REVIEW URRENT C OPINION
Minimally invasive mitral valve repair Henryk Welp and Sven Martens
Purpose of review Meanwhile mitral valve insufficiency is probably the second most common heart valve disease represented in cardiac surgery. Due to low perioperative morbidity and mortality, nowadays mitral valve repair can even be considered in asymptomatic patients. The enhancements of minimally invasive surgical techniques led to a decrease in surgical trauma and accelerated postoperative recovery, resulting in increased acceptance of these operating techniques. Therefore, the present review focuses on the different surgical access ways to the mitral valve and their significance for mitral valve repair. Recent findings The emergence of transcatheter approaches to mitral valve repair has focused attention on outcomes after surgical mitral valve repair. Results from the EVEREST II trial demonstrated worse short-term major adverse event rates for surgical repair. Recently, several studies were published analyzing contemporary outcomes, morbidity, mortality, and quality of life after conventional and minimally invasive surgical mitral valve repair to establish benchmarks for future therapeutic comparisons. Summary Today mitral valve repair is the gold standard for treatment of significant mitral valve regurgitation with low perioperative morbidity and mortality and excellent long-term results. It can be performed through minimally invasive surgical techniques without compromising long-term durability of repair results, but with a decrease in surgical trauma and accelerated postoperative recovery. Currently, endovascular therapy for mitral regurgitation (e.g., the MitraClip procedure) should be limited to patients who otherwise would not be eligible for surgery. Keywords long-term results, minimally invasive, mitral valve repair
INTRODUCTION One of the first surgeons to report a successful repair of the mitral valve through a left thoracotomy was C. P. Bailey in 1951 [1]. He repaired the valve by narrowing the annulus through an external constriction of the base of the heart. Since then mitral valve insufficiency has become probably the second-most common heart valve disease represented in cardiac surgery. With the publication of the landmark article ‘The French correction’ in 1983 by Alain Carpentier, surgical repair of the mitral valve became gold standard therapy for mitral valve incompetence with superior acute and long-term outcomes compared with prosthetic valve replacement [2 ,3–5]. This publication forms the fundament for mitral valve repair and describes the majority of the correction techniques, such as sliding plasty and quadrangular resection depending on the integrity of the anterior leaflet to maintain mitral valve competence. In order to extend reconstructive mitral valve &&
surgery to disorders of the anterior leaflet, the edgeto-edge technique and the implantations of artificial chordae expand the spectrum of surgical repair options [6–10]. Recently, a study with 174 patients who underwent mitral valve repair with the edge-to-edge technique reported more than 85% survival at 14 years. Freedom rates from cardiac death of approximately 95% and freedom rates from reoperation of approximately 90% were reported, demonstrating
Division of Cardiac Surgery, Department of Cardiac and Thoracic Surgery, University Hospital Mu¨nster, Mu¨nster, Germany Correspondence to Dr med. Henryk Welp, Division of Cardiac Surgery, Department of Cardiac Surgery, University Hospital Mu¨nster, AlbertSchweitzer Campus 1, Building A1, 48149 Mu¨nster, Germany. Tel: +49 251 83 47401; fax: +49 251 83 48316; e-mail: henryk.welp@ ukmuenster.de Curr Opin Anesthesiol 2014, 27:65–71 DOI:10.1097/ACO.0000000000000038
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KEY POINTS Mitral valve repair currently is the gold standard for treatment of significant mitral valve regurgitation with low perioperative morbidity and mortality and excellent long-term results. Minimally invasive surgical techniques lead to decreased surgical trauma and accelerated postoperative recovery without compromising long-term durability of repair results. Currently, endovascular therapy for mitral regurgitation (e.g., the MitraClip procedure) should be limited to patients who otherwise would not be eligible for surgery.
very satisfactory long-term results of this repair technique [11]. As a consequence, due to low perioperative morbidity and mortality, nowadays mitral valve repair can even be considered in asymptomatic patients [12]. The enhancements of minimally invasive surgical techniques led to a decrease in surgical trauma and accelerated postoperative recovery, resulting in increased acceptance of these operating techniques among cardiac surgeons as well as patients [13]. Therefore, the present review focuses on the different surgical access ways (for an overview, see Table 1. Modified according to [14]) to the mitral valve and their significance for mitral valve repair.
