Mechanisms of failure of mitral valve repair: An echocardiographic study

doi:10.1016/0002-8703(91)90772-A

American Heart Journal

Volume 122, Issue 1, Part 1, July 1991, Pages 149-156

https://doi.org/10.1016/0002-8703(91)90772-A Get rights and content

Abstract

Surgical valve repair for mitral regurgitation has significant advantages over valve replacement, but little is known about the mechanisms of its failure. This echocardiographic study examined abnormalities leading to falled mitral valve repair in two populations: “immediate failure” of the valve repair in the operating room requiring a second run of cardiopulmonary bypass and “late failure” of valve repair necessitating reoperation on another occasion. Intraoperative echocardiography (IOE) after cardiopulmonary bypass was performed in 309 patients undergoing valve repair for mitral regurgitation over a 3-year period. Twenty-six (8%) of these patients had immediate failure of the repair demonstrated by IOE, requiring further repair or replacement during the same thoracotomy. The causes of immediate failure were left ventricular outflow tract obstruction (10 patients), incomplete correction (10 patients), and suture dehiscence (six patients). Echocardiography was performed on 17 patients requiring reoperation for recurrent mitral regurgitation who had undergone previous primary valve repair. These late failures resulted from progressive degenerative leaflet or chordal disease (n = 9) or suture dehiscence of the annular ring or the leaflet resection site (n = 6). In only two patients early in the series did the problem originate from inadequate initial surgery. IOE is an effective marker for unsuccessful mitral valve repair, and affords an understanding of the mechanism of the persistent dysfunction. Immediate failure of mitral repair may be reduced by greater attention to the mechanism of valve dysfunction and by changes in valvuloplasty technique to avoid outflow tract obstruction. Late failure after mitral repair occurs predominantly due to progression of disease, particularly in patients with severe myxomatous or annular abnormalities that are prone to progress.

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Cited by (82)

