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As transcatheter edge-to-edge mitral valve repair (TEER) evolves and indications broaden to include younger and lower surgical risk patients, it is essential to understand TEER failure trends and potential impact on subsequent mitral valve surgery, especially when pertaining to feasibility of durable valve reconstruction as opposed to de-novo repair.Results of the two largest series analysing mitral valve surgery following TEER have demonstrated remarkably low repairability rates with consequent need for valve replacement. Post TEER surgery was associated with high early and late mortalities, likely as a reflection of patient baseline characteristics and acuity of surgery. Presence and correction of concomitant cardiac pathologies were a frequent finding. Centre and surgeon volumes were important factors in optimizing the likelihood of salvage repair and reducing perioperative risks.Surgical mitral valve repair in reference centres remain the gold standard and the most durable treatment for degenerative mitral disease with excellent perioperative safety outcomes. Given the high likelihood of needing high-risk mitral valve replacement when TEER fails, consideration for potentially less durable transcatheter alternatives should be taken with caution in younger or lower surgical risk patients.

Objective The leadless cardiac pacemaker is typically implanted percutaneously and has been widely used for patients who have already undergone valve surgery. We sought to determine the feasibility and safety of implanting the leadless pacemaker under direct visualization during valve surgery. Methods We performed a retrospective analysis of consecutive adult patients (n = 15) who underwent implantation of a leadless pacemaker under direct visualization at the time of valve surgery. Indications for single-chamber pacing were sick sinus syndrome with pauses (53.3%), atrial fibrillation with slow ventricular rates (13.3%) or complete heart block (6.6%), and elevated risk for postoperative heart block (26.6%). Leadless pacemaker performance and pacing percentage were assessed. Results Patients' age was 67.5 ± 17 years, 6 patients (40%) were male, and 14 patients (93%) had atrial fibrillation. Isolated tricuspid valve replacement was performed in 5 patients (33.3%), and the remainder underwent multivalve surgery that included concomitant tricuspid valve repair/replacement. In 93% of the patients (n = 14), the immediate post–cardiopulmonary bypass pacing thresholds were normal (≤2.0 V at 0.24 ms) and normalized in the remaining patient by the next morning. The impedance/sensing values were normal and stable through follow-up (151 ± 119 days) in all patients. Reliable leadless pacemaker performance allowed for deferral of temporary epicardial wires in 11 patients (73%). There were no procedural complications or device malfunction. Conclusions Leadless cardiac pacemaker implantation during valve surgery is feasible and safe. This hybrid approach to pacing may simplify the perioperative management of patients undergoing valve surgery who have an indication for single-chamber pacing.

Background: For severe mitral valve (MV) degenerative disease, repair is recommended. Prediction of repair complexity and referral to centers of excellence can increase rates of successful repair. This study sought to demonstrate that TEE is a feasible imaging modality to predict the surgical MV complexity score previously developed by Anyanwu et al. Methods: Two hundred TEE examinations of patients who underwent MV repair (2009 – 2011) were retrospectively reviewed and scored by two cardiac anesthesiologists. TEE scores were compared to surgical complexity scores of same subset of patients. Kappa values were reported for the agreement of TEE and surgical scores. McNemar’s tests were used to test the homogeneity of the marginal probabilities of different scoring categories. Results: TEE scores were slightly lower (2[1,3]) than surgical scores (3[1,4]). Agreement was 66% between the scoring methods, with a moderate kappa (0.46). Using surgical scores as the gold standard, 70%, 71% and 46% of simple, intermediate and complex surgical scores, respectively, were correctly scored by TEE. P1, P2, P3, and A2 prolapse were easiest to identify with TEE and had the highest agreement with surgical scoring (P1 agreement 79% with kappa 0.55, P2 96% (kappa 0.8), P3 77% (kappa 0.51), A2 88% (kappa 0.6)). The lowest agreement between the two scores occurred with A1 prolapse (kappa 0.05) and posteromedial commissure prolapse (kappa 0.14) (Figure 3). In the presence of significant disagreement, TEE scores were more likely to be of higher complexity than surgical. McNemar’s test was significant for prolapse of P1 (p=0.005), A1 (p=0.025), A2 (p=0.041), and the posteromedial commissure (p

