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ZusammenfassungBei einer asymptomatischen hochgradigen Aortenklappenstenose (AS) mit normaler linksventrikulärer Funktion sollte eine „Watchful-Waiting“-Strategie verfolgt werden. Asymptomatische Patienten mit Risikofaktoren, wie sehr schwere AS, schwere kalzifizierter AS oder 3-fach erhöhtem proBNP-Level, können bei niedrigem operativem Risiko eine Intervention erhalten. Erste randomisierte Studien weisen auf einen Vorteil des frühzeitigen Aortenklappenersatzes bei niedrigem OP-Risiko hin.Für Patienten mit einer asymptomatischen hochgradigen Aortenklappeninsuffizienz sollte bei niedrigem operativem Risiko bereits frühzeitig eine OP erwogen werden, wenn sich Zeichen der linksventrikulären Schädigung zeigen.Bei asymptomatischer primärer Mitralklappeninsuffizienz (MI) kann die chirurgische Mitralklappenrekonstruktion bereits vor dem Auftreten einer linksventrikulären Dilatation oder anderweitigen Folgeschäden erwogen werden, falls mit einer hohen Rekonstruktionswahrscheinlichkeit zu rechnen ist.

Myocardial native T1 is a known cardiovascular magnetic resonance (CMR) imaging biomarker to quantify diffuse myocardial fibrosis in valvular cardiomyopathy. We hypothesized that diffuse myocardial fibrosis assessed by preoperative T1 mapping might correlate with LV reverse remodeling after valvular surgery. A prospective monocentric cohort study was conducted including 79 consecutive patients with valvular cardiomyopathy referred for surgical treatment of severe aortic or severe functional mitral regurgitation. Native T1 values were assessed by CMR before surgery. LV geometry parameters (i.e., LVEDV, LVESV) were obtained by 2D transthoracic echocardiography before and six months after surgery. Postoperative change of LV geometry parameters was calculated as delta (∆) variable (i.e., six months value minus baseline value). Mean native T1 was 1047 ± 39 ms, mean ∆LVEDV was −33 ± 42 mL, and mean ∆LVESV was −15 ± 27 mL. Native T1 values correlated with ∆LVEDV (Pearson r = 0.29; p = 0.009) and ∆LVESV (Pearson r = 0.29; p = 0.015). Native T1 values < 1073 ms were identified as independent predictor of postoperative reduction of LVEDV (HR 3.0; 95%-CI: 1.1–8.0; p = 0.03) and LVESV (HR 2.9; 95%-CI: 1.1–7.4; p = 0.03). Diffuse myocardial fibrosis assessed by myocardial native T1 correlates with LV reverse remodeling at six months after valvular surgery. T1 mapping may be a valuable tool to predict LV reverse remodeling in valvular heart disease.

Background Systemic inflammation due to cardiogenic shock is associated with vasoplegia leading to organ hypoperfusion, right heart failure, and poor clinical outcome. Extracorporeal cytokine hemoadsorption emerged to attenuate excessive levels of inflammatory cytokines, potentially improving patient outcomes. Nevertheless, its prognostic impact during high-risk left ventricular assist device (LVAD) implantation remains unknown. Methods In total, 40 consecutive patients with advanced heart failure underwent continuous-flow LVAD implantation at our institution between 2018 and 2020. Out of 25 high-risk patients in cardiogenic shock (Interagency Registry for Mechanically Assisted Circulatory Support profile 1 and 2), 9 patients (CytoSorb group) underwent LVAD implantation with and 16 patients (control group) without simultaneous cytokine hemoadsorption during cardiopulmonary bypass. Besides preoperative patient characteristics, postoperative lactate clearance, vasopressor administration and mean arterial pressure, perioperative complication, and 30-day mortality rates were retrospectively analyzed. Results Apart from an increased rate of reoperations within the CytoSorb group, baseline characteristics including the severity of ventricular dysfunction and consecutive signs of end-organ failure were similar in both groups. Preoperative short-term mechanical circulatory support bridging was comparable (66.7 vs. 75%; p = 0.66) prior to LVAD implantation. Procedural characteristics including intraoperative volume management and postoperative vasopressor administration were similar in both groups. There was no difference regarding postoperative lactate clearance, although postoperative mean arterial pressure was significantly higher in the control group (71.3 vs. 57.4 mm Hg; p Conclusion Extracorporeal cytokine hemoadsorption during high-risk LVAD implantation was not associated with a decrease of postoperative vasopressor support, improved hemodynamics, or an accelerated lactate clearance.

