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Objective: Functional mitral regurgitation (FMR) is a cardiac pathology that causes the mitral valve to malfunction, leading to mitral regurgitation (MR). The optimal strategy for FMR remains unclear, and FMR outcomes are poor. All etiologies of FMR might not be the same, and subdividing patients with FMR caused by atrial (AFMR) versus ventricular FMR pathology might be important. Herein, we present outcomes of patients with AFMR to define this "new" population., Methods: Data of patients who underwent mitral valve repair for MR from 2000 to 2020 were reviewed. Patients with degenerative/myxomatous disease, ejection fraction <50% (ventricular FMR), and miscellaneous etiologies including endocarditis and rheumatic disease were excluded to isolate a population of "pure" AFMR patients. Descriptive characteristics and outcomes data were analyzed., Results: Among 123 total AFMR patients, mean preoperative left atrial dimensions were enlarged to 4.9 (95% CI, 4.7-5.0) cm, whereas mean preoperative left ventricular diastolic dimensions remained near normal at 5.0 (95% CI, 4.9-5.2) cm. Preoperative atrial fibrillation was noted in 61% (74/123). Echocardiogram was performed in 58% (71/123) of patients at a median of 569 (interquartile range, 75-1782) days after surgery. Of those, 72% (51/71) had trivial or no MR, 22% (16/71) mild, and only 6% (4/71) moderate or greater MR. Only 1.6% (2/123) required redo mitral valve reoperation. Estimated 5-year survival was 74%., Conclusions: Patients with AFMR do well after mitral valve repair using an annuloplasty ring, with low rates of reoperation, mortality, and recurrence of MR. Mitral annuloplasty should be considered the surgical therapy of choice for AFMR., (Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Racial disparities in health care have come to the forefront. We hypothesized that Black race was associated with worse preoperative risk, lower repair rates, and worse outcomes among patients who underwent mitral valve surgery., Methods: All patients who underwent mitral valve repair or replacement with or without coronary artery bypass grafting from 2011 to 2020 in a statewide collaborative database were stratified into 3 racial groups, White, Black, and other. Preoperative characteristics, procedure type, and outcomes were evaluated., Results: A total of 9074 mitral valve operations were performed at 33 centers (Black 1009 [11.1%], White 7862 [86.6%]). Preoperative combined Society of Thoracic Surgeons morbidity and mortality was higher for Black patients (Black 32%, White 22%, other 23%, [P < .001]) because of a greater proportion of diabetes, hypertension, and chronic lung disease. White patients were more likely to undergo mitral repair (White 66%, Black 53.3%, other 57%; P < .001). Operative mortality was similar across racial groups (White 3.7%, Black 4.6%, other 4.5%; P = .36). After adjusting for preoperative factors, mitral etiology, and hospitals, race was not associated with mitral valve repair, complications, or mortality, but Black patients had higher odds of extended care facility utilization and readmission., Conclusions: Contrary to our hypothesis, there was no difference in the odds of repair or operative mortality across races after accounting for risk and etiology. However, Black patients were more likely to be readmitted after discharge. These findings support a greater focus on reducing disparities in mitral valve surgery., (Copyright © 2022 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: For degenerative mitral disease, repair is superior to replacement; however, the best operative strategy for rheumatic mitral disease remains unclear. We evaluated the association between decision-making in choosing repair versus replacement and outcomes across 2 decades of rheumatic mitral surgery., Methods: Patients undergoing isolated, first-time rheumatic mitral surgery were identified. Era 1 (1997-2008) and Era 2 (2009-2018) were distinguished by intraoperative assessment of anterior leaflet mobility/calcification (Era 2) in deciding between mitral repair versus replacement. Primary outcome was a composite of death, reoperation, and severe valve dysfunction., Results: Among 180 patients, age was 59 ± 14 years, and ejection fraction was 58% ± 10%. A higher proportion in Era 1 (n = 56) compared with Era 2 (n = 124) had preoperative atrial fibrillation (68% vs 46%; P = .006); the groups were otherwise similar. Primary indication was mitral stenosis in 69% (124 out of 180; pure = 35, mixed = 89) and did not differ by era (P = .67). During Era 1, 70% (39 out of 56) underwent repair, compared with 33% (41 out of 124) during Era 2 (P < .001). Freedom from death, reoperation, or severe valve dysfunction at 5 years was higher in Era 2 (72% ± 9%) than Era 1 (54% ± 13%; P = .04). Five-year survival was higher in Era 2 than Era 1, but did not differ between repair versus replacement. Five-year cumulative incidence of reoperation with death as a competing risk did not differ by era, but was higher after repair than replacement., Conclusions: Careful assessment of anterior leaflet mobility/calcification to determine mitral repair or replacement was associated with improved outcomes. This decision-making strategy may alter the threshold for rheumatic mitral replacement in the current valve-in-valve era., (Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: Mitral valve repair is superior to replacement for degenerative disease, but long-term outcomes of anterior versus posterior leaflet repair remain poorly defined. We propensity matched anterior and posterior repairs to compare long-term outcomes., Methods: Patients undergoing first-time degenerative