The “Physio-Ring”: an advanced concept in mitral valve annuloplasty (original) (raw)
Related papers
No ring at all in mitral valve repair: indications, techniques and long-term outcome
European Journal of Cardio-Thoracic Surgery, 2013
OBJECTIVES: In mitral valve (MV) repair, we adhere to a biological concept of preservation of the native valves and avoidance of any prosthetic materials except for sutures whenever possible. Untreated autologous pericardium is the biological tissue of choice we use to support the repair. We report our 25-year institutional experience with no-ring MV repair in terms of indications, repair techniques and long-term results. METHODS: Patients with ruptured chordae or posterior leaflet prolapse from degenerative MV disease, active infective endocarditis (IE), ischaemic mitral incompetence (IMI), annular dilatation with or without ruptured chordae along the posterior leaflet, and various lesions of the MV and its subvalvar apparatus underwent suture-repair techniques tailored to their valve morphology. These are personal series of modified Gerbode-Hetzer posterior leaflet plication and modified Paneth-Hetzer posterior annulus shortening techniques. Indications for the use of each technique and technical details are described in this report. RESULTS: Modified Gerbode-Hetzer posterior leaflet plication: mean duration of the follow-up is 15.84 ± 0.58 years. Overall freedoms from reoperation and cumulative survival rate are 55.4 ± 4.7 and 44.7 ± 5.4%, respectively. Freedom from reoperation is 83.5 ± 4.3%, in ruptured chordae from degenerative disease (n = 161), 74.4 ± 10.1% in active infectious endocarditis (IE) (n = 22) and 100% from both ruptured chordae of ischaemic origin (n = 10) and deceleration trauma (n = 1), respectively. Likewise, freedoms from reoperation at a mean duration of the follow-up of 11.2 ± 7.2 years in 62 children stratified based on age groups are: <3 months: 61.4 ± 2.7%; 3 months to 2 years: 78.7 ± 3.7%; 2-18 years: 97.1 ± 2.4%. Modified Paneth-Hetzer posterior annulus shortening: Mean duration of the follow-up is 11.98 ± 1.14 years. Overall freedoms from reoperation and cumulative survival rate in 179 patients are 82.95 ± 4.1 and 63.4 ± 8.5%, respectively. Freedom from reoperation is 85.9 ± 13.9% in patients with annular dilatation from any form of cardiomyopathy (n = 81), 78.4 ± 5.6% in those with IMI (n = 75) and 100% in those who underwent asymmetric valve repair (n = 23). In IMI, mean New York Heart Association functional class, ejection fraction and degree of mitral incompetence (MI) were significantly abated (P = 0.001). In 78 children, freedoms from reoperation at a mean duration of the follow-up of 11.2 ± 7.2 years stratified based on age groups are as follows: <3 months: 82.79 ± 3.5%; 3 months to 2 years: 71.6 ± 5.3%; 2-18 years: 85.1 ± 4.4%. CONCLUSIONS: No-ring MV repair using the aforementioned techniques in patients with MI resulting from chordal rupture, degenerative valve disease, IE, annular dilatation and posterior leaflet prolapse and from IMI as well as various MV lesions in children offers excellent long-term functional results with satisfactory freedom from reoperation.
Midterm Outcomes Using the Physio Ring in Mitral Valve Reconstruction: Experience in 492 Patients
The Annals of Thoracic Surgery, 2005
Background. Mitral valve reconstruction using standardized Carpentier techniques is the treatment of choice for most patients with regurgitant lesions. Demonstrated predictability and stability make it an attractive alternative to valve replacement. The Physio Ring's inherent flexibility provides a viable alternative in the application of remodeling techniques and appears to be physiologically superior to traditional approaches.
Midterm Results of Mitral Valve Repair: Closed Versus Open Annuloplasty Ring
Annals of Thoracic Surgery, 2010
Background. Closed and open annuloplasty rings are both used for mitral valve repair. This study compared the clinical and echocardiographic results in patients with degenerative mitral disease undergoing MV repair with closed semirigid rings vs open bands. Methods. Between 2004 and 2008, 377 patients (mean age, 59 ؎ 12 years) underwent mitral valve repair. Valve pathology was degenerative in 273 (72%). Closed rings were used in 163 (60%) and open rings in 110 (40%). Patients had similar characteristics and comorbidities. In addition to annuloplasty, repair techniques included leaflet resection (48% and 77%, p < 0.01), artificial chordal (55% and 36%, p < 0.01), and edge-to-edge repair (4% and 4%, p ؍ 0.79), in closed and open groups, respectively. Results. One patient in each group died (0.7%). Mean follow-up was 19 ؎ 14 (closed group) and 34 ؎ 15 months (open group; p < 0.01). Freedom from reoperation was 97.5% (closed group) vs 96.5% (open group). At followup, New York Heart Association functional class was similar between groups, and 91% in the closed group and 84% in the open group were free from moderate or severe mitral regurgitation (p ؍ 0.05). Closed group patients had a longer line of leaflet coaptation (9.1 ؎ 2.7 mm) vs the open group (7.1 ؎ 1.9 mm; p < 0.01). Conclusions. Patients with closed semirigid annuloplasty rings demonstrated significantly longer lines of leaflet coaptation and tendency toward better echocardiographic midterm results than patients with open bands and may, therefore, benefit from improved repair durability. (Ann Thorac Surg 2010;90:489 -96)
Melody Valve-in-Ring Procedure for Mitral Valve Replacement: Feasibility in Four Annuloplasty Types
The Annals of Thoracic Surgery, 2012
Background-The recurrence of regurgitation following surgical mitral valve (MV) repair remains a significant clinical problem. Mitral annuloplasty rings are commonly used in MV repair procedures. The purpose of this study was to demonstrate the feasibility of transvenous valve-inring (VIR) implantation using the Melody® valve, which is a valved-stent designed for percutaneous pulmonary valve replacement, and 4 distinct types of annuloplasty ring (AR) in an ovine model.