Background Due to ongoing left ventricular (LV) remodeling and consecutive geometric displacement of both papillary muscles, end-stage heart failure is frequently associated with relevant functional mitral regurgitation (FMR) Type IIIb. Treatment strategies of FMR and their prognostic impact are still controversial. Case summary We present a case of an 80-year-old patient who suffered from recurrent symptoms of congestive heart failure due to dilated cardiomyopathy and concomitant severe FMR. To specifically address severe tethering of both mitral leaflets heart team decision was to perform minimally invasive mitral valve repair (MVR) including a subannular LV remodeling procedure, instead of an interventional edge-to-edge repair (MitraClip® procedure). In addition to mitral valve ring annuloplasty, standardized relocation of both papillary muscles was performed successfully, leading to a complete resolution of mitral leaflet tethering. There were no procedural complications and the patient was discharged with an excellent functional result without residual mitral regurgitation. Furthermore, after 12 and 24 months, he reported an increase of his functional exercise capacity and a remarkable reverse LV remodeling could be demonstrated. Discussion Novel subannular repair techniques, especially the relocation of both papillary muscles, specifically address severe leaflet tethering in FMR and have an obvious potential to improve long-term competence of MVR. Therefore, they could be considered as a viable therapeutic option even in elderly patients presenting with end-stage cardiomyopathy and severe leaflet tenting.

OBJECTIVES The major drawback of isolated annuloplasty for treatment of secondary mitral regurgitation (SMR) with restricted leaflet motion during systole (type IIIb) is the recurrence of SMR, leading to adverse clinical outcome. Additional papillary muscle relocation (PMR) specifically addresses leaflet tethering to restore mitral valve geometry. We aimed to compare the 2-year outcome of annuloplasty with additional PMR vs isolated annuloplasty. METHODS A total of 105 consecutive type IIIb SMR patients with preoperative left ventricular (LV) ejection faction 55 mm and a tenting height >10 mm reached 2-year postoperative follow-up after mitral valve repair and were included in the current analysis. A total of 51 patients underwent annuloplasty and additional PMR (study group). A total of 54 patients underwent isolated annuloplasty (control group). Primary composite study end point comprised death or recurrence of mitral regurgitation ≥2 at 2 years postoperatively. RESULTS Echocardiographic baseline variables indicating the severity of LV dysfunction and mitral leaflet tethering were similar. Procedural and periprocedural outcome was comparable in both groups. The primary composite end point was significantly improved in the study group (19.6% [10/51]) in comparison to the control group (44.4% [24/54]; P = 0.009). Two-year all-cause mortality was 7.8% [4/51] in the study group vs 18.5% [10/54] in the control group (P = 0.098). After 2 years, a significant improvement in New York Heart Association functional class as compared to the baseline values was observed in the study group. CONCLUSIONS Additional PMR to treat SMR type IIIb resulted in an improved 2-year outcome in comparison to isolated annuloplasty. PMR specifically addressing mitral leaflet tethering represents a valid therapeutic option for heart failure patients with SMR type IIIb.

Objective: Subannular mitral valve (MV) repair techniques have been developed to address increased rates of recurrent mitral regurgitation (MR) in patients with secondary MR (SMR) type IIIb. Endoscopic papillary muscle relocation (PMR) is feasible via minithoracotomy. Nevertheless, the periprocedural outcome of patients with severe left ventricular (LV) dysfunction remains unknown. Methods: A total of 98 consecutive patients with SMR type IIIb underwent PMR at our institution. Due to concomitant coronary artery bypass grafting, 62 patients underwent sternotomy and were excluded from the current analysis, whereas 36 patients were treated by a minimally invasive technique using 3-dimensional endoscopy. Of these, 18 patients had severely depressed LV ejection fraction (LVEF) ≤35% (study group) and were compared to the remaining 18 patients with LVEF >35% (control group). Periprocedural outcome was retrospectively analyzed. Results: Although LVEF was significantly worse in the study group (30% ± 4% vs 43% ± 6%, P