mitral repair between 1992 and 2018 were identified. Primary outcome was overall survival. Secondary outcomes were postprocedural residual mitral regurgitation and reoperation. From 1025 patients, 1:1 propensity score matching was performed, yielding 309 anterior (isolated anterior = 85, bileaflet = 224) and 309 isolated posterior repairs., Results: Age was 58 ± 15 years, ejection fraction was 57% ± 10%, and matched groups were well balanced. Anterior repairs had longer bypass (122 ± 53 vs 109 ± 43 minutes, P = .001) and crossclamp (94 ± 44 vs 85 ± 62 minutes, P = .033) times. Mean residual mitral regurgitation grade was 0.44 (95% confidence interval, 0.24-0.65) for anterior repair and 0.30 (95% confidence interval, 0.13-0.47) for posterior repair (P = .31). Overall, 92% (569/618) of matched patients had no residual mitral regurgitation, with no differences in mitral regurgitation grade between groups (P = .77). Survival did not differ between anterior (10 years: 72% ± 7%; 15 years: 63% ± 7%) and posterior (10 years: 74% ± 7%; 15 years: 60% ± 8%) groups (log-rank P = .93). Linearized incidence of reoperation was 0.62% per patient-year, including 0.74% for anterior and 0.48% for posterior repairs. Cumulative incidence of reoperation at 15 years was 7.5% after anterior repair and 4.9% after posterior repair (Gray's test P = .26)., Conclusions: No long-term survival or reoperation difference was found between posterior and anterior repair. On the basis of these findings, surgeons at centers of excellence should aim for repair of both anterior and posterior leaflet pathology with the same decision-making threshold over valve replacement for degenerative mitral disease., (Copyright © 2020 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: The effect of significant mitral regurgitation (MR) on outcomes after continuous flow left ventricular assist device (cfLVAD) implantation remains unclear., Methods: We performed a retrospective review of prospectively collected data from 159 patients with preoperative severe MR who underwent cfLVAD implantation (2003-2017). Two-step cluster analysis using the log-likelihood distance for post-cfLVAD implantation parameters, which included right ventricular (RV) dysfunction, MR severity, and tricuspid regurgitation (TR) severity. Post-cfLVAD implantation echocardiographic parameters were obtained within the first month., Results: Cluster analysis resulted in 3 groups. Group 1 (n = 67) had mild or less MR with moderate-severe RV dysfunction (RVD). Group 2 (n = 43) had moderate-severe MR with moderate-severe RVD. Group 3 (n = 49) had moderate MR with mild RVD. Group 2 had the largest proportion with Interagency Registry for Mechanically Assisted Circulatory Support score of 1 (30.2%) and 2 (41.9%). They were more likely to undergo temporary mechanical circulatory support (18.6%) and tricuspid valve procedure (62.8%). Group 2 had the highest rate of stroke (30.2%; P = .02), hemolysis (39.5%; P = .01), device thrombosis (30%; P = .01), and worst survival (46.5%; P = .01). Survival at 5 years for groups 1, 2, and 3 were 56.0%, 17.6%, and 55.8%. Regression analysis of the entire population showed that greater MR severity after cfLVAD was associated with RV failure (P < .05; odds ratio, 1.6) and RV assist device use (P = .09; odds ratio, 1.6). After excluding tricuspid valve repairs, MR severity had a positive correlation with TR severity (R = 0.33; P < .01)., Conclusions: After cfLVAD implantation, moderate-severe MR and RVD predicted RV failure. Patients with preoperative moderate-severe MR and TR coupled with moderate-severe RVD might benefit the most from mitral and tricuspid valve intervention., (Copyright © 2019 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Objective: To investigate whether preoperative echocardiography findings determine postoperative continuous-flow left ventricular assist device outcomes., Methods: From January 2003 to June 2017, 490 patients received a durable, continuous-flow left ventricular assist device. Two-step clustering of parameters including heart rate and preoperative echocardiographic findings (ie, left ventricular [LV] ejection fraction, right ventricular [RV] function, aortic insufficiency, mitral regurgitation [MR], tricuspid regurgitation [TR]) was performed and identified 5 distinct clusters associated with LV failure: group 1: moderate right ventricular dysfunction (RVD), severe MR and mild TR (n = 110); group 2: severe RVD, severe MR and TR (n = 64); group 3: moderate RVD and severe aortic insufficiency (n = 16); group 4: mild RVD and mild valvular pathology (n = 163); and group 5: moderate-severe RVD and mild valvular pathology (n = 137). Silhouette measure of cohesion and separation demonstrated satisfactory separation at 0.6., Results: Group 2 had the greatest Interagency Registry for Mechanically Assisted Circulatory Support Level 1 (25%, P = .010), preoperative right atrial pressure (11 ± 5 mm Hg, P < .001), incidence of postoperative right ventricular failure (RVF; 20%, P = .001), delayed closure of the sternum (61%, P = .002), postoperative permanent dialysis (6%, P = .04), rate of tricuspid valve repair (n = 52; 81%, P < .001), and lowest RV stroke work index (489 ± 228 cc mm Hg/m 2 /beat, P < .001). RVF in groups 1, 3, 4, and 5 was 6%, 0%, 4%, and 9%, respectively. No differences in incidence of heart transplantation (P = .400) or survival (P = .535) were found. Severe TR predicted RVF in those with moderate-severe preoperative RVD (P = .001, odds ratio 3.9)., Conclusions: Clustering demonstrated the importance of preoperative TR in predicting RVF. Combined severe LV and RV failure with severe MR and TR portends the worse prognosis., (Published by Elsevier Inc.)