To describe the trend in plasma renin activity over time in patients undergoing cardiac surgery on cardiopulmonary bypass, and to investigate if increased plasma renin activity is associated with postcardiopulmonary bypass vasoplegia.A prospective cohort study.Patients were enrolled from June 2020 to May 2021 at a tertiary cardiac surgical institution.A cohort of 100 adult patients undergoing cardiac surgery on cardiopulmonary bypass.None.Plasma renin activity was measured at 5 time points: baseline, postoperatively, and at midnight on postoperative days 1, 2, and 3. Plasma renin activity and delta plasma renin activity were correlated with the incidence of vasoplegia and clinical outcomes. The median plasma renin activity increased approximately 3 times from baseline immediately after cardiac surgery, remained elevated on postoperative days 0, 1, and 2, and began to downtrend on postoperative day 3. Plasma renin activity was approximately 3 times higher at all measured time points in patients who developed vasoplegia versus those who did not.In patients undergoing cardiac surgery on cardiopulmonary bypass, plasma renin activity increased postoperatively and remained elevated through postoperative day 2. Additionally, patients with vasoplegic syndrome after cardiac surgery on cardiopulmonary bypass had more robust elevations in plasma renin activity than nonvasoplegic patients. These findings support the need for randomized controlled trials to determine if patients undergoing cardiac surgery with high plasma renin activity may benefit from targeted treatment with therapies such as synthetic angiotensin II.

BACKGROUND AND AIM OF THE STUDY: A systematic approach to quantify mitral annular calcification (MAC) in all-comers by multidetector computed tomography (MDCT) is essential to guide treatment, but lacking. METHODS From September 2015 to July 2019, 82 patients with MAC underwent MDCT at two institutions to evaluate for surgical mitral valve replacement (SMVR), transcatheter mitral valve replacement (TMVR), or medical management. Type 1 MAC was defined as

Alternatives to traditional aortic valve replacement now form part of the valve surgeon's armamentarium. Sutureless valves offer decreased bypass and crossclamp times, excellent maneuverability, and promising outcomes. We present a case of a sutureless aortic valve replacement for a late failed David procedure, complicated by postoperative development of severe paravalvular regurgitation. We attempted off-label balloon post-dilation to improve expansion of the valve, however paravalvular regurgitation persisted. The patient underwent subsequent aortic valve replacement using a mechanical valve and experienced no further paravalvular leak.

Mitral annular calcification tends to be significant in patients of advanced age or with underlying processes such as increased mechanical stress. When severe, it can significantly affect perioperative outcomes, especially if mitral decalcification is required for success. This report describes a versatile heart-team approach to a very complex condition. (Level of Difficulty: Advanced.), Graphical abstract, Mitral annular calcification tends to be significant in patients of advanced age or with underlying processes such as increased mechanical stress…

Introduction: Asymptomatic patients on active surveillance for degenerative mitral regurgitation are at risk of ventricular arrhythmia and sudden death. Hypothesis: Abnormal myocardial mechanics may precede ventricular remodeling and may help identify at-risk patients. Methods: Multi-directional myocardial mechanics and LV dyssynchrony were assessed in 204 consecutive patients awaiting surgical mitral repair for severe degenerative MR in a quaternary mitral reference center. Results: The mean age was 58 ±12.5 years and 40% were females. The mean EF was 63% ± 6% and 92% had compensated LV function (EF>60% and LVESD2 ). The median LV mechanical dispersion was 40msec (IQR 30.7-56.5) but increased significantly with ventricular ectopy (65msec, P Conclusions: Left ventricular dyssynchrony manifested by increased mechanical dispersion and imbalanced interpapillary mechanics are observed prior to overt chamber remodeling in significant degenerative MR and is associated with ventricular ectopy. Further studies are needed to assess the related clinical implications and potential impact on risk stratification in this patient group.

