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The prevalence of mitral valve disease has evolved over the past 5 decades from primarily a disease of rheumatic origin to a disease affecting the aging population that encompasses a range of phenotypes from rheumatic mitral stenosis, degenerative mitral regurgitation, and degenerative mitral valve calcification to secondary mitral regurgitation. A reflection on the history of therapy for mitral valve disease is an expedition that follows the birth and development of structural heart intervention from the first percutaneous balloon mitral valvuloplasty to innovative technologies for transcatheter mitral valve repair and replacement. This review will lead you along this journey, pause to acknowledge the feats accomplished, and reflect on the road that lies ahead., (Copyright © 2021 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

The management of valvular heart disease has changed dramatically over the past decade with advances in cardiac imaging, the use of novel biomarkers, and the development of transcatheter valve repair and replacement technology. International society guidelines have kept pace to provide recommendations for diagnosis, follow-up, and timing of intervention. The most challenging patient cohort for clinicians are patients with asymptomatic severe disease in whom the optimal timing of intervention can be ill-defined. It is a fine balance between the risks of early intervention on asymptomatic patients and improving patient outcomes by preventing long-term cardiac complications. The key in optimal patient management is gathering the necessary information on patient risk and combining that with the risk, efficacy, and durability of valve interventions to arrive at the appropriate timing for intervention. This group of patients will be the focus of this review as we delve into the natural history, recommended follow-up, and indications for intervention in patients with degenerative aortic and mitral valve disease., Competing Interests: Disclosures Dr Asgar is a consultant for and has received research support from Abbott. The remaining authors have no conflicts of interest to disclose., (Copyright © 2021 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.)

Objectives: The aim of this study was to determine immediate results and long-term outcomes after surgical management of paravalvular leak (PVL)., Methods: Between 1995 and 2012, a total of 190 patients underwent primary surgical repair (n = 142) or valve replacement (n = 48) for a PVL at our institution. The PVL was mild in 6 (3%) patients, moderate in 85 (45%), moderate to severe in 84 (44%), and severe in 15 (8%). Among these, 120 (63%) had PVL in the mitral position, 63 (33%) had PVL in the aortic position, and 7 (4%) had PVL in both valves. Mean follow-up was 5.3 ± 4.6 years., Results: Mean age at surgery was 63 ± 12 years (64% men). Operative mortality occurred in 13 (7%) patients (10 [8%] in mitral; 2 [3%] in aortic; and 1 [14%] in double valve procedures). Survival at 1, 5, and 10 years was 85% ± 3%, 73% ± 4%, and 56% ± 5%, respectively. The cumulative incidence of PVL recurrence was 3% ± 1%, 14% ± 3%, and 32% ± 6%, at 1, 5, and 10 years, respectively. The number of previous surgeries was a predictor of survival and PVL recurrence. Freedom from New York Heart Association class ≥III was 96% ± 2%, 82% ± 4%, and 58% ± 6%, at 1, 5, and 10 years, respectively. The freedom from rehospitalization for heart failure was 92% ± 2%, 83% ± 4%, and 67% ± 6%, at 1, 5, and 10 years., Conclusions: Surgical treatment of PVL resulted in acceptable outcomes. Nevertheless, the continued risk of PVL recurrence is higher in patients who have had multiple previous surgeries. More studies are needed to compare these results with the transcatheter PVL reduction technique., (Copyright © 2016 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)

