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OBJECTIVES Minimally invasive mitral valve surgery (MIMVS) has been performed increasingly for the past 2 decades; however, large comparative studies on short- and long-term outcomes have been lacking. This study aims to compare short- and long-term outcomes of patients undergoing MIMVS versus median sternotomy (MST) based on real-world data, extracted from the Netherlands Heart Registration. METHODS Patients undergoing mitral valve surgery, with or without tricuspid valve, atrial septal closure and/or rhythm surgery between 2013 and 2018 were included. Primary outcomes were short-term morbidity and mortality and long-term survival. Propensity score matching analyses were performed. RESULTS In total, 2501 patients were included, 1776 were operated through MST and 725 using an MIMVS approach. After propensity matching, no significant differences in baseline characteristics persisted. There were no between-group differences in 30-day mortality (1.1% vs 0.7%, P = 0.58), 1-year mortality (2.6% vs 2.1%, P = 0.60) or perioperative stroke rate (1.1% vs 0.6%, P = 0.25) between MST and MIMVS, respectively. An increased rate of postoperative arrhythmia was observed in the MST group (31.3% vs 22.4%, P CONCLUSIONS The MIMVS approach is as safe as the sternotomy approach for the surgical treatment of mitral valve disease. However, it comes at a cost of a reduced repair rate and more reinterventions in the long term, in the real-world.

A variety of endovascular technologies for valve repair for mitral regurgitation (MR) are under development. Endovascular Edge-to-Edge (E2E) approach recently entered the clinical trial phase. The aim of the present study was to determine the effectiveness of surgical isolated E2E repair without annuloplasty to predict the efficacy of the endovascular E2E approach.Clinical and echocardiographic data of 29 patients with either degenerative or functional MR who had surgical E2E repair without annuloplasty, were retrospectively analysed. Mean age was 63.8+/-8.79 years, 45% were in NYHA class III or IV and 41% had a left ventricular ejection fraction less than 60%. Hospital mortality was 3.4% and overall survival after a mean follow-up of 6.8 year was 93%. At latest follow-up, 68% of patients were in NYHA class I, 28% in class II and 4% in class III; 86% of patients had MRgrade 2. Two patients with recurrent grade 4 MR underwent re-operation. The 5 years freedom from the combined end-point of recurrent MR2+ and re-operation, was 90+/-5%.Isolated surgical E2E mitral repair, intentionally performed without annuloplasty, has acceptable midterm results for degenerative and functional MR, comparable to conventional repair techniques with annuloplasty. These results encourage the evaluation of less invasive endovascular E2E repair approaches in a clinical setting.

The aim of our study was to assess whether the development of chronic uremia in rats with extensive renal mass ablation was associated with an impairment of primary hemostasis as occurs in humans with terminal uremia. We also wanted to assess whether uremic rats had an increased generation of vascular prostacyclin (PGI2) and whether conjugated estrogens could influence such an abnormality. Our results showed that the development of chronic renal failure in rats was associated with a significant prolongation of bleeding time as reported in humans. Thoracic aorta and inferior vena cava specimens from uremic rats produced significantly more 6-keto-prostaglandin F1 alpha (the stable breakdown product of PGI2) than did specimens from the corresponding controls. Conjugated estrogens significantly shortened the bleeding time of uremic rats. The effect on bleeding time was detectable in the majority of animals within 4 hours from conjugated estrogen injection, reached its maximum at 24 hours, and returned to preinjection values within 72 hours from conjugated estrogen injection. Estrogen administration did not influence the generation of vascular PGI2. It is concluded that the model of extensive renal ablation in the rat is a suitable one to study changes in primary hemostasis in chronic renal failure and that the effect of estrogens on primary hemostasis in uremia is not mediated by changes in vascular PGI2.

We have reported previously that conjugated estrogens that are effective in shortening the prolonged bleeding time in uremic patients are also effective on bleeding time in a rat model of uremia. Using such a rat model we have recently demonstrated that nitric oxide (NO), an endothelium-derived vasodilator, is involved in mediating the bleeding tendency of uremia. With the present study we wanted to investigate whether conjugated estrogen mixture or its active component, 17 beta-estradiol, reduce uremic bleeding by interfering with the NO pathway. Our results showed that the shortening effect of conjugated estrogen and 17 beta-estradiol on bleeding time of uremic rats was completely reversed by giving the animals the NO precursor L-arginine, but not D-arginine, which is not a precursor of NO. Dexamethasone which at variance to progesterone inhibits the process of induction of NO-forming enzyme, shortened the prolonged bleeding time of uremic rats within 4 hours from injection. This effect was eliminated by L-arginine but not D-arginine administration. The glucocorticoid receptor antagonist cortexolone prevented the shortening of bleeding time induced by dexamethasone, suggesting that a receptor-mediated mechanism is involved in the hemostatic effect of dexamethasone as previously reported for estrogens. Unlike conjugated estrogens and dexamethasone, progesterone had no effect on bleeding time. All these findings would indicate that the effect of estrogens and dexamethasone on primary hemostasis in uremia might be mediated by changes in NO synthetic pathway.