IMPORTANCE: Myocardial replacement fibrosis has been reported to occur in one-third of patients with mitral valve prolapse (MVP) and significant mitral regurgitation (MR). However, it remains unknown whether there are detectable changes in myocardial metabolism suggestive of inflammation or ischemia that accompany the development of fibrosis. OBJECTIVES: To characterize the burden and distribution of fluorine 18–labeled ((18)F) fluorodeoxyglucose (FDG) uptake and late gadolinium enhancement (LGE) in patients with degenerative MVP and ventricular ectopy. DESIGN, SETTING, AND PARTICIPANTS: Prospective observational study of 20 patients with MVP and significant primary degenerative MR who were referred for mitral valve repair and underwent hybrid positron emission tomography/magnetic resonance imaging (PET/MRI). Ventricular arrhythmias were categorized as either complex (n = 12) or minor (n = 8). Coregistered hybrid (18)F FDG-PET and MRI LGE images were assessed and categorized. Recruitment occurred in the new patient clinic of a mitral valve repair reference center. This study was conducted from January 11, 2018, to June 26, 2019. EXPOSURES: Simultaneous cardiac (18)F FDG-PET and MRI with LGE imaging on a hybrid PET/MRI system and ambulatory rhythm monitoring. MAIN OUTCOMES AND MEASURES: Patients were categorized by the presence and pattern of FDG uptake and LGE, the severity of ventricular arrhythmias, and the indication for mitral valve surgery. RESULTS: In the cohort of 20 patients, the median age was 59.5 years (interquartile range, 52.5-63.2 years). Focal, or focal-on-diffuse uptake, of (18)F-FDG (PET positive) was detected in 17 of 20 patients (85%). The FDG uptake coexisted with areas of LGE (PET/MRI positive) in 14 patients (70%). Of the 5 asymptomatic patients with normal ventricular indices and absence of any surgical indications, all were PET/MRI positive. CONCLUSIONS AND RELEVANCE: In this pilot study, we demonstrate a novel association between degenerative MVP and FDG uptake, a surrogate for myocardial inflammation and/or ischemia. Such evidence of myocardial injury, even in asymptomatic patients, suggests an ongoing subclinical disease process. These findings warrant further investigation into whether imaging for myocardial inflammation, ischemia, and scar has a role in arrhythmic risk stratification and whether it provides incremental prognostic value in patients with chronic severe mitral regurgitation undergoing active surveillance.

Background The durability of mitral valve repair (MVr) is usually defined by the absence of recurrent significant mitral regurgitation. Postrepair mitral stenosis (MS) is a less frequent and less studied mode of failure of MVr. We analyzed our experience in patients who underwent reoperation for postrepair MS to characterize mechanisms resulting in MS and to summarize reoperative surgical strategies and mid-term outcomes. Methods Using a prospective database, we retrospectively analyzed data on 35 consecutive patients who underwent reoperation for symptomatic moderate to severe MS between January 1, 2011, and February 1, 2020. Results The mean patient age was 61.4 ± 11.4 years, and 69% were female. The median annuloplasty ring size used at the initial repair was 28 mm (interquartile range, 26-30 mm). Additional repair techniques at the initial operation included leaflet resection in 12 patients (34%) and commissuroplasty or edge-to-edge repair in 6 patients (18%). At reoperation, the most common mechanism of MS was pannus ingrowth in 20 patients (57%), leaflet calcification in 12 (34%), commissural fusion in 5 (14%), and tunnel effect (functional MS) in 3 (9%). Twenty-two patients (63%) underwent valve replacement, and 13 (37%) underwent valve re-repair. In patients who underwent re-repair, annuloplasty revision was performed in all patients, with 6 patients (46%) converted from complete ring to band, 4 (11%) converted from ring to pericardial annuloplasty, 2 (6%) converted to no annuloplasty, and 1 (8%) with annuloplasty ring upsizing. There were no in-hospital or 1-year mortalities. Survival at the 5-year follow-up was 93.9%. Conclusions MS causing late failure of MVr is frequently associated with smaller ring sizes and inflammatory or calcific changes in the valve. Highly selected patients may be good candidates for mitral valve re-repair.

