Objective To compare the clinical outcomes and safety of minimally invasive and routine mitral valve repair or replacement for patients with single mitral valve disease. Methods We retrospectively analyzed the clinical data of 67 patients with single mitral valve disease （without aortic valve and tricuspid valve lesion or other heart diseases including atrial septal defect） who underwent mitral valve repair or replacement in the First Affiliated Hospital of China Medical University between January and July 2011. The patients were divided into two groups according to different surgical approaches：the minimally invasive surgery group （n=29，8 males and 21 females，age 51.4±9.4 years） underwent minimally invasive mitral valve repair or replacement via right mini-thoractomy；and the routine surgery group （n=38，11 males and 27 females，age 53.6±11.9 years） underwent mitral valve repair or replacement via middle sternotomy. In the minimally invasive surgery group，9 patients underwent mitral valve repair while the other 20 patients underwent mitral valve replacement. And no patient underwent transition to routine operation. In the routine surgery group，15 patients underwent mitral valve repair and 23 patients underwent mitral valve replacement. Clinical outcomes and safety of the operations were compared between the two groups. Results There was no statistical difference in operation time between the two groups （207.9±18.1 min versus 198.4±27.5 min，P=0.076）. The amount of postoperative drainage （126.7±34.5 ml versus 435.6±87.2 ml，P=0.000） and blood transfusion （red blood cell 1.4±0.8 U versus 2.3±1.1 U，P=0.000；blood plasma 164.3±50.4 ml versus 405.6±68.9 ml，P=0.000） of the minimally invasive surgery group were significantly lower than those of the routine surgery group. The cardiopulmonary bypass time （81.7±23.9 min versus 58.7±13.6 min，P=0.000） and aortic-clamping time （51.6±12.7 min versus 38.4±11.7 min，P=0.000） of the minimally invasive surgery group were significantly longer than those of the routine surgery group. The length of ICU stay （22.5±3.6 h versus 31.7±8.5 h，P=0.000），mechanical ventilation （7.4±3.2 h versus 11.2±5.1 h，P=0.000） and postoperative hospitalization （7.1±1.6 d versus 13.5±2.4 d，P=0.000） of the minimally invasive surgery group were significantly shorter than those of the routine surgery group. There was no statistical difference in postoperative complications between the two groups. Minimally invasive surgery group patients were followed up for 5.3±2.4 months with a follow-up rate of 72.4%（21/29）. Routine surgery group patients were followed up for 5.5±3.8 months with a follow-up rate of 71.0%（27/38）. There was no significant complication during follow-up in both two groups. Conclusion Minimally invasive mitral valve operation via right mini-thoracotomy is effective and safe with a good cosmetic result. Compared with routine operation，patients undergoing minimally invasive operation recover better and faster.
Objective To summarize surgical techniques，advantages and clinical outcomes of mitral valvuloplasty for anterior mitral leaflet prolapse with looped artificial chordae. Methods Clinical data of 13 patients with anteriormitral leaflet prolapse and severe mitral regurgitation （MR） who underwent mitral valvuloplasty with looped artificial chordaefrom January 2009 to December 2011 in Beijing Anzhen Hospital were retrospectively analyzed. There were 8 male and 5 female patients with their age of 21-61 （39.5±12.9） years. There were 10 patients with anterior mitral leaflet chordal rupture and 3 patients with anterior mitral leaflet elongation. Preoperative left ventricular end-diastolic diameter （LVEDD） was 52-65 （58.3±1.7） mm，and left ventricular ejection fraction （LVEF） was 53%-65% （58.8%±2.8%）. All the patients underwent mitral valvuloplasty. We measured the neighboring normal chordae with a caliper for reference and constructed the artificial chordal loops on the caliper with expended polytetrafluoroethylene（ePTFE） CV4 Gore-Tex suture lines. Three to five loops were made and fixed to the papillary muscle with a Gore-Tex suture line and the free edge of the prolapsedanterior mitral leaflet with another Gore-Tex suture line，with the intervals between the loops of 5 mm. Left ventricular watertesting was performed to evaluate MR