Mitral Valve Repair for Pure Mitral Regurgitation Followed Years Later by Mitral Valve Replacement for Mitral Stenosis
2017, American Journal of Cardiology
Citation Excerpt :
Had these 2 patients had the repair operation at age 55 years, the average age of the repair procedure in the previously mentioned report,1 both may well have died before developing symptoms of mitral dysfunction again. A number of articles have appeared providing follow-up after a mitral valve repair operation for pure MR, mainly mitral valve prolapse.2–23 Several of them have mentioned the development of MS after the mitral valve repair operation3–5,14–17,21–23 (Table 2).
We describe herein 2 patients who developed severe mitral stenosis (MS) approximately two decades after a mitral valve repair operation for pure mitral regurgitation (MR) secondary to mitral valve prolapse. This report's purpose is to point out that use of a circumferential mitral annular ring during the repair has the potential to produce a transmitral pressure gradient just like that occurring after mitral valve replacement utilizing a mechanical prosthesis or a bioprosthesis in the mitral position.
Mitral Valve Replacement after Failed Mitral Ring Insertion with or Without Leaflet/Chordal Repair for Pure Mitral Regurgitation
2016, American Journal of Cardiology
Mitral repair operations for correction of pure mitral regurgitation (MR) are generally quite successful. Occasionally, however, the reparative procedure incompletely corrects the MR or the MR recurs. From March 1993 to January 2016, twenty nine patients had mitral valve replacement after the initial mitral repair operation, and observations in them were analyzed. All 29 patients at the repair operation had an annular ring inserted and later (<1 year in 6 and >1 year in 21) mitral valve replacement. The cause of the MR before the repair operation appears to have been prolapse in 16 patients (55%), secondary (functional) in 12 (41%) (ischemic in 5), and infective endocarditis which healed in 1 (3%). At the replacement operation the excised anterior mitral leaflet was thickened in all 29 patients. Some degree of stenosis appeared to have been present in 16 of the 29 patients before the replacement operation, although only 10 had an echocardiographic or hemodynamic recording of a transvalvular gradient; at least 11 patients had restricted motion of the posterior mitral leaflet; 10, ring dehiscence; 2, severe hemolysis; and 2, left ventricular outflow obstruction. In conclusion, there are multiple reasons for valve replacement after earlier mitral repair. Uniformly, at the time of the replacement, the mitral leaflets were thickened by fibrous tissue. Measurement of the area enclosed by the 360° rings and study of the excised leaflet suggest that the ring itself may have contributed to the leaflet scarring and development of some transmitral stenosis.
Sizing for mitral annuloplasty: Where does science stop and voodoo begin?
2013, Annals of Thoracic Surgery
Citation Excerpt :
On the small side of the spectrum, a ring may result in functional mitral stenosis [4]. In the setting of MR due to Barlow's disease where there is excessive leaflet tissue and often considerable mitral annular dilation, small rings increase the risk of systolic AML motion with LV outflow tract obstruction as well as that of ring dehiscence [1–3]. On the large side of the ring size spectrum, the ring may prevent adequate leaflet coaptation, resulting in a substantial degree of mitral regurgitation, either immediately after the operation or postoperatively.
The implantation of an improperly sized annuloplasty ring may result in an incompetent valve after surgical mitral valve repair. Consequently, the procedure of ring size selection is considered critical. Although a plethora of sizing strategies are described, the opinions on how to select the appropriate ring size differ widely and often appear arbitrary (ie, without scientific justification). These inconsistencies raise the question where, with respect to ring sizing, science stops and voodoo begins.
The effect of depth of anesthesia on the severity of mitral regurgitation as measured by transesophageal echocardiography
2012, Journal of Cardiothoracic and Vascular Anesthesia
Citation Excerpt :
Each data point was the average of 3 cardiac cycles. MR was graded quantitatively according to the PISA measurements of the effective regurgitant orifice (ERO) area using a simplified proximal convergence method, ERO area = (radius of PISA)2/2,6,7 with ERO areas <0.2, 0.2-0.29, 0.3-0.39, and ≥0.4 cm2 designated as mild (1), mild to moderate (2), moderate to severe (3), and severe (4), respectively.8 All measurements were made with patients in the supine position by an experienced cardiac anesthesiologist (J.-H.C.) who was blinded to the order of the BIS change before skin incision.
The unloading effect of anesthesia on the left ventricle results in a downgrade of mitral regurgitation (MR) severity, which increases as anesthesia deepens. This study examined how the depth of anesthesia could affect the loading condition of the left ventricle and the severity of MR.
A prospective study.
Cardiac operating room at a single institution.
Twenty patients with functional MR and 20 patients with organic MR.
Different anesthetic depths determined by bispectral index (BIS) monitoring.
In patients with functional MR, maximal regurgitant jet area (JA), the vena contracta (VC) width, and the proximal isovelocity surface area (PISA) radius were significantly smaller at a low BIS than at a high BIS (JA, 2.4 cm², 1.9-4.7, v 5.0 cm², 3.4-6.7, p < 0.001; VC width, 2.7 ± 1.6 v 4.2 ± 1.4 mm, p < 0.001; PISA radius, 3.3 ± 2.3 v 5.6 ± 2.4 mm, p < 0.001). Similarly, in patients with organic MR, JA, VC width, and PISA radius were significantly smaller at a low BIS than at a high BIS (JA, 7.0 ± 2.4 v 9.7 ± 3.6 cm², p = 0.002; VC width, 5.7 mm, 4.1-6.6, v 7.1 mm, 5.4-8.4, p < 0.001; PISA radius, 9.0 ± 2.8 v 12.0 ± 3.3 mm, p < 0.001).
It may be helpful to measure the severity of MR at a shallower anesthesia depth guided by BIS monitoring to avoid a downgrade of MR under general anesthesia.
Reoperation for Failure of Mitral Valve Repair in Degenerative Disease: A Single-Center Experience
2008, Annals of Thoracic Surgery
The purpose of this study was to report our 19-year experience in redo surgery for failure of mitral valve repair (MVRep) in degenerative disease.
From 1987 to 2006, 43 consecutive patients (32 males) underwent either redo MVRep (n = 21) or redo mitral valve replacement (n = 22) for failure of MVRep. Age ranged from 10 to 78 years (median, 59 years). Forty-one patients (95%) had grade 3+ or greater mitral regurgitation, and 3 patients had chronic systolic anterior motion of the anterior leaflet of the mitral valve. Repair was mainly performed using Carpentier's techniques.
There was no perioperative death in the MVRep group and 2 deaths in the redo mitral valve replacement group. In univariate analysis, long-term survival was significantly superior in the MVRep group compared with redo mitral valve replacement (p = 0.011). There were three reoperations (14%) in the MVRep group for recurrent severe mitral regurgitation. One patient (5%) in the redo mitral valve replacement group underwent reoperation for prosthetic endocarditis. The 7-year freedom from reoperation rate was 95% (95% confidence interval, 84% to 99%) in both groups. At the latest follow-up, 16 (94%) patients in the MVRep group were in New York Heart Association I or II functional status. Fifteen (88%) had no or mild mitral regurgitation on echocardiography. Two patients (12%) presented with moderate (2+) mitral regurgitation.
In case of failure of MVRep for severe degenerative mitral valve disease, re-repair is feasible in about 50% of the patients with encouraging results at 7 years.
Intraoperative Echocardiography in Mitral Valve Repair
2008, Practice of Clinical Echocardiography, Thrid Edition

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Mechanisms of failure of mitral valve repair: An echocardiographic study

Abstract

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Thorac Cardiovasc Surg

J Am Coll Cardiol

Am J Cardiol

J Thorac Cardiovasc Surg

J Am Coll Cardiol

J Thorac Cardiovasc Surg

Am J Cardiol

J Am Coll Cardiol

Reflections on the development of cardiac surgery

One hundred seventeen cases of valvular rheumatic heart diseases: with preliminary report of two cases of mitral regurgitation treated under direct vision with aid of a pump-oxygenator

JAMA

Surgical correction of pure mitral insufficiency by anuloplasty under direct vision

Lancet