Alternatives to traditional aortic valve replacement now form part of the valve surgeon's armamentarium. Sutureless valves offer decreased bypass and crossclamp times, excellent maneuverability, and promising outcomes. We present a case of a sutureless aortic valve replacement for a late failed David procedure, complicated by post-operative development of severe paravalvular regurgitation. We attempted off-label balloon post-dilation to improve expansion of the valve, however paravalvular regurgitation persisted. The patient underwent subsequent aortic valve replacement using a mechanical valve and experienced no further paravalvular leak.

Purpose of review The aim of the article is to discuss different therapeutic options for patients with severe mitral valve dysfunction because of mitral annular calcification (MAC), including mitral valve repair, conventional mitral valve replacement, percutaneous transcatheter mitral valve replacement (TMVR), and hybrid procedures. Recent findings Optimal management of severe mitral valve disease because of MAC remains challenging. Various 'resect' or 'respect' repair strategies have been standardized and are applicable in eligible patients. Mitral valve replacement with a standard surgical bioprosthesis is often possible in nonrepair candidates, especially with noncircumferential MAC. TMVR has evolved as a feasible option for anatomically and/or clinically prohibitive open-surgery cases, with the caveat of strict anatomic eligibility criteria. Hybrid TMVR provides the advantages of both open-surgery and TMVR and has emerged as a promising alternative in select patients. Summary Surgical management of MAC and severe mitral valve disease continues to evolve. The addition of transcatheter valve options may benefit many patients previously considered inoperable and are now candidates for intervention. This review will summarize state-of-the-art management options for patients with MAC.

Despite the proven superiority of mitral repair over replacement for degenerative mitral disease, mitral valve replacement remains common. Guidelines now recommend referral of patients, particularly those whom are asymptomatic, to valve centers of excellence, although criteria that define such centers remain to be established. The purpose of this review is to define the structure of a mitral center of excellence and to review current clinical outcomes which are possible in such a center.Recently, American College of Cardiology/American Heart Association as well as the European Society of Cardiology/European Association of Cardiothoracic Surgery guidelines define mitral centers of excellence as either centers in which the likelihood of successful and durable repair exceeds 95% and with an operative mortality risk of less than 1% (American College of Cardiology/American Heart Association definition) or centers with high repair rates, low operative mortality, and a record of durable results (European Society of Cardiology/European Association of Cardiothoracic Surgery definition). There is however less clarity about the structure and function of a center that achieves these outcomes.The importance of centers of excellence in mitral valve surgery are now well recognized, and this review will highlight the key components and outcomes of an established mitral valve reference center.

Graphical abstract, Highlights • Left ventricular thrombi (LVT) formation is associated with impaired LVEF. • LVT are extremely rare among patients with normal ejection fraction. • LVT may be clinically silent but may also present with embolization. • Cardiac magnetic resonance is the gold standard noninvasive test to diagnose LVT. • Large LVT are preferably treated with surgical excision.

