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Mitral annular calcification (MAC) represents a surgical challenge to mitral valve replacement. The presence of MAC at the time of mitral valve replacement is associated with perivalvular leak and atrial-ventricular groove injury. Although percutaneous and hybrid approaches may offer alternatives to surgical mitral valve replacement, the early and late results from these techniques remain unknown. As such, the surgical management of MAC remains relevant in the contemporary treatment of patients with MAC. Herein, we present a systematic approach to the management of MAC at the time of mitral valve replacement., (Copyright © 2022 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Mitral regurgitation due to bileaflet prolapse can be corrected with height reduction of the posterior leaflet through detachment at its base, division of accompanying secondary chordae, and leaflet-annular reapproximation. This technique lowers the posterior leaflet height to approximately 1.5 cm, thereby displacing the line of coaptation posteriorly to achieve symmetry without the need for additional artificial chordae. Of 37 patients who underwent this type of repair at our institution, no patient had recurrent mitral regurgitation ≥ 2 at an average follow-up of 1.9 years (range, 0.2-4.5)., (Copyright © 2021 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Recent data suggest sex-specific differences in left ventricle (LV) remodeling in patients with ventricular dysfunction or volume overload. Data describing LV remodeling in patients after repair of degenerative mitral regurgitation (MR) is scarce., Methods: Between 2002 and 2017, 1012 patients underwent repair of MR due to myxomatous degeneration and were monitored serially in a dedicated clinic. Patients were a mean age of 63.8 ± 12.7 years, and 277 (27%) were women. Mean preoperative indexed LV end-systolic dimension was 19.0 ± 4.3 mm/m 2 . Clinical and echocardiographic follow-up averaged 5.1 years and extended to 14.7 years. There were 3112 postoperative echocardiograms performed for these patients., Results: Overall, freedom from recurrent MR exceeding 2+ was 98.3% ± 5.5% at 5 years and 86.9% ± 2.0% at 10 years. After a mean of 5.1 years, the mean postoperative indexed LV end-systolic dimension was 17.3 ± 4.2 mm/m 2 . Postoperative indexed LV end-systolic dimension decreased compared with their preoperative measurement in 63% of patients. Notably, women were less likely to experience a postoperative decrease in indexed LV end-systolic dimension than men (hazard ratio, 0.7 ± 0.1; P = .04), even after adjusting for differences in age, preoperative atrial fibrillation status, preoperative right ventricle systolic pressure, and the subsequent development of recurrent MR. Similar results were also obtained in a propensity analysis of 275 matched female-male pairs (hazard ratio, 0.7 ± 0.1; P = .03)., Conclusions: Few data are available describing LV remodeling after repair of degenerative MR. In a large population registry, we have observed sex-specific differences in late LV remodeling. These data therefore raise equipoise that earlier surgical intervention of women with degenerative MR may be warranted., (Copyright © 2019 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Data comparing outcomes after repair versus replacement of chronic ischemic mitral regurgitation (MR) is evolving. Recent data suggest that repair is associated with recurrent MR, but not survival, when compared with replacement. However, it remains unclear when either surgical strategy should be applied based on preoperative mitral valve anatomy., Methods: Between 2001 and 2013, 161 patients underwent repair or replacement of chronic ischemic MR. The mean age of these patients was 68.2 ± 9.0 years, 44 (27%) were female, and concomitant coronary artery bypass grafting was performed in 126 (78%). The mean preoperative posterior leaflet angle was 27.7 ± 14.2 degrees, and the left ventricular ejection fraction was 41.2 ± 12.4%. Detailed preoperative assessments of mitral valve anatomy were determined by transesophageal echocardiography. Clinical and echocardiographic follow-up was for 4.6 ± 3.2 years and extended to 11.7 years., Results: Overall, perioperative death occurred in 6 (3.3%) patients; 2 patients died after valve repair and 4 after valve replacement. Five-year survival and freedom from recurrent MR (≥2+) rates were 74.0 ± 5.6% and 