and also causes less chronic anticoagulation requirement.Finally, we feel that the most important point is a detailed examination of all valvular components during surgery and intraoperative echocardiographic guidance decreases the risk of late re-operation.             Conflicts of interest: Each author declares that he or she has no commercial associations (e.g. consultancies, stock ownership, equity interest, patent/licensing arrangement etc.) that might pose a con-flict of interest in connection with the submitted article.References1. Braunberger E, Deloche A, Berrebi A, et al. Very long-term results (more than 20 years) of valve repair with Carpentier’s techniques in nonrheumatic mitral valve insufficiency. Cir-culation 2001; 104 (Suppl 1): 8-11.2. Gillinov AM, Cosgrove DM, Blackstone EH, et al. Dura-bility of mitral valve repair for degenerative disease. J Thorac Cardiovasc Surg 1998; 116: 734-43.3. Enriquez-Sarano M, Schaff HV, Orszulak TA, et al. Valve repair improves the outcome of surgery for mitral regur-gitation. A multivariate analysis. Circulation 1995; 91: 1022-1028.4. Suri RM, Schaff HV, Dearrani JA, et al. Survival advantage and improved durability of mitral repair for leaflet prolapse subsets in the current era. Ann Thorac Surg 2006; 82: 819-826.Progress in Nutrition 2022; Vol. 24, Supplement 1: e20220586Correspondence:Hayati DenizFatih Mahallesi, 22 Sokak, Çankaya Sitesi C  Blok Daire: 2 Şehitkamil, Gaziantep, TURKEYTel no: +90 505 6222642E-mail: hayatideniz@gmail.comlate results of valve repair. J Thorac Cardiovasc Surg 1985; 89: 491-498.  22. Schravone WA, Cosgrove DM, Lever HM, et al. Long-term follow-up of patients with left ventricular outflow tract obstruction after Carpentier ring mitral valvuloplasty. Cir-culation 1988; 78:160-165.

Evaluation of Early and Midterm Mitral Valve Repair Results in Consecutive Severe Mitral Regurgitation Patients

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