SURGICAL APPROACH Basically for all minimally invasive approaches to mitral valve surgery, two different perfusion strategies are available. With the antegrade perfusion route, direct cannulation of the ascending aorta is performed. Venous drainage is usually achieved through the
femoral vein, which is percutaneously accessed. Percutaneous cannulation of the superior vena cava can also be instituted to maximize venous drainage. With the retrograde route, cardiopulmonary bypass can be initiated by way of the femoral artery and vein cannulation. The femoral artery is connected to the extracorporeal circulation either directly or by sewing an 8-mm tube graft to the femoral artery, which is attached to the arterial cannula. With this perfusion strategy, the blood flow in the iliac arteries and aorta is subsequently reversed for brain perfusion. In patients with aortoiliac atherosclerotic disease, peripheral cannulation and flow reversal has been shown to be associated with an increased risk of embolic cerebrovascular complications. In a propensity score analysis on 1280 patients undergoing minimally invasive mitral valve surgery, Murzi et al. [15] showed that retrograde arterial perfusion was associated with a higher incidence of stroke, postoperative delirium, and aortic dissection. They identified retrograde arterial perfusion as an independent risk factor. Thus, it would be important to understand the atherosclerotic burden in patients being considered for retrograde brain perfusion during cardiac surgery [16 ]. Preoperative multidetector computed tomography angiography might serve to reduce complications of this approach in the future [17]. &
HEMISTERNOTOMY Surgical access can be achieved either through a lower or upper hemisternotomy. For lower hemisternotomy, a 6-cm skin incision, two fingerbreadths distal to the manubrium, is extended distal to a level of two fingerbreadths proximal to the xiphoid process. A hemisternotomy is performed from the xiphoid to the second intercostal space and extended into the second intercostal space on the right.
Table 1. An overview on possible access ways to minimally invasive mitral valve surgery Thoracotomy
Partial sternotomy
Robot-assisted
Video-assisted
Right anterior (second and third intercostal spaces)
Upper sternotomy:
AESOP 3000
Port access
Right anterior (fourth and fifth intercostal spaces)
J or reversed L-shaped partial upper sternotomy
Da Vinci
Left lateral
L-shaped partial upper sternotomy
Zeus
Left posterior
Inverted T sternotomy
Right vertical infra-axillary
Lower sternotomy:
Parasternal incision
T mini sternotomy V incision
Most commonly used access ways are marked in bold letters. Modified with permission from [14].
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For upper hemisternotomy through an 8-cm midline skin incision, a J-shaped partial upper sternotomy with extension into the fourth left intercostal space is performed (Fig. 1). Usually when hemisternotomy is used, the valve is approached through an extended transseptal incision. With this approach to the valve, the incision to the heart is often longer than the skin incision. Consequently, Little et al. [18] presented a series of 42 patients in whom the left atrial incision was limited to the dome. In all cases, the operation was completed without extending the sternotomy or atrial incision. They reported a repair rate of 71% without observing any operative deaths. In a review of the Brigham Cardiac Valve database, McClure et al. [10] analyzed the echocardiographic outcomes of 1000 patients who were operated via a minimally invasive access to the
(a)
(b)
FIGURE 1. Intraoperative access through an upper hemisternotomy (a) for mitral valve repair and the repaired valve (b) after a quadrangular resection and a sliding plasty of the posterior leaflet are displayed. Repair result is stabilized by an annuloplasty ring.