Ring-first Mitral Valve Repair
Research Ideas and Outcomes, 2020
Mitral valve repair is one of the most frequent interventions in cardiac surgery. It involves eliminating the dysfunctional part(s) of the mitral valve and reconstructing, using the residual tissue or with the addition of prosthetic components, a properly functioning valve, without residual stenosis or regurgitation. A fundamental component of mitral repair is the implantation of a ring (annuloplasty) which reconstitutes the normal, saddle-shaped geometry of the valve. Such ring is usually implanted at the end of the surgical reconstruction regardless of the repair techniques. The implantation of the ring can however change the final anatomy of the valve in an unexpected way and therefore force new corrective surgical actions. We therefore propose a research project that plans the execution of annuloplasty as the first surgical step and then the correction of the valvular disease affecting the leaflets and chordae. The sizing of the ring is always performed on parts of the valve tha...
Journal of Thoracic Disease, 2019
Background: Restrictive mitral annuloplasty is the mainstay of surgical correction of chronic ischaemic mitral regurgitation (CIMR). Long-term data on the various types of annuloplasty rings is limited. The aim of this study was to investigate the clinical and echocardiographic outcomes of restrictive mitral annuloplasty in patients with CIMR, comparing the use of flexible versus semi-rigid annuloplasty rings. Methods: A retrospective review was conducted for 133 patients with CIMR who underwent restrictive mitral annuloplasty at our institution between 1999 and 2015. Patient demographics and postoperative outcomes were analyzed. Results: Mean age was 61.9±9.2 years and 103 patients (77.4%) were male. All patients underwent coronary artery bypass grafting, with a mean of 3.3±0.8 grafts. Flexible rings was implanted in 39 patients (29.3%, group F) and semi-rigid rings in 94 (70.7%, group R). Preoperative New York Heart Association class was III/IV in 104 patients (78.2%). Mean preoperative left ventricular ejection fraction was 28.8%±10.2%. Preoperative mitral regurgitation was moderate in 51 patients (38.3%) and severe in 82 (61.7%). In-hospital mortality occurred in 11 patients (8.3%). Overall survival at 1, 5 and 10 years were, respectively, 86.4%, 69.7% and 45.9%. At 10 years, overall survival (group F 53.1%, group R 40.0%, P=0.330) and freedom from moderate to severe MR (group F 53.1%, group R 53.8%, P=0.725) did not differ significantly. Freedom from hospitalization for heart failure was 59.3%. Left ventricular reverse remodelling, defined as a reduction of left ventricular end-systolic volume index >15%, occurred more commonly in Group R (51.1%) compared to Group F (23.1%), P=0.003. Conclusions: Restrictive mitral annuloplasty was associated with an operative mortality of 8.3%. Heart failure symptoms and significant MR recur in approximately 40% of patients after 10 years. Survival remained suboptimal and was not influenced by the type of annuloplasty ring.
Transcatheter valve-in-ring implantation after failure of surgical mitral repair
European Journal of Cardio-Thoracic Surgery, 2013
OBJECTIVES: Redo surgery after failed mitral valve repair may be high risk, or contraindicated in patients with comorbidities. Because of this high risk, other interventional possibilities like transcatheter valve implantation might be of benefit. We report our experience with transcatheter mitral valve-in-ring implantation (TVIR) in high-risk patients after failure of surgical ring annuloplasty. METHODS: From January 2010 to February 2012, following a multidisciplinary discussion, 17 high-risk patients underwent TVIR using Edwards SAPIEN XT prostheses, via either a transvenous transseptal (n = 8), or a transapical approach (n = 9). RESULTS: Patients were aged 70 ± 16 years, in New York Association classes III/IV. Their mean logistic EuroSCORE was 36 ± 17% and mean Society of Thoracic Surgeons risk score 13 ± 9%. The mean time interval between surgery and repair failure was 7 ± 3 years. Annuloplasty rings were semi-rigid in 14 cases, flexible in 2, and rigid in 1. Manufacturers ring diameters were 26 mm in 4 patients, 27 mm in 1, 28 mm in 9, 30 mm, 31 mm and 34 mm in 1. The predominant failure mode was regurgitation in 12 cases and stenosis in 5. SAPIEN XT diameters were 26 mm in 15 patients, 23 mm and 29 mm in 1. Procedural success rate was 88% (15/17). Emergency surgery was needed in 1 patient due to acute dislodgement of the ring. The degree of mitral regurgitation was reduced to none or mild in all but 2 patients; final mean gradient was 7 ± 3 mmHg. Thirty-day survival was 82% (14/17 patients). At last follow-up (13 ± 5 months), survival rate was 71% (12/17). CONCLUSIONS: These preliminary results suggest that TVIR is feasible, with low operative risk, and may provide short-term clinical and haemodynamic improvement in selected high-risk patients with failure of mitral ring annuloplasty.