Background: With improved durability of contemporary bioprostheses, surgeons are now recommending biologic valves in younger patients. However, long-term outcomes of patients younger than 60 years old undergoing biologic aortic valve implantation are not well known., Methods: From November 1991 to March 2011, 144 patients less than 60 years old underwent aortic valve replacement (AVR) with Carpentier-Edwards pericardial valves (Edwards Lifesciences, Irvine, CA). Mean follow-up was 10±4 years. Outcomes were reported according to published guidelines., Results: Seventy-five percent of patients were male, with a mean age of 51±9 years. Actuarial survival rates including early deaths were 89%±3%, 79%±4%, and 57%±6% after 5, 10, and 15 years of follow-up, respectively. Survival of patients was comparatively lower than a gender- and age-matched general population at all time points. The freedom from major adverse cardiac events (myocardial infarction, heart failure, hemorrhage, thromboembolic event, and endocarditis) was 89%±3%, 87%±3%, and 75%±6% at 5, 10, and 15 years after surgery. The freedom rate from prosthetic valve dysfunction was 97%±2%, 84%±4%, and 57%±6% at 5, 10, and 15 years after surgery. Patients with a diagnosis of structural valve deterioration (29 of 37, 78%) underwent reoperation 11±5 years after the initial valve replacement with no perioperative mortality., Conclusions: In patients younger than 60 years undergoing AVR, the Carpentier-Edwards Perimount bioprosthesis provided satisfactory clinical outcomes. However, late survival was inferior to an age- and gender-matched population. Structural valve deterioration and the need for reintervention were common late after implantation, but reoperation for prosthetic valve dysfunction was associated with a very low risk of mortality., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The CarboMedics mechanical prosthesis (CarboMedics Inc, Austin, TX) has been used for mitral and aortic valve replacement for more than 20 years in our institution. This study describes the long-term survival of patients with this prosthesis as well as the valve-related events., Methods: Between June 1988 and May 2010, 3,297 patients underwent either single aortic valve replacement (AVR) (2,242 patients) or mitral valve replacement (MVR) (1,055 patients) with the CarboMedics mechanical valve prosthesis. They were followed annually for valve-related complications at the Montreal Heart Institute valve clinic., Results: Operative mortality was 4% with AVR and 7% with MVR. Total follow-up was 23,671 patient-years (range, 1 month to 21 years; average, 7.5 ± 5.3 years). At 20 years, patient freedom from late mortality was 43.2% in the AVR group and 40.9% in the MVR group. Freedom from valve-related mortality was 78.3% for AVR and 74.6% for MVR. Freedom from thromboembolic event was 91.6% for AVR and 88.5% for MVR. Freedom from reoperation was 89.2% for AVR and 80.3% for MVR. Freedom from bleeding event was 89.5% for AVR and 88% for MVR. Freedom from endocarditis was 97.3% for both AVR and MVR. Freedom from valve thrombosis was 98.9% for AVR and 91.4% for MVR. There was no structural valve failure in our cohort., Conclusions: The CarboMedics valve is an effective and durable mechanical valve prosthesis with a low event rate and no structural failure at 20 years., (Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)

Background: The objectives were to describe morbidity and mortality after tricuspid valve (TV) surgery, to compare outcomes after repair versus replacement, and to assess risk factors for mortality and tricuspid regurgitation (TR) recurrence., Methods: A retrospective cohort study including 926 consecutive cases of TV surgery (792 repairs and 134 replacements) performed at the Montreal Heart Institute was conducted. Median follow-up was 4.3 years (4,657 patient-years). Median age was 62 years (interquartile range 53-69 years), and 72% of patients were women., Results: Operative mortality was 14% (128 patients: 1977-1998 20%, 1999-2008 7%, P < .001). Independent risk factors for operative mortality in the 1999 to 2008 period were hypertension (odds ratio [OR] 6.03, P = .02), daily furosemide dose (by 10 mg) (OR 1.06, P = .05), weight (by 10 kg) (OR 0.36, P < .01), and cardiopulmonary bypass time (by 10 minutes) (OR 1.29, P < .001). Ten-year survival was 49% ± 2% and 38 ± 5% in the repair and replacement groups, respectively (P = .012). At discharge, severity of TR was ≥3/4 in 13% and 2% of patients in the repair and replacement groups, respectively (P = .01). Propensity score analysis showed that tricuspid repair was associated with higher rates of TR ≥3/4 at follow-up compared with replacement (hazard ratio 2.15, P = .02). Forty-eight reoperations (7% of patients at risk) were performed during follow-up (repair group, 6%; replacement group, 15%; P = .01). At last follow-up, New York Heart Association functional class was improved compared with baseline in both groups (P < .001)., Conclusion: Tricuspid valve surgery is associated with substantial early and late mortalities but with significant functional improvement. Replacement is more effective in early and late corrections of regurgitation, but it does not translate into better survival outcomes., (Copyright © 2012 Mosby, Inc. All rights reserved.)