mitral valve. In this series, the predominant surgical access was through a lower hemisternotomy (75%). They reported a repair rate of 92.3% with the predominant underlying mitral valve pathology being myxomatous degenerative disease. Perioperative mortality was 0.8% and overall survival at 15 years was 79% with a freedom rate from reoperation of 90% for patients with mitral valve repairs. Echocardiographic data after 10 years showed that almost 70% of the repaired valves had a regurgitation of under grade 3. In a series of 1503 patients, DiBardino et al. [19] reported on long-term outcomes of mitral valve repair for different diseases. The incision types included in this retrospective study consisted of full sternotomy (57%), right thoracotomy (1%), right parasternal (9%), and hemisternotomy (33%). They reported a conversion rate to full sternotomy in the hemisternotomy group of 1.2% for the inability to defibrillate in two cases, poor exposure in three cases, and an acute dissection of the ascending aorta, which is comparable to the findings of Vollroth et al. [20 ] for the thoracotomy approach. In the cohort reported by DiBardino et al., an overall 30-day mortality of 1.3% was reported. Their longterm follow-up data up to 36 years demonstrated that the cause of mitral valve regurgitation strongly determined survival and durability of mitral valvuloplasty. Patients with rheumatic valve disease survived more than 20 years without requiring reoperation. However, functional mitral regurgitation carries the highest short-term and long-term mortality rates and lowest freedom from reoperation. Mitral valvuloplasty for myxomatous valves demonstrates the longest durability, with many patients free from reoperation at 30 years. However, survival data were not stratified according to the surgical approach [19]. Furthermore, even more complex repair strategies can be performed through this limited access. Santana et al. [21] report on a series of 19 consecutive patients undergoing minimally invasive mitral valve repairs with papillary muscle sling placement for severe functional mitral regurgitation. In this small study population, there were no reoperations for bleeding or any cerebrovascular accidents or early deaths observed. A follow-up echocardiogram, obtained at a median of 3 months, demonstrated none to trivial mitral regurgitation in all patients. However, long-term data to evaluate the effects on left ventricular remodeling and to assess the durability of the repair are still lacking for this approach. Mihos and coworkers [22,23] report on a total of 24 consecutive patients who underwent a transaortic edge-to-edge repair of the mitral valve in
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combination with concomitant aortic valve replacement. In this study, a 4% operative mortality was observed. Mitral valve regurgitation grade was reduced by at least two degrees.
(a)
MINITHORACOTOMY/VIDEO-ASSISTED ACCESS Today, the standard access via minithoracotomy is primarily through the fourth or fifth intercostal space by way of a 6-cm skin incision made either just below the mammillae or within the inframammary crease for men and women, respectively (Fig. 2). In addition to perioperative morbidity and mortality with a minimally invasive approach to mitral valve repair, two other key issues, namely the conversion rate to full sternotomy and the long-term durability of the repair come to the focus of interest. Most studies investigating the outcome of minimally invasive mitral valve procedures report a significantly longer operating and cross-clamp time compared with procedures performed via full sternotomy [10,24,25]. Vollroth et al. [20 ] report on a total of 3125 patients undergoing mitral valve repair through a right lateral minithoracotomy. They found that conversion to full sternotomy was required in only 1.0% of all patients. As the main reasons for conversion, they specified major bleeding, severe pulmonary adhesions, and aortic dissection. When a conversion to full sternotomy was indicated, it was associated with a high 30-day mortality of 23.5%. In a study by Holzhey et al. [26], the outcome after mitral valve surgery through either standard sternotomy or right lateral minithoracotomy in elderly patients with higher perioperative risk was examined in 1027 patients. The minimally invasive approach led to longer duration of surgery, cardiopulmonary bypass time, and cross-clamp time. There were no differences between the matched groups in 30-day mortality (7.7 vs. 6.3%), combined major adverse cardiac and cerebrovascular events (11.2 vs. 12.6%), or other postoperative outcome. In a series of 299 patients, Yoo et al. [27] report on long-term results of mitral valve repair via minithoracotomy compared with conventional repair by full sternotomy. In this series, 210 patients were operated through a right-sided minithoracotomy. No significant differences in 30-day mortality were observed. After a risk adjustment, the minithoracotomy group had similar risks for major adverse cardiac events compared with a control group of conventionally operated patients. Long-term echocardiographic evaluation of mitral valve function
(b)
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(c)
FIGURE 2. Thoracoscopic mitral valve repair: operative setting (a), access through a window access retractor (b), and intraoperative view on the anterior mitral valve leaflet (c). By courtesy of Dr A. Rukosujew.
