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Chronic heart valve regurgitation induces left ventricular (LV) volume overload, leading to the development of hypertrophy and progressive dilatation of the ventricle to maintain physiological cardiac output. In order to prevent potential irreversible LV structural changes, the identification of the best timing for treatment is pivotal.To assess the presence and extent of fibrosis in myocardial tissue in asymptomatic patients with valvular heart disease (VHD) and preserved LV dimensions and function undergoing cardiac surgery.Thirty-nine patients were enrolled. Sixteen patients were affected by aortic or mitral regurgitation: they were all asymptomatic, undergoing valve surgery according to VHD European Society of Cardiology guidelines. Twenty-three patients with end-stage nonischemic dilated cardiomyopathy (DCM) and severe LV dysfunction undergoing cardiac surgery for implantation of a durable left ventricular assist device (LVAD) served as controls. During surgery, VHD patients underwent three myocardial biopsies at the level of the septum, the lateral wall and LV apex, while in LVAD patients the coring of the apex of the LV was used. For both groups, the tissue samples were analyzed on one section corresponding to the apical area. All slides were stained with hematoxylin and eosin and Masson's trichrome staining and further digitalized. The degree of fibrosis was then calculated as a percentage of the total area.Of 39 patients, 23 met the inclusion criteria: 12 had mitral or aortic insufficiency with a preserved ejection fraction and 11 had idiopathic dilated cardiomyopathy. Quantitative analysis of apical sections revealed a myocardial fibrosis amount of 10 ± 6% in VHD patients, while in LVAD patients the mean apical myocardial fibrosis rate was 38 ± 9%. In VHD patients, fibrosis was also present in the lateral wall (9 ± 4%) and in the septum (9 ± 6%).Our case series study highlights the presence of tissue remodeling with fibrosis in asymptomatic patients with VHD and preserved LV function. According to our results, myocardial fibrosis is present at an early stage of the disease, well before developing detectable LV dysfunction and symptoms. Since the relationship between the progressive magnitude of myocardial fibrosis and potential prognostic implications are not yet defined, further studies on this topic are warranted.

Moderate secondary mitral regurgitation is common in patients with severe aortic regurgitation, but whether it has to be addressed at the time of aortic valve surgery remains unclear. With this study, we evaluated the long-term fate of moderate secondary mitral regurgitation in this specific scenario.Between January 2004 and January 2018, in 154 patients admitted to our institution for treatment of severe aortic regurgitation, a moderate secondary mitral regurgitation was diagnosed. Ninety-four patients underwent isolated aortic valve replacement (group 1) and 60 patients underwent also concomitant mitral valve annuloplasty (group 2).One death (1.1%) occurred in group 1, whereas two deaths (3.3%) occurred in group 2 (p = .561). At 11 years, the cumulative incidence function of cardiac death, with noncardiac death as a competing risk was 11.5 ± 5.11% in group 1 and 8.3 ± 5.15% in group 2 (p = .731). The cumulative incidence function of mitral valve reintervention, with death as a competing risk, was 3.7 ± 2.61% in group 1 and 4.5 ± 4.35% in group 2 (p = .620) at 11 years. Secondary mitral regurgitation improved to ≤mild in 66% and 76% of the survivors of group 1 and group 2, respectively (p = .67).In our experience, in patients with moderate secondary mitral regurgitation undergoing aortic valve replacement for severe aortic regurgitation, concomitant mitral valve annuloplasty did not improve the long-term survival, the incidence of cardiac death and mitral valve reoperation or the evolution of the mitral valve disease.

OBJECTIVES With the expanding use of cardiac implantable electronic devices (CIEDs), lead interference with the tricuspid valve (TV) causing significant tricuspid regurgitation (TR) has gained increasing recognition. However, current knowledge about the long-term results of the surgical treatment of TR in this setting is scanty. Therefore, increasing this information was the goal of this study. METHODS A retrospective review of our institutional database was carried out to select all patients with previously implanted CIEDs who underwent tricuspid valve repair and replacement from 2000 through 2019. Kaplan–Meier methods were used to analyse long-term survival. To describe the time course of TR, we performed a longitudinal analysis using generalized estimating equations. RESULTS A total of 151 patients were identified. Mechanical interference with leaflet mobility and coaptation was detected in 103 patients (68%) (CIED-induced group); in the remaining 48 patients (32%), the lead was associated with TR without being the cause of it (CIED-associated group). A total of 105 patients underwent TV repair; in the remaining 46, a TV replacement was necessary. In patients who underwent TV repair, no significant difference in moderate TR recurrence rate was highlighted between CIED-induced and CIED-associated TR. CONCLUSIONS In patients with CIEDs and surgically treated tricuspid regurgitation, TR is CIED-induced in about two-thirds of the cases and CIED-associated in one-third of them. In our experience, TV repair was still possible in 63% of the cases, with good long-term results and no significant durability difference between CIED-induced and CIED-associated TR.