Background and Aim of the Study: Triple-valve disease is a challenge that surgeons face periodically, yet the clinical benefits of triple-valve surgery, in relation to the high operative risk, are not well known. The study aims were to describe the early and late mortality associated with triple-valve surgery, to assess the risk factors, and describe the long-term outcomes., Methods: A retrospective analysis of 178 consecutive triple-valve surgeries performed at the Montreal Heart Institute between 1977 and 2008 was performed. The median follow up was 5.0 years (inter-quartile range: 1.6 to 9.4 years)., Results: Among 170 patients (122 females, 48 males; mean age 60 +/- 11 years), the preoperative NYHA functional class was > or = III/IV in 93% of cases; 61% of the patients had undergone previous cardiac surgery. The operative mortality was 12% between 1999 and 2008, and 25% between 1977 and 1998 (p = 0.033). Independent risk factors between 1999 and 2008 period included tricuspid regurgitation severity (OR = 13.71; p = 0.03) and the presence of a right intraventricular pacemaker lead (OR = 11.25; p = 0.039). Survival rates at five and 10 years were 61 +/- 4% and 38 +/- 5%, respectively. A lower left ventricular ejection fraction at discharge was associated with a poor late survival, independent of patient age and gender (OR = 0.95; p = 0.035). Twenty-three patients (18%) required reoperation during the follow up period, at which time the NYHA functional class was improved compared to baseline (p < 0.001)., Conclusion: Although triple-valve surgery is associated with substantial operative mortality, this situation has improved significantly over the years. Currently, survivors experience a significant improvement in their cardiac functional capacity, justifying the continued use of triple-valve procedures, though preferably earlier during the course of the disease.

Background and Aim of Study: This study evaluated the long-term outcome of linear, endocardial, radiofrequency (RF) atrial ablation for the treatment of atrial fibrillation (AF) concomitantly to open-heart procedures for acquired cardiac organic disease., Methods: A saline-irrigated "pen-like" RF ablation catheter (Cardioblate(®), Medtronic, Minneapolis, MN, USA) was used to perform endocardial lines of conduction block in 293 patients with AF who underwent open-heart procedures between September 2000 and February 2008., Results: Patients (age of 65 ± 11 years) underwent left atrial ablation for permanent (44%), paroxysmal (51%), or undetermined (4.4%) AF. Maintenance in sinus rhythm (SR) at discharge and at the end of follow-up (average 3.3 ± 1.2 years) was observed in 52% and 71% of patients, respectively. Preoperative type or duration of AF did not influence the results (p = NS). Multivariate analysis with a logistic regression model showed left atrial diameter and increasing age were independent predictors of recurrent AF. In this study, return to SR did not influence survival., Conclusions: This study confirmed that concomitant intraoperative RF ablation is an effective technique to restore long-term SR after cardiac surgery in patients with preoperative AF but does not influence long-term survival. , (© 2010 Wiley Periodicals, Inc.)

Background and Aim of the Study: The purpose of this investigation was to evaluate both long-term functional status and quality of life (QoL) following valvular replacement surgery in octogenarians. The influence of gender and discharge location was also examined., Methods: A total of 133 patients (age range: 80-89 years) who underwent surgical valve replacement between January 2003 and December 2006 was identified. Two questionnaires evaluating QoL (SF-12v2 and MLHFQ), as well as a demographic questionnaire, were sent to these patients., Results: The response rate was 64.4%. Among the participants, the mean NYHA functional class improved from 2.7 to 1.4 after surgery. Men showed results similar to those of the age-matched general Canadian population on the mental and physical component scales of the SF-12v2. The data on women were similar to those of the general population on the physical component scale, but their scores were significantly lower on the mental component scale of the SF-12v2. Further analysis of the results comparing discharge location for each gender revealed that women discharged to a convalescence resource had significantly better QoL scores than those discharged to home with regards to the physical component scale of the SF-12v2, the total score of the MLHFQ, and the physical dimension score of the MLHFQ., Conclusion: Patients aged > or = 80 years benefit from heart valve replacement surgery in terms of both QoL and functional status. Women may be at increased risk of a decline in their emotional well-being and, postoperatively, may benefit more from convalescence than from discharge to home.

Background: The prognostic value of right ventricular myocardial performance index (RVMPI) and right ventricular fractional area change (RVFAC) in mitral or aortic valve surgery has not been well described. The main objective of this study is to assess the prognostic value of RVMPI and RVFAC in predicting postoperative mortality or circulatory failure., Methods: RVMPI and RVFAC were prospectively measured after induction of anesthesia using transesophageal echocardiography in 50 consecutive patients undergoing corrective mitral or aortic valve surgery. Univariate and multivariate analyses were performed for the primary clinical end point of in-hospital mortality or circulatory failure., Results: In the study population, the mean age was 67 +/- 9 years. The primary end point occurred in 17 patients (34%); three patients died, and 14 patients presented signs of circulatory failure. Multivariate regression analysis identified RVMPI and RVFAC as variables of prognostic significance., Conclusion: Preoperative RVMPI and RVFAC could have an incremental value in predicting postoperative mortality and morbidity in valvular heart surgery. Future studies are needed to validate these results in a larger population.