Tricuspid valve replacement (TVR) is associated with high mortality and morbidity. Frequently, TVR is performed in critically ill patients with high frequency of re-intervention. We analyzed our experience in TVR focusing on predicting risk factors, mid-term survival and quality of life assessed with a Short-Form 36 Health Survey (SF-36) questionnaire. Between January 1992 and May 2007, 81 consecutive patients underwent TVR (54 re-interventions, 66.7%; 46 procedures, associated with a left-sided operation, 56.8%). There were 59 females (73%) with a mean age of 59.3+/-11.6 years. The most prevalent etiology was rheumatic fever (61.7%). Pulmonary hypertension was present in 64%. Mean left ventricle ejection fraction (LVEF) was 56.6% and mean right ventricle ejection fraction (RVEF) was 48.1%. All but four patients (4.9%) received a bio-prosthesis. Hospital mortality was 9.88%. The mean follow-up was 61+/-42 months. Survival was 68% at five years. Univariate predictors of hospital mortality were atrial fibrillation (AFib) (P

The authors report two cases of unexplained active inflammatory endocarditis with totally different clinical presentations. The patients had undergone previous mitral repair surgery and were referred for multiple soft mobile masses on the mitral ring without clinical or laboratory signs of endocarditis. Serologic screening and blood culture results were negative, including those for specific fastidious bacteria, as well as immunologic tests to rule out "nonbacterial thrombotic endocarditis." Before new surgery, both patients were treated with long-term antibiotic and anticoagulant therapy, with no significant changes in clinical setting and echocardiographic patterns. In neither case was it possible to characterize a specific microorganism: the intraoperative findings were highly evocative of active endocarditis with a macroscopic infiltration of the mitral ring, and culture results from surgical material and valvular tissue were negative. (J Am Soc Echocardiogr 2010;23:221.e1-221.e4.)

Objective: Mitral valve surgery for organic mitral regurgitation (MR) in the elderly has been debated. In the elderly, quality of life is a better indicator of surgical success than survival. We assessed quality of life of elderly patients submitted to surgery for MR using the Minnesota Living with Heart Failure (MLHF) questionnaire. Methods: Between August 2003 and August 2006, 225 consecutive patients >70 years old underwent surgical treatment of organic MR. Mean age was 77 3.3 years (range 71—87 years). Mean EF was 50 11%. Degenerative disease was the most prevalent (77%) etiology. CABG was associated in 25% of patients. Mean Charlson score was 4.3 1.5 and 101 patients (45%) were NYHA class III and IV. Hospital survivors were followed up and quality of life by MLHF score was assessed. Results: Mitral repair and replacement were equally distributed in this population. Hospital mortality was 2.7%. Late survival was 91 1.9% at 3 years. MLHF was obtained from 204 patients at mean 2 1 years of follow-up. MLHF score was 38 18; there were 135 (66%) patients with MLHF >30. MLHF tended to increase with age at follow-up (p = 0.007). Multivariable predictors of MLHF were preoperative atrial fibrillation (p = 0.019), diabetes (p = 0.03), higher creatinine level (p = 0.0009), higher EuroSCORE (p = 0.02), residual mitral regurgitation grade at follow-up echocardiography (p < 0.0001) and systolic pulmonary artery pressure at follow-up (p = 0.04). Type of surgical treatment (repair vs replacement and choice of prosthesis) did not predict MLHF at follow-up, although those who had recurrent MR after repair had the highest scores compared to patients who had repair and durable result and those treated by replacement (MLHF was 51 21, vs 34 16, vs 39 18, respectively, p = 0.0013). Conclusions: Quality of life following mitral valve surgery is suboptimal in more than half of elderly patients. MLHF score at follow-up is mostly related to preoperative conditions. Type of surgery does not influence MLHF score, however, quality of life is worse in patients with recurrent/residual MR following repair.

Annular dilation is a common feature of chronic degenerative mitral regurgitation caused by leaflet prolapse. Accordingly, patients undergoing surgical repair usually undergo concomitant reductive annuloplasty to restore a normal annular-to-leaflet relation. With the evolution of transcatheter valve repair technologies, patient selection criteria for those who do not require annuloplasty are needed. A series of patients undergoing mitral repair was analyzed, and the role of annular-to-leaflet mismatch in identifying patients requiring reductive annuloplasty was explored. Preoperative data for 82 patients undergoing mitral repair with annuloplasty for degenerative mitral regurgitation were prospectively collected, including annular intercommissural (IC) and septolateral (SL) dimensions and heights of anterior (ALH) and posterior leaflets. An SL/ALH ratio1.4 was used to define annular-to-leaflet mismatch. After mitral repair, the ratio between preoperative IC distance and the size of the implanted annular prosthesis (Seguin ring [SR], IC/SR1.2) was used to identify patients for whom annuloplasty was nonreductive. All patients underwent successful mitral repair. Mean preoperative IC was 46 +/- 6 mm, SL was 42 +/- 5 mm, and ALH was 31 +/- 5 mm. Mean SR was 34 +/- 3 mm, with a mean IC/SR ratio of 1.34 +/- 0.14. Sixteen patients (19%) had an IC/SR ratio1.2. IC/SR ratio1.2 was predicted by a SL/ALH ratioor =1.4 (p = 0.009). In conclusion, annular dilation is negligible in20% of surgical candidates. In this subgroup, an isolated leaflet repair may be indicated. SL/ALH ratio is a good indicator of annular-to-leaflet mismatch and could be used as an adjunct to other methods of annular function assessment to select patients for ringless mitral repair.