OBJECTIVES The appropriateness of moderate aortic regurgitation treatment during mitral valve (MV) surgery remains unclear. The goal of this study was to evaluate the immediate and long-term outcomes of patients with moderate aortic regurgitation at the time of MV surgery. METHODS We included 183 patients admitted to our institution for elective treatment of MV disease between 2004 and 2018, in whom moderate aortic regurgitation was diagnosed during preoperative evaluation. One hundred and twenty-two patients underwent isolated MV surgery (study group) whereas 61 patients underwent concomitant MV surgery and aortic valve replacement (control group). RESULTS One death (0.8%) occurred in the study group, and 3 deaths (4.8%) occurred in the control group (P = 0.52). The rate of the most common postoperative complication was similar between the 2 groups. At 12 years, the cumulative incidence function of cardiac death, with non-cardiac death as a competing risk, was 4.7 ± 2.8% in the study group; no cardiac deaths were observed in the control group (P = 0.078). At 6 and 12 years, in the study group, the cumulative incidence function of aortic valve reintervention, with death as a competing risk, was 2.5 ± 1.85% and 19 ± 7.1%, respectively. CONCLUSIONS The appropriate management of moderate aortic regurgitation at the time of MV surgery deserves a careful evaluation by balancing the reintervention rate with the age, the operative risk and the life expectancy of the patient. Our findings suggest that a patient-tailored approach is the key to achieving the best clinical outcome for each individual patient.

Introduction Unlike secondary mitral regurgitation (MR) in the setting of left ventricular disease, results of surgical treatment of severe atrial functional MR has remained largely unspoken. The aim of this study is to analyze short to midterm results of isolated ring annuloplasty in patients with severe atrial functional MR, in comparison with a matched cohort of patients with secondary MR. Methods A retrospective review of our Institutional database was carried out to find all patients fulfilling strict echocardiographic criteria to define atrial functional MR. A control group of patients with MR secondary to ventricular disease was selected. All patients underwent mitral repair by means of isolated ring annuloplasty. Mortality, reoperation for severe MR, and recurrence of MR were assessed by clinical and echocardiographic follow-up. Cumulative incidence function (CIF) of recurrence of MR using death and reoperation as the competitive risk was used. Results Twenty patients were selected for the study group and 25 for the control group. There were no differences between the two groups in terms of mortality and reoperation rate. At 2 years, the CIF of recurrence of MR ≥ 3+ and ≥ 2+ was significantly higher in patients with secondary MR compared to patients with atrial functional MR (20.8 ± 8.29% vs 5.9 ± 5.71% and 45.8 ± 10.17% vs 5.9 ± 5.71%) CONCLUSION: In patients with severe atrial functional MR, mitral valve repair by means of isolated ring annuloplasty seems a more effective and durable treatment as compared to patients with MR secondary to ventricular disease. Larger cohorts with longer follow up are needed to confirm these results.

OBJECTIVES To assess by a continuous implantable rhythm monitoring (ILR) the mid-term outcomes of a staged-hybrid approach for patients with persistent/long-standing persistent atrial fibrillation (AF) and dilated atria. METHODS Fifty patients [age 57 (standard deviation, SD: 8.3), previous catheter ablation 66%, AF history 6.5 (2–12) years, left ventricular ejection fraction 56 (SD: 7.9)%, left atrial volume index 44 (38–56) ml/m2] with persistent (44%) or long-standing persistent (56%) AF, underwent a 2-staged hybrid ablation (thoracoscopic epicardial procedure with Cobra-Fusion system and transcatheter Rhythmia mapping with endocardial touch-up of gaps). All patients received an ILR. RESULTS No hospital deaths and no stroke occurred. Follow-up was 98% complete [median 22 (11–34) months]. The 2-year arrhythmia-free survival off class I–III antiarrhythmic drugs/electrical cardioversion/redo catheter ablation and the arrhythmia control (maintenance of sinus rhythm with or without antiarrhythmic drugs/electrical cardioversion) were 65 (SD: 7.1)% and 82 (SD: 5.8)%, respectively. The occurrence of AF in the blanking period was identified as an independent predictor of AF recurrence (odds ratio 26.6, 95% confidence interval 5.3, 132.3; P CONCLUSIONS A staged hybrid approach yields promising results in selected patients with persistent/long-standing persistent AF and dilated left atrium who are at very high risk of AF recurrence. The use of ILR in this setting should become a standard to optimize patient management.