Background and Aim of the Study: Mechanical prostheses are used in young patients, the CarboMedics valve having been the mechanical valve of choice of the present authors during the past 15 years. The study aim was to analyze long-term clinical and echocardiographic results obtained with CarboMedics mechanical valves., Methods: A total of 2,953 patients underwent valve replacement with the CarboMedics valve between 1988 and 2004 at the Montreal Heart Institute. Patients were prospectively followed at the outpatient valve clinic. Subsequently, 1,004 patients underwent echocardiographic examinations during follow up., Results: In total, 1,597 patients (mean age 57 +/- 12 years) underwent isolated aortic valve replacement (AVR), 1,043 patients (mean age 59 +/- 10 years) underwent isolated mitral valve replacement (MVR), and 313 patients (mean age 58 +/- 11 years) underwent AVR+MVR. The mean five-, 10- and 15-year actuarial survival rates were 83 +/- 1%, 70 +/- 2% and 62 +/- 3% in AVR patients, 76 +/- 1%, 59 +/- 2% and 40 +/- 14% in MVR patients, and 68 +/- 3%, 51 +/- 4% and 33 +/- 9% in AVR+MVR patients. The mean 15-year freedom from cerebral embolism, hemorrhage and reoperation was 95 +/- 1%, 97 +/- 1% and 95 +/- 1% in AVR patients, 92 +/- 1%, 97 +/- 1% and 93 +/- 1% in MVR patients, and 94 +/- 2%, 93 +/- 2% and 91 +/- 4% in AVR+MVR patients. AVR patients had a mean aortic gradient of 29 +/- 14, 20 +/- 8, 18 +/- 7, 16 +/- 7, 12 +/- 5 and 11 +/- 5 mmHg with 19, 21, 23, 25, 27 and 29 mm prostheses, respectively (p = 0.001). MVR patients had a mean mitral gradient of 5.3 +/- 3, 4.9 +/- 2.2, 4.6 +/- 2, 4.4 +/- 2.9 and 4.9 +/- 1.8 mmHg with 25, 27, 29, 31 and 33 mm prostheses, respectively (p = 0.63)., Conclusion: Patient survival and valve-related complications were satisfactory at 15 years after valve replacement with the CarboMedics valve. Mean aortic gradients were high with the 19-mm aortic prostheses, but all other valve sizes showed good hemodynamic performance, as measured using transthoracic echocardiography.

Objective: Atrial fibrillation (AF) is frequently associated with valvular heart disease and a common complication of valve surgery. Its contribution to long-term mortality and morbidity remains debated. Our objective was to determine the impact of AF on long-term mortality and embolic complications after valvular surgery and the benefit of conversion to sinus rhythm. This may provide insight to the clinical advantages of surgical anti-AF procedures., Methods: Data concerning rhythm status, mortality and embolic complications were prospectively collected for 5466 patients with valve surgery. Patients had surgery between 1979 and 2003. Follow-up was complete and all patients had a yearly EKG., Results: Patients with preoperative AF had poorer long-term survival than patients without preoperative AF (20-year survival 23.7 and 33.4%, respectively, P<0.0001). However, preoperative AF was not an independent risk factor of long-term mortality (HR=1.04, P=0.6). In patients with preoperative sinus rhythm, postoperative development of AF had an impact on long-term mortality (HR=1.46, P=0.0012). In patients with preoperative AF, postoperative rhythm did not influence mortality when adjusted for other variables (AF vs. sinus rhythm, HR=1.07, P=0.5709). Mitral valve surgery (HR=1.55, P=0.0270) but not preoperative or postoperative AF had a significant impact on the advent of embolic complications., Conclusions: The conversion to sinus rhythm did not improve long-term survival or reduce the incidence of embolic complications after valve surgery. Patients with preoperative AF had poorer survival than patients without preoperative AF. AF may be a marker of advanced disease in these patients.

Aspergillus endocarditis is an ominous condition whose prevalence is increasing in the hospital population. Despite the life-threatening nature of the disease, detection of the source, establishment of the diagnosis, and treatment remain highly challenging. A cluster of three cases of Aspergillus endocarditis recently encountered at the Montreal Heart Institute are presented.