Degenerative mitral valve repair rates remain highly variable, despite established benefits of repair over replacement. The contribution of surgeon-specific factors is poorly defined.This study evaluated the influence of surgeon case volume on degenerative mitral valve repair rates and outcomes.A mandatory New York State database was queried and 5,475 patients were identified with degenerative mitral disease who underwent mitral valve operations between 2002 and 2013. Mitral repair rates, mitral reoperations within 12 months of repair, and survival were analyzed using multivariable Cox modeling and restricted cubic spline function.Median annual surgeon volume of any mitral operations was 10 (range 1 to 230), with a mean repair rate of 55% (n = 20,797 of 38,128). In the subgroup of patients with degenerative disease, the mean repair rate was 67% (n = 3,660 of 5,475), with a range of 0% to 100%. Mean repair rates ranged from 48% (n = 179 of 370) for surgeons with total annual volumes of ≤10 mitral operations to 77% (n = 1,710 of 2,216) for surgeons with total annual volumes of 50 mitral operations (p 0.001). Higher total annual surgeon volume was associated with increased repair rates of degenerative mitral valve disease (adjusted odds ratio [OR]: 1.13 for every additional 10 mitral operations; 95% confidence interval [CI]: 1.10 to 1.17; p 0.001); a steady decrease in reoperation risk until 25 total mitral operations annually; and improved 1-year survival (adjusted hazard ratio: 0.95 for every additional 10 operations; 95% CI: 0.92 to 0.98; p = 0.001). For surgeons with a total annual volume of ≤25 mitral operations, repair rates were higher (63.8%; n = 180 of 282) if they operated in the same institution as a surgeon with total annual mitral volumes of 50 and degenerative mitral valve repair rates of 70%, compared with surgeons operating in the other institutions (51.3%; n = 580 of 1,130) (adjusted OR: 1.79; 95% CI: 1.24 to 2.60; p 0.001).This study suggests that individual surgeon volume is a determinant of not only mitral repair rates, but also freedom from reoperation, and survival. The data from this study support the guideline's concept of reference referral to experienced mitral surgeons to improve outcomes in patients with degenerative mitral valve disease.

Tricuspid valve disease has received much less attention in terms of intervention. The main reason for this is the widely held belief that treatment of left-sided valve disease leads to resolution of functional tricuspid regurgitation. Recent data show that tricuspid regurgitation is not benign and that many patients will benefit from intervention at the time of left-sided valve surgery, or in isolated tricuspid disease. This review describes the latest surgical and interventional options and strategies.Latest valve guidelines now recommend a more aggressive surgical approach to the treatment of moderate or severe tricuspid regurgitation, with annuloplasty being the preferred technique. Guidelines now also promote treatment of isolated significant tricuspid dilatation even without significant regurgitation, as a prophylactic strategy to prevent disease progression. This renewed interest in surgical repair has been accompanied by development of newer tricuspid annuloplasty rings. For patients in whom surgery would be high risk, transcatheter therapies are emerging as a promising alternative. Various repair devices have reported early experience.Recent surgical and transcatheter innovations in the treatment of tricuspid valve disease are promising and have the potential of removing the stigma of the tricuspid valve as the 'forgotten valve'.

Objectives Residual mitral regurgitation reduces the efficacy of mitral repair and is associated with worse outcomes. We adopted a policy using a second bypass run for patients with residual mitral regurgitation (>+1) and described our decision-making algorithm and outcomes. Methods From January 1, 2011, to December 31, 2016, 40 patients with degenerative disease underwent a second bypass run to address residual mitral regurgitation. The echocardiographic criteria for a second bypass run was the presence of moderate or greater mitral regurgitation or mild mitral regurgitation with unfavorable mechanism. Results A second bypass run was used in 40 patients. The mean age was 57.3 ± 13.5 years (21-79 years), and 14 patients (35%) were asymptomatic. Residual mitral regurgitation was mild in 25 patients, moderate in 9 patients, and moderate/severe in 6 patients. The cause of postbypass mitral regurgitation was technical or residual pathology in 35 patients and systolic anterior motion in 5 patients. Re-repair techniques were cleft closure in 22 patients, primary suture repair in 13 patients, and expanded polytetrafluoroethylene chordoplasty in 9 patients. After re-repair, 34 patients (85%) had no mitral regurgitation, 4 patients (10%) had trace mitral regurgitation, and 2 patients (5%) had mild mitral regurgitation. Median total cardiopulmonary bypass time was 208.5 minutes, first crossclamp time was 106 minutes, and second crossclamp time was 34 ± 12 minutes. Median intensive care stay was 2 days, and hospital stay was 8 days. On discharge, there was no mitral regurgitation in 13 patients (33%), trace in 23 patients (58%), and mild mitral regurgitation in 4 patients (10%). Freedom from moderate or greater mitral regurgitation at 5 years was 100%. Conclusions Residual mitral regurgitation can be effectively treated using a second bypass run with good long-term outcome and minimal incremental risk.