The management of non-paroxysmal atrial fibrillation (AF) remains controversial. We examined the efficacy and safety of the 2 stage Hybrid AF ablation approach by analysing the largest series of this technique reported so far. Methods: The approach aims to electrically isolate the left atrial posterior wall incorporating the pulmonary veins (‘box-set’pattern). An initial video-assisted thoracoscopic (VATS) epicardial ablation is followed after a minimum of 8 weeks by endocardial radiofrequency catheter ablation. Results: Of 175 patients from 4 European cardiothoracic centers, who underwent the surgical (COBRA Fusion, AtriCure Inc) 1st stage ablation, 166 went on to complete 2nd stage catheter ablation. At median follow up of 18 months post 2nd stage procedure 93/166 (56%) had remained free of AF or atrial tachycardia (AT) recurrence off antiarrhythmic drugs. 110/175 62.9% were in sinus rhythm off all antiarrhythmic drugs at last clinic follow-up (132/175 75.4% including those on antiarrhythmic drugs). 18 patients (10.8%) underwent a further re-do ablation (mean of 1.1 ablations per patient) 105/166 (63%) remained free of AF/AT recurrence off antiarrhythmic drugs following last ablation procedure.Latterly, ILRs have been implanted in patients (n = 56); 60% have remained fully arrhythmia free and 80% have shown AF burden

Papillary muscle rupture is a rare and life-threatening complication of acute myocardial infarction (AMI). We present a unique case of double papillary muscle rupture in a patient with three vessel disease and acute thrombotic occlusion of left circumflex obtuse marginal artery as the culprit lesion. (Level of Difficulty: Beginner.), Graphical abstract, Papillary muscle rupture is a rare and life-threatening complication of acute myocardial infarction (AMI). We present a unique case of double…

Purpose Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) stabilizes patients in refractory cardiogenic shock. However, ECMO-related complications strongly affect the outcome, especially if a long-term LVAD is needed. Methods and materials We describe a new strategy in management of INTERMACS 1 patients consisting in early weaning from VA-ECMO with axillary Impella 5.0 as a bridge to LVAD implantation. Nine patients in two European centres are described. Results All patients were implanted with VA-ECMO for initial hemodynamic and metabolic stabilization. After a median time of 8 days, Impella 5.0 was implanted. Impella support allowed in all patients weaning from inotropes and from VA-ECMO (after a median time of 22 h). No patients had right ventricular failure after ECMO-weaning and most patients were mobilized and orally fed (88.9%) during Impella support. All patient underwent LVAD implantation after a median Impella time of 17 days. Only one patient had right-ventricular failure after LVAD implantation. All patients were discharged from hospital after a median time of 40 days. Conclusion Early weaning from VA-ECMO with Impella 5.0 as a bridge to LVAD is a safe and effective strategy in management of INTERMACS 1 patients. This approach minimizes ECMO-related complications and allows patient mobilization and right ventricular function optimization before LVAD implantation.