OBJECTIVES Papillary muscle repositioning in functional mitral regurgitation (FMR) alleviates mitral valve (MV) tenting by reducing the distance between papillary muscle tips and MV annular plane, i.e. apical left ventricular (LV) displacement. We aimed to quantify the effect of papillary muscle repositioning on papillary muscle geometry and to evaluate whether improved papillary muscle geometry after papillary muscle repositioning translates into the global LV reverse remodelling in FMR type IIIb. METHODS Patients with severe FMR type IIIb were prospectively enrolled and underwent pre- and postoperative 1.5-T cardiac magnetic resonance imaging. A new variable was defined, the papillary muscle to mitral annulus distance, which quantifies the distance between papillary muscle tips and MV annular plane. All parameters were measured by 2 independent investigators. RESULTS A total of 63 patients were enrolled. In all patients, papillary muscle to mitral annulus distance correlated significantly with established markers of LV remodelling and MV tenting severity. In patients who underwent subannular papillary muscle repositioning procedure (surgical cohort, n = 23), preoperative median papillary muscle to mitral annulus distance was 30 mm [interquartile range (IQR): 27–34 mm] and was significantly reduced postoperatively to 25 mm (IQR: 21–27 mm) (P = 0.001). LV end-diastolic diameter was reduced from 66 mm (IQR: 60–71) preoperatively to 58 mm (IQR: 53–67) after the surgery (P = 0.001). CONCLUSIONS MV repair with papillary muscle repositioning results in a papillary muscle to mitral annulus distance reduction and significantly improved MV tenting parameters. Improved papillary muscle geometry after papillary muscle repositioning is associated with a global LV reverse remodelling and may, thereby, improve the prognosis of FMR patients.

ObjectiveVentricular secondary mitral regurgitation (SMR) (Carpentier type IIIb) results from left ventricular (LV) remodelling, displacement of papillary muscles and tethering of mitral leaflets. The most appropriate treatment approach remains controversial. We aimed to assess the safety and efficacy of standardised relocation of both papillary muscles (subannular repair) at 1-year follow-up (FU).MethodsREFORM-MR (Reform-Mitral Regurgitation) is a prospective, multicentre registry that enrolled consecutive patients with ventricular SMR (Carpentier type IIIb) undergoing standardised subannular mitral valve (MV) repair in combination with annuloplasty at five sites in Germany. Here, we report survival, freedom from recurrence of MR >2+, freedom from major adverse cardiac and cerebrovascular events (MACCEs), including cardiovascular death, myocardial infarction, stroke, MV reintervention and echocardiographic parameters of residual leaflet tethering at 1-year FU.ResultsA total of 94 patients (69.1% male) with a mean age of 65.1±9.7 years met the inclusion criteria. Advanced LV dysfunction (mean left ventricular ejection fraction 36.4±10.5%) and severe LV dilatation (mean left ventricular end-diastolic diameter 61.0±9.3 mm) resulted in severe mitral leaflet tethering (mean tenting height 10.6±3.0 mm) and an elevated mean EURO Score II of 4.8±4.6 prior to surgery. Subannular repair was successfully performed in all patients, without operative mortality or complications. One-year survival was 95.5%. At 12 months, a durable reduction of mitral leaflet tethering resulted in a low rate (4.2%) of recurrent MR >2+. In addition to a significant improvement in New York Heart Association (NYHA) class (22.4% patients in NYHA III/IV vs 64.5% patients at baseline, pConclusionsOur study demonstrates the safety and feasibility of standardised subannular repair to treat ventricular SMR (Carpentier type IIIb) in a multicentre setting. By addressing mitral leaflet tethering, papillary muscle relocation results in very satisfactory 1-year outcomes and has the potential to durably restore MV geometry; nevertheless, long-term FU is mandatory.Trial registration numberNCT03470155.

Summary Systolic heart failure is frequently accompanied by a relevant functional mitral valve regurgitation (FMR) which develops as a direct sequela of the ongoing left ventricular remodelling. The severity of mitral regurgitation is further aggravated by progressive left ventricular enlargement causing leaflet tethering and reduced systolic leaflet movement. The prognosis of such patients is obviously limited by an underlying left ventricular disease, and the correction of secondary FMR has been previously suggested as predominantly ‘cosmetic’ surgery in the setting of ongoing cardiomyopathy. Inferior results of an isolated annuloplasty in type IIIb FMR supported the philosophy of malignant course of progressive cardiomyopathy and resulted in increasingly restricted indications for mitral valve surgery for FMR in the guidelines. The lack of a standardized pathophysiological approach to correct type IIIb FMR led to the development of valve replacement strategy and edge-to-edge catheter-based mitral valve procedures, which became the most frequent procedures in the FMR setting in Europe. Modern mitral valve surgery combines the advantages of 3-dimensional endoscopic minimally invasive surgical approach with standardized subannular repair to address the pathophysiological background of type IIIb FMR. The perioperative results have been significantly improved, and there is a growing evidence of improved long-term stability of subannular repair procedures as compared to isolated annuloplasty. This review article aims to present the current state-of-the-art of the modern mitral valve surgery in FMR and provides suggestions for future trials analysing the potential advantages in these patients.