Objective: Right thoracotomy using ventricular fibrillation with cooling has been used for redo mitral valve surgery. This approach avoids the complications of redo sternotomy, such as injury to prior grafts and hemorrhage. As a further refinement, we have used a beating heart technique to further minimize complications while simplifying the operation., Methods: We reviewed the outcomes of 450 patients who underwent redo mitral valve surgery via a right thoracotomy from 1996 to 2011 at the University of Michigan. Of these, 134 patients underwent redo mitral valve surgery with ventricular fibrillation, and 316 patients underwent beating heart surgery. Although operative eras were consecutive, patients' age, risk factors, New York Heart Association, and preoperative left ventricular ejection fraction were not significantly different. Core temperature on cardiopulmonary bypass for beating heart surgery was 32°C versus 26°C for ventricular fibrillation., Results: Patients undergoing beating heart surgery had shorter periods of cardiopulmonary bypass: 81±9 minutes versus 113±36 minutes. Beating heart surgery required less blood products than ventricular fibrillation: 1.65±2 units versus 3.8±5 units packed red blood cells, 0.6±1.2 units versus 1.8±4 units fresh-frozen plasma, and 1.02±4 versus 7.5±17 platelet packs (all P<.01). Conversely, patients receiving ventricular fibrillation required longer postoperative ventilation: 34±101 hours versus 15.5±27 hours (P<.01). The 30-day mortality was similar for both (6.5% for beating heart and 7.4% for ventricular fibrillation), and postoperative length of stay was the same at 7 days. Stroke rate was 2.6% for patients undergoing beating heart surgery and 3% for patients receiving ventricular fibrillation. Significant operative complications were uncommon; there was no catastrophic hemorrhage, and only 2 patients receiving ventricular fibrillation and 2 patients undergoing beating heart surgery required reexploration., Conclusions: As reoperative cardiac surgery continues to increase, techniques that safely facilitate operation while improving outcome should be adopted. As an operative alternative, redo right thoracotomy mitral valve surgery on the beating heart is associated with shorter bypass time, less transfusion requirements, shorter postoperative ventilation, and lower mortality. This safe and effective approach should be considered for this complex operation., (Copyright © 2012. Published by Mosby, Inc.)

Background: There has been resurgent interest in coronary revascularization performed on the beating heart. Heretofore, there has been no long-term comparison of this technique to traditional coronary artery bypass with cardioplegia., Objective: The purpose of this study was to provide a comparison of long-term survival and intervention-free outcome between patient groups subjected to coronary bypass accomplished with or without the use of cardiopulmonary bypass., Method: From June 1989 to July 1990, all patients treated for coronary revascularization by three surgeons were considered for coronary revascularization with the heart beating: 107 patients underwent coronary bypass on the beating heart, and 112 patients underwent revascularization with the aid of bypass with cardioplegia. Mean ages (65 +/- 10 years) and risk factors were identical. Patients operated on with the heart beating had 2.4 +/- 0.9 grafts versus 3.2 +/- 1.1 grafts for patients having cardiopulmonary bypass with cardioplegia., Results: At 7-year follow-up, 86 of 107 (80%) patients operated on with the heart beating were alive versus 88 of 112 (79%) patients in whom cardiopulmonary bypass with cardioplegia was used. Cardiac deaths occurred in 13 of 107 (12%) patients in the former group versus 10 of 112 (9%) patients in the latter group. However, 32 of 107 patients operated on with the heart beating (30%) needed catheterization for their symptoms versus 18 of 112 (16%) patients in the bypass with cardioplegia group (p = 0.01). This results in 21 of 107 (20%) patients in the beating heart group needing angioplasty or a second coronary bypass versus only 8 of 112 (7%) patients in the bypass with cardioplegia group. No patient in the bypass with cardioplegia group required reoperation. Most of the reinterventions for the beating heart group were percutaneous transluminal coronary angioplasty (15 of 21 [71%] patients)., Conclusion: Despite one less graft per patient, survival and cardiac death rates were similar for the two groups. However, twice as many patients in the beating heart group required recatheterization (30% versus 16%), and 20% needed a second intervention. Only 7% of the bypass with cardioplegia group required reintervention. Limited revascularization of the beating heart provides long-term results comparable to full revascularization with cardiopulmonary bypass, but at the cost of a threefold increase in reinterventions.