Purpose Left ventricle assist devices (LVAD) have contributed to improve survival and quality of life in patients with advanced heart failure, in temporary or lifetime support. Despite technological, bio-compatibility and hemodynamic progress, patients with LVAD have still a relevant incidence of adverse events, such as disabling stroke. The outflow cannula (OC) position and angulation, and the anastomosis site seem to modify the flow in the ascending aorta (AA), and consequently the incidence of cerebral embolism and aortic cusps stress. Methods We evaluated the combination of LVAD flow and the residual cardiac output pulsatile flow with computational fluid dynamics (CFD) software based on CT Scan images. Results Two patients with centrifugal pump LVAD underwent CT Scan regardless of this study, respectively at 7 months and 1.5 years after LVAD implant. We analyzed CT images and made a CFD reconstruction of the anastomosis site, to evaluate the flow in AA. At the same time, in a bench validation test we anastomosed a dacron 32 mm graft (reproducing the AA) and a 14 mm graft (reproducing the OC). We simulated the difference in flow and turbulence, according to different angles of the anastomosis, and the alternative distances from the major cranial branches. Following results of the CFD analysis, we can affirm that it is possible to simulate the optimal flow, improving the laminar flow and reducing the turbulence in the aortic lumen. Moreover, based on the desired angle of the aortic-graft anastomosis, the surgeon can perform the anastomosis with the best shape of the OC (cutting the graft with the angle obtained by the CFD simulation, and incising the AA with the right extension). Conclusion The optimized combination of flows could reduce the incidence of thromboembolic events, aortic endothelium stress, and aortic cusps stress/thrombosis. Further studies are necessary to validate this technology in clinical and surgical practice.

The study sought to assess the long-term outcomes of the stand-alone Cox-Maze IV procedure in symptomatic patients with refractory, persistent, or long-standing persistent atrial fibrillation (AF).Fifty-nine consecutive patients (mean age 52 ± 10.5 years, previous catheter ablation 80%, left ventricular ejection fraction 55% ± 3.4%, median left atrial volume index 41 [interquartile range, 34-47] mL/mNo hospital deaths occurred and 1 (1.7%) patient required postoperative pacemaker implantation. Follow-up was 97% complete (median 5.8 [interquartile range, 3.92-7.11] years). The overall survival at 7 years was 97% ± 2.3%. The 7-year cumulative incidence function of AF recurrence and of AF recurrence off class I or III antiarrhythmic drugs (AADs), with death as competing risk, was 14.2% ± 5.6% (95% confidence interval [CI], 5.5%-26.8%) and 26.5% ± 6.9% (95% CI, 14.2%-40.4%), respectively. Multivariate analysis identified the duration of AF as the only predictor of AF recurrence (hazard ratio, 1.01; 95% CI, 1.01-1.02; P.001). At 7 years, the proportion of patients in sinus rhythm was 84%, of whom 74% were off class I or III AADs. At the last follow-up, 75% of patients were in European Heart Rhythm Association functional class I, no stroke and thromboembolic events were documented, and 70% of patients were off anticoagulation therapy. Left ventricular ejection fraction improved from 53% ± 3.4% at baseline to 59% ± 3.4% at follow-up (P = .003).This study confirmed the safety and efficacy in the long term (7 years) of the stand-alone Cox-Maze IV surgical procedure for persistent or long-standing persistent AF. Indeed, more than 70% of the patients were in sinus rhythm off class I or III AADs and off oral anticoagulation.

For the past few decades, the transaortic septal myectomy (Morrow’s procedure) has been the gold standard for treating severe left ventricular outflow tract obstruction in hypertrophic obstructive cardiomyopathy (HOCM) patients. 30-day mortality has been reported at less than 1% in dedicated centers. However, in a subgroup of patients, the interventricular septal obstruction is localized very distally, below the aortic valve plane, and the transaortic approach can be very challenging. A subset of these patients can present with residual obstruction after surgery, due to inadequate length of septal excision, leading to reoperation. The aim of this work is to illustrate an original application of cryoenergy to improve the transaortic exposure of the interventricular septum and thus enable surgeons to perform very distal myectomies in HOCM patients.

An alternative to coronary sinus implantation for a left ventricular pacing lead is frequently needed for cardiac resynchronization therapy. We have developed a transapical approach to implant an endocardial pacing lead that will reach the most delayed segment of the left ventricle. This method is easily combined with other transapical heart surgeries. After some technological improvement, our technique should offer easier access and better results than other currently available implantation methods.