Surgical mitral valve replacement (SMVR) in severe mitral annular calcification (MAC) remains a challenge. Transcatheter mitral valve replacement (TMVR) is an emerging alternative in higher risk patients with appropriate valve anatomy. PubMed, Embase, and Cochrane Register were searched for studies

The tricuspid valve has historically received less attention than any other cardiac valve with regard to pathophysiology and surgical management. The tricuspid valve is part of a complex functional apparatus that includes the right atrium, right ventricle, and pulmonary circulation. Functional tricuspid regurgitation is the most common tricuspid valve disease and it occurs secondary to dilatation of tricuspid annulus and/or tethering of valve leaflets from right ventricular dilatation and dysfunction. However, recent expansion in the use of right-sided transvenous devices such as pacemakers and implantable defibrillators has been met with a parallel increase in the risk of organic tricuspid disease. Recent data suggest that tricuspid regurgitation is not benign, and many patients will benefit from intervention at the time of left-sided valve surgery, or early in isolated tricuspid valve disease. This review describes the various surgical options and strategies in the treatment of common tricuspid valve diseases. Current American and European guidelines advocate for a more proactive surgical approach in the treatment of tricuspid regurgitation and/or annular dilatation at the time of left-sided valve surgery. Tricuspid annuloplasty is the preferred technique given its superior long-term outcomes. This renewed interest in surgical repair has been ushered by the development of a newer generation of tricuspid annuloplasty rings, as well as technological strides in transcatheter therapies which now extend to include tricuspid pathologies in otherwise inoperable patients with advanced tricuspid disease and cardiomyopathy. Tricuspid disease is not a benign entity. An aggressive approach to surgical management as well as prophylactic interventions are becoming more widely adopted. Aggressive tricuspid surgery however, remains an area of controversy in cardiac surgery, although surgical repair remains the gold standard for functional tricuspid regurgitation with replacement reserved for advanced or organic tricuspid disease. Transcatheter therapy is primarily directed toward non-surgical patients and is not included in this review.

Objective This study sought to determine if 3-dimensional (3D) echocardiography would more closely correspond to direct surgical measurements of the maximal tricuspid valve (TV) annular diameter than 2-dimensional (2D) measurements. Design Prospective study. Setting The cardiothoracic operating rooms (ORs) at Mount Sinai Medical Center in New York, NY. Participants Fifty-nine patients over 18 years of age underwent elective mitral valve surgery for severe mitral regurgitation from 2014 to 2015. Interventions None. Measurements and Main Results Two-dimensional and 3D data sets and surgical TV annular dimensions were measured. Bland-Altman analysis was conducted and absolute differences were compared using paired t tests and the McNemar test. The observed mean difference between the 2D measurements by transgastric right ventricular diastolic view and the surgical measurements was 0.21 cm (standard deviation [SD] = 0.36 cm); the mean difference between the 3D measurements and surgical measures was -0.03 cm (SD = 0.19 cm). The McNemar test showed that the rate of highly successful measurements, defined as those within 0.2 cm of the true surgical score, using the 3D technique (66%) was significantly better than the rate of highly successful measurements using the 2D technique (25%), p Conclusion Three-dimensional imaging and measurement of the TV annular diameter is feasible in the OR setting. The superiority of the 3D measurements versus 2D measurements allows for greater precision and accuracy and may guide better intraoperative surgical decision-making.