57.8 ± 8.0%, respectively, after valve repair and 69.4 ± 6.2% and 87.1 ± 7.0%, respectively, after valve replacement. Valve repair was associated with recurrent MR (≥2+) (hazard ratio [HR], 5.3 ± 3.3; p = 0.007), but not survival (HR, 0.9 ± 0.3; p = 0.8). Preoperative posterior leaflet tethering angle was associated with survival (HR, 1.09 ± 0.04; p = 0.005) and also recurrent MR (≥2+) (HR, 1.04 ± 0.02; p = 0.03) after valve repair. Based on a receiver operator curve describing the relationship between recurrent MR (≥2+) and posterior leaflet tethering angle, a threshold of 22 degrees was determined., Conclusions: Surgical correction of chronic ischemic MR can be performed with favorable early and late results, although recurrent MR occurred more often after repair. Among patients who underwent repair of ischemic MR, a preoperative posterior leaflet tethering angle of 22 degrees or greater was associated with worse late outcomes., (Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Repair of mitral regurgitation (MR) caused by prolapse has been well validated. Although favorable early and late results after repair have been reported, few data are available that mechanistically describe how a mitral repair fails beyond the mere need for mitral valve reoperation. We therefore sought to determine the modes of valve repair failure in patients who underwent surgical correction of MR caused by prolapse., Methods: Between 2001 and 2015, 855 patients underwent repair of MR caused by prolapse. Patients were a mean age of 63.7 ± 12.7 years, and 380 (44%) had bileaflet prolapse. The overall repair rate was 97.2%. These patients were monitored as part of a cohort initiative and underwent serial clinical and echocardiographic assessments at 1, 3 to 6, and 12 months after the operation. Beyond the first year of the MR repair, patients were assessed by echocardiography every 1 to 2 years or when clinically indicated. Clinical and echocardiographic follow-up averaged 4.3 ± 3.5 years., Results: Freedom from recurrent MR of 2+ or higher was 92.4% ± 1.3% at 5 years and 86.6% ± 2.4% at 10 years. Overall, recurrent MR of 2+ or higher developed in 49 patients (5.7%) at a mean of 3.1 ± 2.5 years after the repair, of whom 14 (1.6%) had recurrent MR of 3+ or 4+. Among patients with bileaflet prolapse, recurrent MR of 2+ or higher was observed in 24, of whom 9 had 3+ or 4+ MR., The development of recurrent MR of 2+ or higher was categorized as prolapse in 6 and nonprolapse in 43. Severe mitral stenosis occurred in 3 patients at 8.2 years after the MR repair. Mitral reoperation was ultimately performed in 21 patients. Patients who had recurrent MR 2+ or higher within the first year after the operation were more likely to undergo a subsequent mitral valve reoperation (incident rate ratio, 5.2 ± 2.9; p = 0.003), although no association between recurrent MR and reoperation was observed after the first year., Conclusions: Severe MR after repair is rare, although some may have recurrent moderate MR. Patients who required a subsequent mitral valve reoperation were most likely to have recurrent MR of 2+ or higher within the first year after the operation., (Copyright © 2016 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The evidence supporting early surgical intervention in patients with chronic asymptomatic mitral regurgitation (MR) is steadily accumulating. Although left ventricular (LV) enlargement and preoperative pulmonary hypertension are considered when deciding on surgical intervention, the threshold above which these factors influence clinical outcomes remains poorly defined., Methods: One-hundred fifty asymptomatic patients of aged 59.3 ± 13.4 years underwent mitral valve repair of severe MR caused by myxomatous degeneration between 2001 and 2012. Mean preoperative left atrial diameter, LV end-systolic diameter (LVESD), and right ventricular systolic pressure were 41.2 ± 6.9 mm, 34.6 ± 5.4 mm, and 38.4 ± 11.8 mm Hg, respectively. Preoperative LV ejection fraction (LVEF) was greater than 60% in 136 (91%) patients, and none had preoperative atrial fibrillation. Clinical and echocardiographic follow-up averaged 3.3 years and extended to 9.1 years., Results: There were no perioperative deaths. Five-year survival and freedom from recurrent MR greater than or equal to 2+ were 93.4% ± 3.2% and 94.0% ± 3.2%, respectively. A threshold LVESD indexed to body surface area greater than 19 mm/m(2) (hazard ratio [HR], 