status，annuloplasty ring implantation or “edge to edge” technique was used if nece-ssary，and left ventricular water testing was performed again to confirm satisfactory closure of the mitral valve. Patientsreceived re-warming on cardiopulmonary bypass and the heart incision was closed. The effect of mitral annuloplasty was alsoassessed by transesophageal echocardiography （TEE） after heart rebeating. Warfarin anticoagulation was routinely used for 3 months after discharge. Results There was no perioperative death in this group. Twelve patients received satisfactory outcomes after 1-stage mitral valvuloplasty with looped artificial chordae and annuloplasty ring implantation. One patient didn’t receive satisfactory outcomes in the left ventricular water testing after mitral valvuloplasty with looped artificial chordae，but satisfactory outcome was achieve after “edge to edge” technique was used，and annuloplasty ring was not used for this patient. Postoperative echocardiography showed trivial to mild MR in all the patients，their LVEDD was significantly reducedthan preoperative LVEDD （47.5±2.1 mm vs. 58.3±1.7 mm，P＜0.05），and there was no statistical difference between postoperative and preoperative LVEF（58.5%±2.6% vs. 58.8%±2.8%，P＞0.05）. All the patients were followed up for 3-36 （19.5±3.7） months. Echocardiography showed mild MR in 4 patients and none or trivial MR in 9 patients during follow-up.Conclusion Mitral valvuloplasty with looped artificial chordae is an effective surgical technique for the treatment of anterior mitral leaflet prolapse with satisfactory clinical outcomes，and this technique is also easy to perform.
Objective To analyze early and midterm outcomes and summarize clinical experience of mitral valve repair with artificial chordae for degenerative mitral regurgitation （MR）. Methods Clinical data of 78 patients with degenerative MR who underwent mitral valve repair with Gore-Tex artificial chordae from October 2008 to December 2011 in General Hospita1 of Shenyang Military Command were retrospectively analyzed. There were 47 male patients and 31female patients with their age of 52.7±9.6 years，who all had degenerative MR. Operation techniques included simple GoreTex artificial chordae replacement in 15 patients，artificial chordae replacement plus quadrangular resection of the posterior leaflet in 58 patients，artificial chordae replacement plus quadrangular resection of the posterior leaflet and Sliding technique in 5 patients. One to three （2.15±1.05） Gore-Tex artificial chordae were used for each patient，and annuloplasty ring was used for all the patients. Thirty-nine patients underwent concomitant tricuspid valvuloplasty. Intraoperative transesophagealechocardiography showed none obvious MR in 62 patients，trivial MR in 13 patients and mild MR in 3 patients. All thepatients were followed up after discharge. Echocardiography was used to evaluate heart function and MR degree duringfollow-up. Results There was no in-hospital death in this group. Postoperative complications included sinus bradycardiain 5 patients，supraventricular tachycardia in 8 patients，late cardiac tamponade in 1 patient，and permanent pacemakerimplantation in 1 patient. Seventy patients were followed up for 1-2 years with the follow-up rate of 89.74% （70/78）. Duringfollow-up，1 patient died of cerebral embolism 13 months after discharge，and all the other patients remained alive. There were 60 patients with NYHA classⅠand 9 patients with NYHA classⅡ. Echocardiography at 1 year after dischargeshowed that left atrial diameter，left ventricular end-diastolic diameter，left ventricular end-systolic diameter，and pulmonary artery systolic pressure were significantly smaller or lower than preoperative values （P＜0.05），left ventricular ejection fraction （68.00%±7.00% vs. 55.00%±6.00%） and cardiac output were significantly higher than preoperative values（P＜0.05），and MR degree （ratio of regurgitation beam area and left atrial area） was significantly reduced compared with preoperative MR degree （3.45%±5.56% vs. 39.55%±9.86%，P＜0.05）. No artificial chordae rupture was found. There were47 patients without MR and 22 patients with trivial MR during follow-up. Conclusion Gore-Tex artificial chordae replacement is a safe and effective surgical technique for the treatment of degenerative MR.