ObjectivesMitral valve (MV) tenting parameters are indicators of left ventricular remodelling severity and may predict outcome in functional mitral regurgitation (FMR). We hypothesised that indexing of MV tenting area to body surface area (BSA), to mitral annulus diameter or gender-adjusted analysis of tenting parameters may improve their prognostic value.MethodsWe identified retrospectively 240 patients with consecutive FMR (mean age 68±10 years; men=135) from our institutional database who underwent isolated MV annuloplasty during a period of 7 years (2010–2016). Using preoperative two-dimensional transthoracic echocardiographic images, MV tenting parameters including tenting area, tenting height and annulus diameter were systematically assessed. Follow-up protocol consisted of chart review and structured clinical questionnaire. Primary study endpoint was the composite of death and adverse cardiac events (ie, MV reoperation, cardiac resynchronisation therapy implantation, ventricular assist device implantation or heart transplantation).ResultsBSA-indexed MV tenting area was identified as independent predictor of primary study endpoint (HR 1.9; 95% CI 1.1 to 3.5; p=0.02). After cut-off point analysis, BSA-indexed MV tenting area >1.35 cm2/m2 was significantly associated with primary study outcome (HR 2.3; 95% CI 1.3 to 4.0; p=0.003). Annulus-indexed MV tenting area showed only a tendency towards primary study endpoint prediction (HR 2.8; 95% CI 0.6 to 12.6; p=0.17). Between female and male patients, BSA-indexed MV tenting area was similar (1.42±0.4 cm2/m2 vs 1.45±0.4cm2/cm2; p=0.6) and gender was not associated with primary study outcome (HR 0.8; 95% CI 0.5 to 1.4; p=0.5).ConclusionIn our FMR cohort, BSA-indexed MV tenting area showed the strongest association with negative outcomes following isolated MV annuloplasty. Patients with BSA-indexed MV tenting area >1.35cm2/m2 could potentially benefit from additional surgical maneuvers addressing left ventricular remodelling.

OBJECTIVES Mitral valve (MV) repair in functional mitral regurgitation is still associated with suboptimal outcomes. Our goal was to determine whether the clinical outcome following MV repair correlates with preoperative tenting parameters. METHODS We retrospectively identified consecutive patients with functional mitral regurgitation who underwent an isolated MV annuloplasty during a 7-year period (2010–2016) from our institutional database. Preoperative tenting parameters (i.e. tenting height, coaptation length, tenting area, posterior mitral leaflet and anterior mitral leaflet angles and interpapillary muscle distance) were systematically measured. The primary end point was the composite of survival and freedom from adverse cardiac events. The follow-up protocol consisted of a structured clinical questionnaire and an analysis of the echocardiographic data. RESULTS A total of 240 patients (mean age 67.8 ± 9.8 years, 57% of men) were analysed. The overall 5-year survival rate for the whole study cohort was 74.7 ± 4.2%, and freedom from adverse cardiac events was 84.8 ± 3.4%. A tenting area ≥2.4 cm2 was identified as a cut-off value, independently predicting the composite primary study end point (hazard ratio 2.0; P = 0.03). Furthermore, a Kaplan–Meier analysis revealed a strong tendency towards worse 5-year outcomes in patients with a tenting area ≥2.4 cm2 (n = 153) versus patients with a tenting area CONCLUSIONS MV annuloplasty is associated with acceptable clinical and echocardiographic outcomes in patients with functional mitral regurgitation 5 years postoperatively. A preoperative tenting area ≥2.4 cm2 showed a strong trend towards a worse 5-year survival rate and an increased risk of adverse cardiac events after an isolated MV annuloplasty.