OBJECTIVES: To report the long-term results of the clover technique for the treatment of complex forms of tricuspid regurgitation (TR). METHODS: Ninety-six consecutive patients (mean age 60 ± 16.4, left ventricular ejection fraction 58 ± 8.8%) with severe or moderatelysevere TR due to important leaflets prolapse/flail (81 patients), tethering (13 patients) or mixed (2 patients) lesions underwent clover repair combined with annuloplasty. The aetiology of TR was degenerative in 74 cases (77.1%), post-traumatic in 9 (9.4%) and secondary to dilated cardiomyopathy in 13 (13.5%). All patients but 3 (96.8%) underwent ring (59 patients, 61.5%) or suture (34 patients, 35.4%) annuloplasty. Concomitant procedures (mainly mitral surgery) were performed in 82 patients (85.4%). RESULTS: Hospital mortality was 7.2%. At hospital discharge 92 (95.8%) patients had no or mild TR. Follow-up was 98% complete (median 9 years, interquartile range 5.1; 10.9). At 12 years the overall survival was 71.6 ± 7.22% and the cumulative incidence function of cardiac death with non-cardiac death as competing risk 16 ± 4.1% [95% confidence interval (95% CI) 9.5-25.7]. At 12 years the cumulative incidence function of TR ≥3+ and TR ≥2+ with death as competing risk were 1.2 ± 1.2% (95% CI 0.1-5.8) and 28 ± 7.7% (95% CI 14.3-43.5), respectively. Preoperative left ventricular ejection fraction (hazard ratio 0.9, CI 0.9-1, P = 0.05) and previous cardiac surgery (hazard ratio 2.7, 95% CI 1-7.1, P = 0.03) were predictors of recurrent TR ≤2+ at univariable but not at multivariable analysis. CONCLUSIONS: Complex forms of TR due to severe prolapse or tethering of the leaflets can be effectively treated with the clover technique with very satisfactory long-term results and extremely low recurrence of severe TR.

International audience; OBJECTIVE: To verify the rate of thromboembolic and hemorrhagic complications during the first 6 months after mitral valve repair and to assess whether the type of antithrombotic therapy influenced clinical outcome. METHODS: Retrospective data were retrieved from 19 centers. Inclusion criteria were isolated mitral valve repair with ring implantation. Exclusion criteria were ongoing or past atrial fibrillation and any combined intraoperative surgical procedures. The study cohort consisted of 1882 patients (aged 58 +/- 15 years; 36% women), and included 1517 treated with an oral anticoagulant (VKA group) and 365 with antiplatelet drugs (APLT group). Primary efficacy outcome was the incidence of arterial thromboembolic events within 6 months and primary safety outcome was the incidence of major bleeding within 6 months. Propensity matching was performed to obtain 2 comparable cohorts (858 vs 286). RESULTS: No differences were detected for arterial embolic complications in matched cohort (1.6% VKA vs 2.1% APLT; P = .50). Conversely, patients in the APLT group showed lower incidence of major bleeding complications (3.9% vs 0.7%; P = .01). Six-month mortality rate was significantly higher in the VKA group (2.7% vs 0.3%; P = .02). Multivariable analysis in the matched cohort found VKA as independent predictor of major bleeding complications and mortality at 6 months. CONCLUSIONS: Vitamin K antagonist therapy was not superior to antiplatelet therapy to prevent thromboembolic complications after mitral valve repair. Our data suggest that oral anticoagulation may carry a higher bleeding risk compared with antiplatelet therapy, although these results should be confirmed in an adequately powered randomized controlled trial

OBJECTIVES: The ‘edge-to-edge’ technique (EE) can be used as a bailout procedure in case of a suboptimal result of conventional mitral valve (MV) repair. The aim of this study was to assess the long-term outcomes of this technique used as a rescue procedure. METHODS: From 1998 to 2011, of 3861 patients submitted to conventional MV repair for pure mitral regurgitation (MR), 43 (1.1%) underwent a rescue edge-to-edge repair for significant residual MR at the intraoperative hydrodynamic test or at the intraoperative transoesophageal echocardiography. Residual MR was due to residual prolapse in 30 (69.7%) patients, systolic anterior motion in 12 (27.9%) and post-endocarditis leaflet erosion in 1 (2.3%). According to the location of the regurgitant jet, the edge-to-edge suture was performed centrally (60.5%) or in correspondence with the anterior or posterior commissure (39.5%). The original repair was left in place. RESULTS: There were no hospital deaths. Additional cross-clamp time was 15.2 ± 5.6 min. At hospital discharge, all patients showed no or mild MR and no mitral stenosis. Clinical and echocardiographic follow-up was 97.6% complete (median length 5.7 years, up to 14.6 years). At 10 years, actuarial survival was 89 ± 7.4% and freedom from cardiac death 100%. Freedom from reoperation and freedom from MR ≥3+ at 10 years were both 96.9 ± 2.9%. At the last echocardiogram, MR was absent or mild in 37 patients (88%), moderate in 4 (9.5%) and severe in 1 (2.4%). No predictors for recurrence of MR ≥2+ were identified. The mean MV area and gradient were 2.8 ± 0.6 cm 2 and 2.7 ± 0.9 mmHg. NYHA I–II was documented in all cases. CONCLUSIONS :A ‘rescue’ EE can be a rapid and effective option in case of suboptimal result of ‘conventional’ MV repair. Long-term durability of the repair is not compromised.