Abstract： Objective To evaluate the effect of a surgical method for treating mild- to moderate-ischemic mitral regurgitation（IMR） using a self-designed device during off-pump coronary artery bypass grafting（OPCAB）. Methods From September 2009 to August 2011, six patients（4 males, 2 females； age was 52-73 years） with mild- to moderate-IMR underwent OPCAB and concomitant mitral valvuloplasty using a self-designed device in Beijing An Zhen Hospital. Their degree of IMR, anteroposterior diameter of mitral annulus, left ventricular long-axis diameter, left ventricular short-axis diameter and left ventricular spherical index（left ventricular short-axis diameter/left ventricular long -axis diameter）were measured using transesophageal Doppler echocardiography before and after mitral valvuloplasty. Their mean aorta pressure, mean pulmonary artery pressure and central venous pressure were also measured via Swan-Ganz catheter before and after mitral valvuloplasty. Perioperative cardiac function indexes were compared. Results There was no in-hospital death. IMR of all patients disappeared postoperatively. After mitral valvuloplasty their anteroposterior diameter of mitral annulus（3.43±0.08 cm vs.3.68±0.08 cm；t=5.430, P=0.001）, left ventricular short-axis diameter（4.80±0.21 cm vs.5.53±0.11 cm；t=7.530, P=0.001）and left ventricular spherical index（0.64±0.02 vs.0.74±0.01；t=11.110, P=0.002）significantly decreased than those before mitral valvuloplasty . But their left ventricular long-axis diameter and hemodynamic indexes did not change significantly after mitral valvuloplasty. All the six patients were followed up at the out-patient department 3 months postoperatively without autonomous symptoms. Their heart function improved to I class（New York Heart Association）. Echocardiography showed 4 patients without IMR and 2 patients with trace of minimalIMR. Conclusion Off-pump surgical therapy for mild- to moderate- IMR during OPCAB can help the patients reverseremodeling of the left ventricle, avoid the risks of cardiopulmonary bypass and improve cardiac function with good short-term effects. This method may be a good choice for treating patients with IMR.
Abstract: Objective To summarize the clinical results of homemade flexible annuloplasty ring in mitral valve repair, in order to discuss the appropriate ring size. Methods Sixtysix patients (55 males,and 11 females with a mean age of 44.62±15.94 years) with mitral insufficiency underwent mitral valve repair with homemade flexible annuloplasty ring from April 2002 to November 2009 in Fu Wai Hospital. In order to choose the ring with an appropriate size, we made and kept to the following principles: if the intercommissural distance was bigger than size 30, we chose a ring 2size smaller; if the measured distance was smaller than size 30, 1size smaller ring would be chosen. Patients were followed by echocardiography to observe the mitral valve function. Results All patients were cured and discharged from the hospital. The results of echocardiography showed mild to moderate regurgitation in 1 patient, mild regurgitation in 11 patients, and normal mitral function or trace regurgitation in the rest 54 patients. Mitral valve forward velocity was 1.40±0.30 m/s with no mitral stenosis or systolic anterior motion (SAM) of the anterior mitral leaflet. Fiftyone patients were followed up from 2 months to 7 years(24.60±25.90 months). The results of echocardiography on 38 patients showed that 1 patient had moderate regurgitation, 5 patients had mild to moderate regurgitation, 9 patients had mild regurgitation and others had normal mitral function or trace regurgitation. For these 38 patients included in the followup study, mitral valve forward velocity was 1.50±0.40 m/s with no mitral stenosis, SAM or left ventricular outlet tract obstruction. During the followup, the left atrium size (43.19±10.48 mm vs. 48.59±9.40 mm, t=4.524, P=0.000) and left ventricular end diastolic diameter (52.64±7.35 mm vs. 6269±8.77 mm, t=7.607, P=0.000) decreased significantly than the preoperative size and diameter respectively. The application of restrictive homemade flexible annuloplasty ring in mitral valve annuloplasty had satisfactory, durable and stable clinical results.