OBJECTIVES Functional mitral regurgitation (FMR) is a sequel of left ventricular (LV) remodelling in heart failure patients. Relocation of both papillary muscles aims to specifically address mitral leaflet tethering to improve long-term durability of modern FMR repair. Nevertheless, the prognostic impact of the underlying cardiomyopathy on the outcome after FMR repair is unknown. METHODS We analysed 84 consecutive heart failure patients with severe FMR, LV ejection fraction 10 mm, who underwent ring annuloplasty and simultaneous bilateral papillary muscles relocation between June 2016 and March 2019. One-year outcome of 54 patients with ischaemic cardiomyopathy (‘ICM group’) was prospectively compared to the remaining 30 patients with dilated cardiomyopathy (‘DCM group’). RESULTS One-year survival was similar in both groups (96% in the ‘ICM group’ vs 97% in the ‘DCM group’; P = 0.93). Furthermore, primary composite outcome (i.e. freedom from death or mitral regurgitation ≥ 2) at 1-year postoperatively was comparable between the study groups (94%in the ‘ICM group’ vs 87% in the ‘DCM group’; P = 0.10). LV end-diastolic diameter 1-year after surgery was significantly reduced, as compared to preoperative values, in the ‘DCM group’ (P = 0.018), but not in the ‘ICM group’ (P = 0.058). Improvement of New York Heart Association functional class and reduction of serum levels of N-terminal pro-B natriuretic peptide at 1 year was comparable in both study groups. CONCLUSIONS Standardized relocation of both papillary muscles to correct FMR resulted in very satisfactory in-hospital and 1-year outcomes, in both ICM and DCM. DCM patients showed similar improvement in heart failure symptoms and LV re-remodelling compared to ICM patients. Subannular repair is developing towards a valid therapeutic option in heart failure patients presenting with severe FMR.

Background The major drawback of isolated annuloplasty in secondary mitral regurgitation (MR) is the reoccurrence of MR. We prospectively compared the results of isolated annuloplasty vs annuloplasty with simultaneous standardized subannular repair. Methods The study comprised 101 patients with secondary type IIIb MR. Of these, 51 underwent annuloplasty plus standardized subannular repair with realignment of both papillary muscles (subannular repair) and 50 underwent isolated annuloplasty. The primary study end point was the reoccurrence of MR >2 at the 1-year follow-up. Secondary end points were survival, freedom from major adverse cardiac events, and residual leaflet tethering. Results Baseline characteristics were comparable in both groups. There was no significant difference in in-hospital mortality (P = .3). Although postrepair MR was comparable between the subannular repair and isolated annuloplasty subgroups, the residual leaflet tethering (tenting area, 127.6 ± 35.8 mm2 vs 166.3 ± 47.3 mm2, P = .02; posterior mitral leaflet angle, 19.2 ± 4.7 degrees vs 24.8 ± 5.2 degrees, P = .001; anterior mitral leaflet angle, 25.4 ± 5.8 degrees vs 34.1 ± 4.0 degrees, P = .001; and tenting height, 5.9 ± 1.4 mm vs 9.2 ± 2.2 mm, P = .001) were significantly increased in the isolated annuloplasty group (P 2 of 98% (50 of 51) for subannular repair vs 86.7% (39 of 45) for isolated annuloplasty (P = .045) and mortality of 0% (0 of 51) for subannular repair vs 10% (5 of 50) for isolated annuloplasty (P = .025). Conclusions In secondary MR with reduced leaflet motion, the combination of annuloplasty and standardized subannular repair is associated with a significantly reduced MR reoccurrence, decreased residual leaflet tenting, and significantly improved 1-year outcome compared with annuloplasty alone.

OBJECTIVES Subannular repair techniques in addition to undersized ring annuloplasty have been developed to address high mitral regurgitation (MR) recurrence rates after mitral valve repair in type IIIb MR. We compared the results of annuloplasty with simultaneous standardized subannular repair versus isolated annuloplasty, focusing on the periprocedural outcomes of minimally invasive procedures. METHODS A consecutive series of 108 patients with type IIIb functional MR with severe signs of bileaflet tethering underwent an annuloplasty + subannular repair (group A; n = 60) versus isolated annuloplasty (group B; n = 48). The primary end point of this prospective, parallel cohort study was death or recurrent MR >2, 1 year postoperatively. The secondary end points were survival and clinical outcomes, with special regard for the minimally invasively treated subgroups. RESULTS Duration of surgery, cardiopulmonary bypass time and aortic cross-clamp time were comparable between both study groups. Procedural outcomes as well as echocardiographic outcome parameters were similar and independent of access (fully endoscopic versus full sternotomy). At the 12-month follow-up, death or MR >2 occurred in 3.3% (2/60) of patients in group A vs in 20.8% (10/48) of patients in group B (P = 0.037). The overall mortality rate during the follow-up period was 1.7% (1/60) in group A vs 12.5% (6/48) in group B (P = 0.041). CONCLUSIONS Standardized realignment of papillary muscles is feasible and reproducible via a minimally invasive approach, resulting in excellent periprocedural outcomes, and has a clear potential to significantly decrease MR recurrence and improve 1-year outcomes compared to isolated annuloplasty.