Several new considerations in mitral valve repair
The Journal of Heart Valve Disease, 2004
Background and aim of the study: A retrospective evaluation was made of a small personal series of patients undergoing mitral valve repair in order to address four contemporary questions: (i) What is the best method of achieving a stable repair in mitral valve prolapse?; (ii) How should patients with pure annular dilatation without prolapse or antecedent ischemia be categorized?; (iii) Are valve procedures in ischemic mitral regurgitation (MR) still associated with less satisfactory early and late outcomes?; and (iv) Is prophylactic amiodarone therapy safe and effective in reducing postoperative arrhythmias? Methods: Between 1993 and 2002, a total of 118 patients with non-rheumatic MR undergoing isolated mitral valve repair with or without coronary bypass was analyzed retrospectively: of these patients, 66 had prolapse (Group I), 21 had pure annular dilatation (Group II), and 31 had ischemic MR (Group III). All three groups routinely underwent Carpentier ring annuloplasty. Twenty-three patients in Group I were managed with leaflet resection and reconstruction (LRR), but in 1996 the technique for Group I was changed to uniform artificial chordal replacement (ACR) and no leaflet resection (n = 43). Also in 1996, prophylactic amiodarone therapy was first used routinely, and postoperative arrhythmia data were compared to those from prior patients. Baseline and outcome variables were assessed for each group and compared between the three groups. Survival data were evaluated using the Cox proportional hazards model. Results: Significant differences in baseline characteristics were observed: Group II was predominantly female; Group III more often experienced acute presentation; and Groups II and III had more comorbid disorders and left ventricular dysfunction (all p < 0.01). ACR was highly successful for repair of prolapse, and no ACR patient exhibited significant residual MR or outflow tract obstruction. Operative mortality and morbidity were low in all groups, and ischemic etiology failed to be an independent predictor of early or late adverse outcome (p > 0.10). Cox model analysis to nine years of follow up (median 4 years) identified only advanced age and number of comorbidities as influencing late mortality (both p < 0.03). Over the follow up period, 8.7% of LRR patients required reoperation for valve failure due to late chordal rupture, whereas none of the ACR patients failed. Finally, prophylactic amiodarone significantly reduced postoperative arrhythmias (p = 0.03) with no observed complications, and also eliminated death due to arrhythmia. Conclusion: Ischemic etiology may be diminishing as an independent risk factor in Group III, at least partially because of uniform valve repair. Group II comprised a distinct entity of females with higher comorbidity, and prophylactic amiodarone therapy seemed useful as a routine measure. Finally, ACR appeared to produce a stable repair in virtually all Group I patients, suggesting that prolapse might be appropriately managed with ring annuloplasty and uniform ACR. However, future studies are suggested for further consideration of these hypotheses.
Pakistan Journal of Medical Sciences, 2012
Objective: To examine the mid-term results of patients on whom a coronary revascularization as well as a mitral ring and suture annuloplasty have been performed due to coronary artery disease (CAD) and ischaemic mitral regurgitation (IMR). Methodology: Totally 73 patients on whom a revascularization and a mitral valve repair due to CAD and IMR had been performed in our clinic between 2000-2008 were included in the study. Patients were divided into two groups one of which included 38 patients (52.05%) on whom a coronary artery bypass graft (CABG) and a ring annuloplasty on the mitral valve had been performed (Group 1) and the other one 35 patients (47.95%) on whom only suture annuloplasty as well as a CABG had been performed (Group 2). The study was planned retrospectively and study data have been obtained by screening the hospital registries retrospectively. In the mid-term, patients were invited for a check and their intragroup and intergroup echocardiographic parameters and functional capacities were assessed statistically. Results: In pre-operational and post-operational intragroup assessment in terms of echocardiographic findings; although LVEDD, LVESD, EDV, PAP and the degree of recurrent MR have been decreased in both groups, the decrease in LVESD and PAP and the low degree of recurrent MR were statistically significant in Group 1 patients (p=0.047, p=0.023, p=0.01, respectively). When the mid-term intergroup echocardiograpic findings were assessed; PAP and recurrent MR have been determined statistically lower in Group 1 patients (p=0.005, p=0.08, respectively). The length of intensive care unit stay, length of hospitalization and length of detachment from respiratory support were statistically significantly longer in ring annuloplasty performed group (p=0.012, p=0.033, p=0.029, respectively). Conclusions: In moderate to severe IMR patients, a positive contribution can be provided to ventricular remodeling by a ring annuloplasty through a significant decrease in left ventricular diameter and a low recurrent MR and PAP.