Objective To compare chordal transposition and chordal shortening in repairing anterior leaflet prolapse (ALP)， and explore the surgical indications as well as merits and demerits of these two techniques. 〖WTHZ〗Methods We retrospectively reviewed the data of 90 ALP patients recruited into Anzhen Hospital between March 1986 and March 2008, and classified them into chordal shortening group (n=23) and chordal transposition group (n=67). KaplanMeier survival curve and freedom from reoperation curve were established to compare the two groups. Univariate analysis and multivariate logistic analysis regression were used to identify independent risk factors for early death and late cardiac events. 〖WTHZ〗Results There were three perioperative deaths in chordal shortening group（13.0%）, and three deaths in chordal transposition group (4.4%), and the difference was not significant (χ2=2.019，P=0.155). The follow-up time ranged from 1 month to 18 yrs（7.70±5.41 yrs）. There were 5 late deaths, of which 3 were in chordal shortening group and 2 in chordal transposition group. The KaplanMeier survival curve showed that 5-year survival rate of chordal shortening group was significantly lower than chordal transposition group (70.00%±18.24% vs.98.00%±1.98%,χ2=12.50, P=0.000); And the KaplanMeier freedom from reoperation curve showed [CM(159mm]that 5-year reoperation rate of chordal shortening group was also significantly lower than chordal transposition group (83.30%±15.20% vs.96.10%±2.71%,χ2=10.27，P≤0.001). By the univariate analysis, we found that age＞55 yrs old, concomitant CABG procedure, New York Heart Association (NYHA) function class Ⅲ-Ⅳ, preoperative heart failure history, aortic clamping time＞90 min, and preoperative lefe ventricular ejection fraction (LVEF)＜45% were the risk factors for perioperative death and risk factors for late cardiac events included postoperative mitral regurgitation＞2+, chordal shortening technique, preoperative heart failure history, and aortic clamping time＞90 min. The multivariate logistic analysis regression showed that aortic clamping time＞90 min, concomitant CABG procedure, preoperative LVEF＜45% were the independent predictors for perioperative death, and NYHA class ⅢⅣ, chordalshortening technique and residual mitral regurgitation＞2+ were the independent predictors for the late cardiac events. Conclusion （1） There is no statistically difference between chordal transposition and chordal shortening in the perioperative survival rate. (2) Chordal transposition has a relative superiority to chordal shortening in terms of 5-year survival rate. (3) Chordal transposition has a higher mid and longterm rate of freedom from reoperation than chordal shortening. （4） Although chordal transposition has a lower incidence of reoperation and ahigher mid and longterm survival rate, the indication for it is restricted to less extensive ALP and patients with transferrable chord in the posterior leaflet. Chordal shortening is an independent risk factor for late events.
Abstract: Objective To explore whether clinically mild functional tricuspid regurgitation should be addressed at the time of mitral valve repair (MVP) for moderate or severe mitral regurgitation due to myxomatous degeneration. Methods We retrospectively analyzed the outcomes of 135 patients with moderate or severemitral regurgitation due to myxomatous degeneration with mild functional tricuspid regurgitation. All patients were treated between January 1993 and March 2008 in the Department of Cardiothoracic Surgery of Changhai Hospital, the Second Military Medical University. We divided the patients into a MVP group (n=76) and a MVP+tricuspid valvuloplasty (TVP) group(n=59) according to whether they underwent combined TVP, and observed the perioperative mortality rate, degree of tricuspid regurgitation, and compared survival rate, and freedom from longterm moderate or severe tricuspid regurgitation after operation. Cox regression was used to analyzethe risk factors for longterm moderate or severe tricuspid regurgitation after operations. Results (1) There were no deaths during the perioperative period, and postoperative transthoracic echocardiography of all patients indicated that tricuspid regurgitation was mild or less. (2) Survival rate at 5 years, 10 years after operations in MVP group was 98.4%, 95.0%, respectively, and survival rate at 5 years, 10 years after operations in MVP+TVP group was 100.0%, 93.7%, respectively, and there was no significant difference in the survival rate after operations between the two groups(P=0.311), butthere was a significant difference in the freedom from longterm moderate or severe tricuspid regurgitation after operations between the two groups (P=0.040). Multivariate Cox regression showed that preoperative pulmonary artery pressure gt;30 mm Hg (95%CI 1.127 to 137.487, P=0.040 )and atrial fibrillation (95%CI 1.177 to 23.378, P=0.030) wereindependent risk factors for longterm moderate or severe tricuspid regurgitation afteroperations.Conclusion TVP is necessary for most patients undergoing MVP for moderate or severe mitral regurgitation due to myxomatous degeneration who have coexistent mild functional tricuspid regurgitation, especially those patients with preoperative pulmonary artery pressure gt;30 mm Hg or atrial fibrillation.