We present a novel approach characterizing mitral annular calcification(MAC) to determine feasibility of transcatheter mitral valve replacement(TMVR). 28 patients from 1/2017 to 9/2018 underwent 3Mensio CT imaging software analysis to evaluate MAC for TMVR candidacy. Mitral valve variables included

A 47-year-old woman with a mechanical mitral valve underwent a catheter-based atrial fibrillation ablation procedure, which was complicated by the dislodgment and immediate embolization of one of the valve leaflets. Acute severe mitral regurgitation and cardiogenic shock developed, necessitating emergency reoperative mitral valve re-replacement. She subsequently underwent a successful staged retrieval of the embolized leaflet from the abdominal aorta.

OBJECTIVE: Although mitral valve repair is the preferred treatment for degenerative mitral valve disease, valve replacement still remains prevalent, particularly in the setting of anterior leaflet prolapse. We sought to determine the feasibility and mid-term durability of a lesion-based surgical strategy applied systematically in a consecutive and nonexclusionary (all comers) series of patients with degenerative mitral valve disease and either isolated anterior leaflet or bileaflet prolapse. METHODS: From January 2002 to December 2010, 188 consecutive patients [mean age 56 ± 14 years (range 12–86), 31% female, mean left ventricular ejection fraction 55 ± 9%] underwent surgery for degenerative anterior mitral leaflet prolapse [isolated (n= 42, 22%) or bileaflet prolapse (n= 146, 78%)]. Degenerative aetiology was Barlow’s disease in 110 (58%) patients and fibroelastic deficiency in 78 (42%). RESULTS: Patients with anterior leaflet prolapse were significantly more symptomatic (New York Heart Association functional Class III–IV) than those with bileaflet prolapse (28.6 vs 9.6%; P= 0.003) at the time of surgery. All patients underwent mitral valve repair and ring annuloplasty. There was 1 immediate valve replacement due to atrioventricular groove bleeding and consequent haematoma in an elderly female patient (99.5% repair rate). Predominant repair techniques were polytetrafluoroethylene neochordoplasty (or loop technique) in 93 (49%) patients, chordal transfer in 86 (46%) and posterior leaflet flip technique in 21 (11%). Median length of stay was 6 (interquartile 5–8) days. In-hospital mortality was 1% (n= 2). Predischarge transthoracic echocardiography showed none to trace mitral regurgitation in 91% of the patients and mild mitral regurgitation in 9%. The Kaplan–Meier estimates for cumulative survival at 1 and 7 years were 98.4 ± 0.9 and 88.7 ± 2.2%, respectively. Freedom from ≥moderate mitral regurgitation was 100% at 1 year, 93.7 ± 2.2% at 4 years and 90.3 ± 3.7% at 7 years. When the interval-censored estimator was used, freedom from ≥moderate mitral regurgitation at 1, 4 and 7 years was 100, 96 and 92%, respectively. CONCLUSION: A lesion-based surgical approach with an intention to repair all degenerative valves with anterior leaflet prolapse was applied to a consecutive series of patients with degenerative mitral valve disease. We were able to achieve a near-100% repair rate. Repair of all degenerative valves may be feasible with good mid-term durability, regardless of valve morphology, patient age or comorbidities.

Unroofed coronary sinus (UCS) is a rare cardiac anomaly that results in communication between the coronary sinus and the left atrium. We described an unusual presentation of UCS in a 48-year-old female that was not corrected during an initial secundum ASD repair 22 years ago.

We report the use of a right axillary skin incision to institute a ventricle assist device support in a two-year-old 14 kg male with fulminant myocarditis. The ease of conversion to a long-term support, avoidance of a sternotomy, and a less visible incision made this approach an attractive option in this group of sick patients. doi: 10.1111/jocs.12342 (J Card Surg 2014;29:581–583)

Orthotopic heart transplantation (OHT) has evolved as the “gold standard” therapy for end stage cardiomyopathy, Advances in the fields of immunosuppression, infection prophylaxis and treatment, surgical techniques as well as intensice care management have transformed heart transplantation from what was once considered an experimental intervention into a standard therapy. This chapter focuses on the standard care for OHT including surgical techniques, perioperative management and management of common postoperative complications.