OBJECTIVE: This study assesses the results of the 'clover technique' (suturing together the middle point of the free edges of the tricuspid leaflets) for the treatment of tricuspid regurgitation (TR) due to severe prolapse or tethering. METHODS: From 2001, 66 patients with severe TR due to prolapsing or tethered leaflets underwent 'clover repair'. Annuloplasty was associated in 64 patients (97%). The aetiology of TR was degenerative in 52 cases (79%), post-traumatic in eight (12%) and secondary to dilated cardiomyopathy (DCM) in six (9%). The main mechanism of TR was prolapse/flail of one leaflet in 15 patients (23%), of two leaflets in 31 (47%) and of all three leaflets in 14 (21%). The remaining six patients (9%) presented with severe leaflets' tethering. RESULTS: Four deaths (6%) occurred during hospitalisation and one patient died 3.6 years after surgery. Survival was 91 + or - 4.1% at 5 years. Follow-up of the 62 hospital survivors was 100% complete (mean length 3.5 + or - 1.6 years, range 13 months-7.1 years). At the last echocardiogram, no or mild TR was detected in 55 (88.7%) patients, moderate (2+/4+) in six (9.6%) and severe (4+/4+) in one patient (1.6%). Mean tricuspid valve area and gradient were 4.3 + or - 0.6 cm(2) and 2.8 + or -1.4 mmHg. In six patients, stress echocardiography was performed and no signs of tricuspid stenosis were detected. At the multivariable analysis, the degree of TR at hospital discharge was identified as the only predictor of TR > or = 2+ at follow-up. CONCLUSIONS: Midterm clinical and echocardiographic results confirm the role of the 'clover technique' in the surgical treatment of TR due to lesions, which are unlikely to be effectively treatable by annuloplasty alone.

Objective: To assess the evolution of tricuspid regurgitation (TR) in dilated cardiomyopathy (DCM) patients submitted to mitral repair for functional mitral regurgitation (MR). Methods: Ninety-one DCM patients (mean age 61 +/- 11.3) submitted to MV repair (+/- tricuspid repair) for functional MR were included. Preoperative EF was 30.9 +/- 6.5%, left ventricular (W) end-diastolic volume 113 +/- 31.5 ml/m(2), LV end-systolic volume 81.8 +/- 26.7 ml/m(2), functional MR >= 3+/4+. TR was classified as = 3+/4+ in 13 (14.2%). Most of the patients were in NYHA class III or IV. A tricuspid annuiopiasty was associated to mitral repair whenever preoperative TR was >= 3+. Therefore 13 patients (14.2%) underwent concomitant tricuspid annuloplasty whereas the remaining 78 (with preoperative TR = 3+ was 78 +/- 8.8% at 3.5 years. Among the 78 patients not submitted to tricuspid repair, 14 (18%) showed a progression of TR severity equal or greater than two grades. The multivariate analysis identified grade of TR at discharge (OR 5.4, p = 0.01) and preoperative RV dysfunction (OR 19.6, p, = 0.02) as the only independent predictors of TR >= 3+/4+ at follow-up. Conclusions: A significant number of patients submitted to mitrat repair for functional MR present >= 3+ TR at follow-up as consequence of progression of untreated TR or failure of tricuspid repair. A more aggressive and effective treatment of functional TR in this setting should be pursued. (C) 2008 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights reserved.