3.5 ± 2.0; p = 0.03) and a preoperative right ventricular systolic pressure greater than 45 mm Hg (HR, 3.8 ± 12.1; p = 0.01) were independently associated with postoperative LV dysfunction, defined as a LVEF less than 60%., Conclusions: Mitral valve repair can be performed with favorable early and late outcomes in patients with asymptomatic severe MR. The presence of minimal LV enlargement and preoperative pulmonary hypertension were associated with postoperative LV dysfunction in this otherwise healthy population. Mitral valve repair may be considered in asymptomatic patients with an indexed LVESD (ILVESD) greater than 19 mm/m(2) or preoperative right ventricular systolic pressure greater than 45 mm Hg., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Dialysis-dependent renal failure occurs infrequently after cardiac surgery but leads to substantial morbidity and mortality. In contrast, milder degrees of acute kidney injury (AKI), based on small increases in serum creatinine, occur frequently but the independent impact of mild AKI on outcome remains unclear., Methods: Between January 2010 and December 2012, 3,869 consecutive patients undergoing cardiac surgery comprised the study cohort. Acute kidney injury was defined according to the AKI Network criteria as stage I, II, or III. A nonparsimonious multivariable logistic regression model including preoperative and intraoperative variables was constructed to determine a propensity score for the development of stage I AKI followed by a greedy matching algorithm to create 1:1 propensity-matched pairs., Results: The incidence of stage I AKI in the entire cohort was 22.4%. Stage I AKI patients were more likely to be older; to have diabetes mellitus, hypertension, preoperative renal dysfunction, and poorer left ventricle function; and to require more urgent surgery and longer cardiopulmonary bypass. After propensity matching, the 833 matched pairs were similar in terms of all of the above characteristics (all p > 0.5). Within the matched cohort, AKI patients had higher mortality (2.6% versus 1.2%, p = 0.01), higher incidence of neurologic dysfunction (15.2% versus 8.1%, p < 0.001), and longer duration of mechanical ventilation (41.7 ± 125.0 versus 19.3 ± 58.6 hours, p < 0.001). Intensive care unit stay (5.2 ± 10.7 versus 2.7 ± 3.8 days, p < 0.0001), and hospital length of stay (17.9 ± 20.1 versus 14.7 ± 18.3 days, p = 0.0007) was significantly longer for matched AKI patients., Conclusions: Patients with even mild degrees of AKI have increased mortality and morbidity compared with their matched counterparts. Interventions that prevent or mitigate AKI after cardiac surgery can yield substantial clinical benefit., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: Percutaneous therapies to manage mitral regurgitation are emerging as an alternative to conventional operations, especially for patients with a high estimated perioperative risk. However, contemporary risk models may not accurately reflect outcomes at reference mitral valve centers. The purpose of this study was to describe perioperative mortality rates after mitral valve operations in a contemporary cohort., Methods: Between 2001 and 2011, 1,154 patients underwent mitral valve operations at a reference center. Of these, 851 underwent repair and 303 underwent replacement. Concomitant coronary artery bypass grafting was performed in 201 (17%). The Society of Thoracic Surgeons (STS) risk score version 2.73 and European System for Cardiac Operative Risk Evaluation (EuroSCORE) II were used to estimate the number of perioperative deaths., Results: The observed perioperative mortality was 1.0%. The STS score was 2.3%±2.6% and was higher than the observed mortality rate for each of the STS subgroups (all p<0.001). The EuroSCORE II expected mortality was 3.0%±3.4% and was greater than the observed mortality rate for isolated and combined procedures (both p<0.001). The STS and EuroSCORE II provided fair death discrimination, with an area under the receiver operating characteristic curve of 0.74 and 0.67, respectively., Conclusions: Although current risk models aid in risk stratifying patients, the contemporary perioperative mortality rate at a reference mitral valve center is significantly lower than expected. The use of alternate therapies must therefore take into consideration differences in perioperative risk based on the treating center., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)