The purpose of this study was to examine the early and late results in 29 patients who underwent 32 (6 mechanical and 26 bioprostheses) isolated tricuspid valve replacement (TVR) from a total of 79 TVR and 375 tricuspid annuloplasties performed at the Montréal Heart Institute, between January 1978 and January 1998. Patients' ages ranged from 25 to 70 years (mean 48 years), and 62% were females. Twenty-seven patients (84%) were in New York Heart Association (NYHA) functional class III and IV. Previous valve surgery had been performed in 22 patients (69%) of which 9 had undergone TVR. Postoperatively, permanent pacemaker was implanted in 9 patients (28%), and immediate reoperation was required in 2 patients because of bleeding. Mean follow-up period was 67.7 months (93% complete). Serial echocardiography showed 3 prosthesis dysfunctions, leading to a second replacement in 2 patients at 12.8 and 7.7 years after initial surgery. All but three patients showed an improvement of their NYHA class. Hospital mortality occurred in 6 patients (19%) and 7 patients died during late follow-up: mean 38.1 months after surgery, including one valve-related death (mechanical valve thrombosis). Actuarial survival rate of all patients was 63% after 5 years, and 47% after 10 years. Isolated TVR remains a high-risk procedure. Most survivors, however, should expect a better quality of life with improvement in their NYHA class.

Extensive calcification of the mitral valve anulus is a pathologic entity frequently associated with degenerative valvular disease. The calcification process remains localized to the anulus in 77% of the cases. It may extend, however, to the underlying myocardium. Whenever an operation is necessary for an associated valve insufficiency, the question arises whether it is preferable to repair or to replace the valve and how to manage the calcification. In the first part of this paper the pathology of this disease is studied, and in the discussion a mechanism is proposed to explain the development of the process of calcification. In the second part, a new operation is described, which comprises the temporary detachment of the leaflets, en bloc resection of the calcium deposit, annular reconstruction, and valve repair. For patients in whom the calcification extends to the myocardium a "sliding atrioplasty" of the left atrium is described, which allows the area of exposed muscular fibers to be covered. Between 1986 and 1994, among 68 patients with extensive calcification of the anulus and severe mitral valve insufficiency, 67 benefited from these repair techniques. Ages ranged from 18 to 82 years (mean 62 years). Thirty-two patients had a billowing mitral valve (Barlow), 27 a fibroelastic deficiency, and two Marfan's disease. The calcification involved more than one third of the anulus in 88% of the patients, the posterior anulus in 10.5%, and the whole anulus in 1.5%. The calcification process extended to the myocardial wall in 12% of the patients and to the papillary muscles in 4.5%. In the group of 67 valve repairs, there were two hospital deaths (2.9%), no instances of anulus dehiscence, and no early reoperations. The follow-up period extended from 4 months to 8 years (mean 3 years 8 months). There were two late deaths, 2 and 17 months after the operations, for an actuarial survival of 93% at 7 years. Late reoperation (6 to 62 months) was necessary in four patients (6.4%) for residual mitral valve incompetence (n=2), hemolysis (n=1), or endocarditis (n=1). In one of these patients a new repair was possible, whereas the three other patients required a valve replacement. All patients but one survived the reoperation. Actuarial freedom from reoperation was 87% at 7 years. All 60 patients with valve repair were reviewed for this study by clinical examination and echocardiography. All but one were in functional class I or II. There was no incompetence or trivial residual mitral valve incompetence in 55 patients and moderate incompetence in five. Two thromboembolic events have been recorded for a linearized rate of 1%/pt-yr. This study shows that complete anulus decalcification and valve repair can be done safely in patients with mitral valve insufficiency and extensive calcification of the anulus, even when the calcification process deeply involves the myocardium. It also demonstrates that an initially good result remained stable up to 7 years.

Surgical treatment of valvular heart disease is a field of constant clinical and experimental research. Recently, much attention has been devoted to the improvement of valve repair techniques. The physiopathology of the left ventricular outflow tract obstruction following mitral valve repair has become better understood. Surgical techniques to correct this infrequent complication have been developed. Conservative valvular surgery or homograft use are among the surgical treatments for infective endocarditis; innovative experimental and clinical studies on mitral and tricuspid homografts have provided interesting results. New biological valves have come into use; intraoperative creation of a cardiac bioprosthesis using glutaraldehyde-treated autologous pericardium is an attractive surgical innovation. Stentless bioprostheses are also under investigation, to evaluate their hemodynamic and clinical characteristics. The biology of bioprosthesis deterioration progresses at the cellular level, with the implication of phagocytosis as a contributing factor.