Background. The aim of this study was to assess the occurrence of reverse left ventricular (LV) remodeling after effective mitral valve repair in advanced dilated cardiomyopathy and its impact on clinical outcome and repair durability. Methods. Of 111 patients undergoing mitral valve repair in ischemic or idiopathic dilated cardiomyopathy, 79 patients with no or trivial residual mitral regurgitation (MR) at discharge and with a follow-up length of at least 6 months were included in this study. Preoperatively they had 3 to 4+ functional MR, an ejection fraction of 0.28 +/- 0.055, an indexed LV end-diastolic volume of 113 +/- 33.0 mL/m(2), an indexed LV end-systolic volume of 80.8 +/- 26.3 mL/m(2), a tenting area of 2.7 +/- 0.9 cm(2), and a coaptation depth of 1.1 +/- 0.3 cm. Sixty-three patients (79.8%) were in New York Heart Association class III or IV. A complete, rigid or semirigid undersized ring annuloplasty (with or without "edge-to-edge") was used. Concomitant procedures were coronary artery bypass grafting (49 of 79 patients, 62%), tricuspid valve repair (11 of 79 patients, 13.9%), and ablation of permanent atrial fibrillation (13 of 79 patients, 16.4%). Results. At a mean follow-up of 2 +/- 1.3 years (median, 1.8 years), LV reverse remodeling was documented in 41 patients (51.8%), whereas in 38 patients (48.1%) LV dimensions remained unchanged or increased compared with preoperative values. The persistence or progression of LV remodeling paralleled the recurrence of MR and worsening of symptoms. Recurrence of MR of 3+ or greater was 0% in the "reverse remodeling" group and 18.4% in the "no reverse remodeling" one (p = 0.008). At 3 years, freedom from recurrence of MR of 2+ or greater was 74% +/- 11.7% and 62% +/- 9.2% (p = 0.004) and New York Heart Association class was 1.5 +/- 0.61 and 2 +/- 0.72 (p < 0.0001), respectively. Predictors of reverse remodeling were ischemic etiology (p = 0.04), concomitant coronary artery bypass grafting (p = 0.02), successful ablation of atrial fibrillation (p = 0.05), and shorter history of congestive heart failure (p = 0.06). The use of the edge-to-edge showed a trend toward favoring reverse remodeling compared with isolated annuloplasty (p = 0.08). Conclusions. In patients with functional MR undergoing effective repair, the occurrence of reverse LV remodeling is associated with longer repair durability and a better clinical outcome compared with those with persistence or progression of the remodeling process.

36-YEAR-OLD woman, scheduled to undergo surgical correction of severe mitral and moderate tricuspidal regurgitation, whose surgical plan switched from a minithoracotomy to midsternotomy after an unexpected transesophageal echocardiography (TEE) finding, is presented. After induction of general anesthesia, the patient was intubated with a doublelumen endotracheal tube, and a TEE probe was inserted to perform a baseline examination (the preoperative diagnosis was made only by transthoracic echocardiography because the patient refused TEE examination) and to supervise the insertion of the venous cannula (in the minithoracotomic approach a large 14F cannula is placed percutaneously through the right jugular vein into the superior vena cava). 1

Background— The aim of this study was to assess the results of mitral valve (MV) repair in functional mitral regurgitation because of end-stage dilated cardiomyopathy (DCM). Methods and Results— Seventy-seven patients with end-stage idiopathic (26 patients) or ischemic (51 patients) DCM underwent MV repair for functional mitral regurgitation (3 to 4+/4+). Fifty-eight patients (75.3%) were in New York Heart Association class III, and 19 (24.6%) were in IV. In 23 patients (29.8%) with a coaptation depth P P =0.03). Freedom from repair failure at 1.5 years was 95.0±3.4% and 77±12.1%, respectively ( P =0.04). The absence of the edge-to-edge was the only predictor of repair failure ( P =0.03). When residual MR was absent or mild, a reverse left ventricular remodeling was clearly documented. Conclusions— In patients with end-stage DCM, MV repair is feasible with low hospital mortality and important symptomatic improvement. The association of the edge-to-edge technique to the undersized annuloplasty can significantly improve the durability of the repair.