To develop a score to allow stratification of complexity in degenerative mitral valve repair.Retrospective modeling of data from 668 consecutive patients who underwent surgery for mitral valve prolapse. A complexity scoring scale was developed using a consensus approach, assigning a score to each valve, based on the following: prolapsing segments (weight 1 for each posterior segment; weight 2 for each anterior or commissural segment); presence of valve restriction (weight 2); presence of calcification (weight 3 if annulus involved, otherwise weight 2); and prior mitral valve repair (weight 3). Valve repairs were categorized into 3 groups based on the complexity score: 1: Simple (n = 244); 2-4: Intermediate (n = 260); ≥5: Complex (n = 164).Mitral valve repair was successfully performed in 667 patients (repair rate: 99.9%). The complexity score was directly correlated with surrogates of technical complexity. The mean cardiopulmonary bypass time increased with lesion complexity ([in minutes] simple: 152; intermediate: 167; complex 195; P .001). The median number of repair techniques utilized was related to lesion complexity (simple: 3; intermediate: 4; complex: 5; P .001). Barlow's type etiology was more prevalent in complex cases (63%), compared with simple (9%) and intermediate (35%) cases (P .001). Advanced repair techniques were required to complete repair in 51% of complex cases, compared with 14% of intermediate and 0% of simple cases (P .001). Early and late outcomes were similar.Our scoring system may allow effective stratification of complexity of mitral valve repair. Future studies are required to evaluate the use of our score in a prospective setting.

From the *Department of Cardiothoracic Anesthesiology, Mount Sinai Hospital, New York, NY, †Department of Anesthesiology, Morton Plant Mease Healthcare, Clearwater, FL; and ‡Department of Cardiothoracic Surgery, Mount Sinai Hospital, New York, NY. Address reprint requests to Amanda J. Rhee, One Gustave L. Levy Place, Department of Anesthesiology, New York, NY 10029. E-mail: amanda.rhee@mountsinai.org © 2015 Elsevier Inc. All rights reserved. 1053-0770/2602-0033$36.00/0 http://dx.doi.org/10.1053/j.jvca.2015.04.029

Consensus guidelines recommend repair over replacement for the surgical treatment of active native mitral valve infective endocarditis. However, contemporary practice and long-term outcome data are limited.Multivariable Cox regression was used to compare outcomes of 1970 patients undergoing isolated primary mitral valve repair (n = 367, 19%) or replacement (n = 1603, 81%) for active infective endocarditis between 1998 and 2010 in New York and California states. The primary outcome was long-term survival. Secondary outcomes were recurrent endocarditis and mitral reoperation. Median follow-up time was 6.6 years (range 0-12), and last follow-up date was December 31, 2015.Mitral valve repair rates increased from 10.7% to 19.4% over the study period (P .001). Patients undergoing mitral repair were younger (55 ± 15 vs 57 ± 15 years, P = .005), less likely to have congestive heart failure (46.3% vs 57.1%, P .001), and less likely to have staphylococcal infections (21.3% vs 32.0%, P .001). Twelve-year survival was 68.8% (95% confidence interval [CI], 62.5%-74.3%) after mitral repair, versus 53.5% (95% CI, 50.6%-56.4%) after replacement (adjusted hazard ratio, 0.71; 95% CI, 0.57-0.88; P = .002). Mitral repair was associated with lower rate of recurrent endocarditis at 12 years than replacement (4.7% [95% CI, 2.8%-7.2%] vs 9.5% [95% CI, 8.0-11.1%]; P = .03), and similar rate of reoperation (9.1% [95% CI, 6.2%-12.8%] vs 8.6% [95% CI, 7.1%-10.4%]; P = .12).In active endocarditis, mitral valve repair is associated with better survival and lower risk of recurrent infection compared with valve replacement and should be the surgery of choice when feasible.