Objectives: Correction of tricuspid regurgitation due to complex lesions (not treatable with annuloplasty only) is associated with suboptimal results. To improve the efficacy of valve repair in this context, we developed a new surgical approach, which consists of stitching together the central part of the free edges of the leaflets producing a 'clover' shaped valve. Our preliminary experience with this novel technique is reported. Methods: Between 2001 and 2003, 14 patients (mean age 57 17 years), with severe tricuspid regurgitation due to complex lesions, underwent valve repair with this novel approach in combination with annuloplasty. The aetiology of the disease was post-traumatic in five cases, degenerative in eight and secondary to dilated cardiomyopathy in one. Anterior leaflet prolapse/flail was present in most patients associated with posterior and/or septal leaflet prolapse or tethering. Annular and right ventricular dilatation was present in all cases. Mitral valve repair/replacement was concomitantly performed in nine patients. Results: Hospital mortality was 7.1% (1/14). At follow-up extending to 22 months (mean 12 +/- 6.3), all survivors were asymptomatic. At the last echocardiogram tricuspid regurgitation was absent or mild in 13 patients and moderate in one. Mean tricuspid valve area and gradient were 4.2 +/- 0.4 cm(2) and 2.7 +/- 1.4 mmHg, respectively. Conclusions: Despite the short follow-up, this novel technique appears to be an easy, rapid and effective approach to correct severe tricuspid regurgitation due to complex lesions. Such a repair restored tricuspid valve competence, even in the presence of huge RV dilatation and pulmonary hypertension. (C) 2004 Elsevier B.V. All rights reserved.

Objective: To describe a novel technique, named "clover," to correct complex post-traumatic tricuspid valve lesions. Methods: Five patients with severe post-traumatic tricuspid insufficiency underwent valve reconstruction with the clover technique, a new surgical approach that consists of stitching together the middle point of the free edges of the tricuspid leaflets, producing a clover-shaped valve. The mechanism of tricuspid regurgitation was complex in all patients, and right ventricular function was always moderately to severely depressed. An echocardiographic study was performed after cardiopulmonary bypass, at discharge, and at follow-up. Results: Cardiopulmonary bypass time was 32 +/- 6.3 minutes and crossclamp time was 23 +/- 7.4. There was no hospital mortality or morbidity. Intraoperative transesophageal and predischarge transthoracic echocardiography showed perfect results in all patients. No late deaths occurred. At the latest follow-up, extending to 14.2 months (mean 11.3; median 12.4), all patients were asymptomatic (New York Heart Association class 1) with trivial (2 patients) or no residual regurgitation (3 patients) on 2-dimensional echocardiogram. No transvalvular gradient was revealed in any patient. A significant reduction of the right ventricular end-diastolic dimensions was noted as well (from 54 +/- 7.1 mm to 40 +/- 7.5 mm, P < .001). Conclusions: In this preliminary experience, the clover technique increased the feasibility of tricuspid valve repair in case of severe traumatic tricuspid valve insufficiency, leading to very satisfactory mid-term results even in the presence of complex lesions or dilatation and deterioration of the right ventricle.

Objective The results of mitral valve repair for anterior leaflet prolapse have been less gratifying than those reported for posterior leaflet prolapse. We compared the long-term durability of 2 different surgical techniques: the edge-to-edge repair, which is used for the treatment of anterior leaflet prolapse, and quadrangular resection, which has been adopted for correction of posterior leaflet prolapse. Methods From 1991 through April 2004, 133 patients with anterior leaflet prolapse and 605 with posterior leaflet prolapse caused by degenerative mitral disease underwent valve repair. The edge-to-edge repair was used for correction of anterior leaflet prolapse, and quadrangular resection of the posterior leaflet, with or without sliding plasty, was used for correction of posterior leaflet prolapse. All patients received a concomitant annuloplasty procedure. Results No hospital deaths occurred in the anterior leaflet prolapse group, whereas 2 (0.3%) patients died in the posterior leaflet prolapse group ( P = .7). Follow-up was 100% and 97.2% complete in the anterior and posterior leaflet prolapse groups, respectively. At 10 years, overall survival was 91% ± 4.06% for anterior leaflet prolapse and 93.5% ± 1.81% for posterior leaflet prolapse ( P = .18), and freedom from cardiac death was 95.8% ± 2.83% for anterior leaflet prolapse and 97.4% ± 0.95% posterior leaflet prolapse ( P = .27). Freedom from reoperation was 96% ± 2.3% in the anterior leaflet prolapse group and 96.5% ± 1.18% in the posterior leaflet prolapse group ( P = .37). At follow-up (mean, 4.5 ± 3.12 years; range, 1 month-13.2 years), New York Heart Association functional class I or II was documented in 93.2% of patients in the anterior leaflet prolapse group and 92.8% in the posterior leaflet prolapse group ( P = .98). Conclusions The long-term results of the edge-to-edge repair in the setting of anterior leaflet prolapse are similar to those obtained with quadrangular resection for the treatment of posterior leaflet prolapse.