after 5 years showed similar rates for freedom from significant mitral regurgitation in the conventionally operated group (86.1%) and in those patients operated through a minithoracotomy (85.3%). By propensity-matched groups, Goldstone et al. [28] compared 455 mitral valve repair operations performed through full sternotomy to 556 repairs Volume 27 Number 1 February 2014
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performed through right minithoracotomy. In-hospital mortality was similar between propensitymatched groups. Incidence of stroke, infection, myocardial infarction, exploration for postoperative hemorrhage, renal failure, and atrial fibrillation were also comparable. Transfusion was less frequent in the minimally invasive groups (11.8 vs. 20.3%), but time to extubation and discharge was similar. A 99% repair rate was achieved in the overall population and a minimally invasive approach did not significantly increase the likelihood of a failed repair resulting in mitral valve replacement. Patients undergoing minimally invasive mitral repair were more likely to have no residual mitral regurgitation. Over 9 years of follow-up, there was no significant difference in long-term survival between the groups.
ROBOTIC APPROACH The use of telemanipulative robotic arms with near three-dimensional valve visualization has allowed for near complete endoscopic robotic assisted mitral valve surgery, providing increased patient satisfaction and cosmesis. Today, most robotic procedures are performed with the three-dimensional da Vinci telesurgical system. Mihaljevic et al. [29] report on a series of 443 patients who underwent robotic mitral valve repair for degenerative disease. In 248 patients, resectional techniques were employed and in 86 patients, the valve was reconstructed by implantation of neochordae. In both groups, no in-hospital mortality was observed. In addition, outcomes concerning perioperative morbid events, especially permanent stroke and perioperative myocardial infarction, were similar. Stevens et al. [30] presented their experiences with 2255 patients who underwent mitral valve operations (1305 isolated repairs). Surgical approaches were sternotomy in 377, video-assisted right minithoracotomy in 481, or robot-assisted in 447 patients. The robotic approach led to a higher mitral valve repair rate and increased use of leaflet/chordal procedures, but had longer cardiopulmonary bypass and aortic cross-clamp times. The 30-day mortality for isolated mitral valve repair was similar for all approaches. Fewer neurological events were observed in the videoscopic and robotic groups. At present, mitral valve repair can be combined with atrial fibrillation cryoablation using a robotic approach. Nifong et al. [31] report on a series of 540 patients with either grade 3 or grade 4 mitral insufficiencies who underwent mitral valve repair. Of those, 84.1% underwent robotic mitral valve repair and 15.9% underwent robotic mitral valve repair and cryoablation.
Postrepair transesophageal echocardiography showed 82.8% patients with no mitral insufficiency, 14.8% with trivial, 2.2% with mild, and 0.6% with moderate mitral insufficiency. In those who underwent robotic mitral valve repair and cryoablation, freedom from atrial fibrillation without taking antiarrhythmic drugs or warfarin was achieved in 96.5% of patients [31].
PERCUTANEOUS APPROACH With more than 6000 implantations performed worldwide so far, to date the MitraClip (Abbott Vascular, Santa Clara, California, USA) is probably the only relevant percutaneous approach to mitral valve repair. So far it seems to be the only interventional method, which might have an influence on the morphology of the mitral valve as well as on the configuration of the mitral annulus. Basically, the procedure resembles the operative edge-to-edge repair for mitral valve insufficiency, first introduced by Otavio Alfieri [8]. Briefly, portions of the anterior and posterior leaflet are attached to the clip and moved toward each other. Thereby, a double orifice mitral valve is created and the mitral annulus is gathered together. In contrast to the procedure described by Alfieri et al., the result of the reconstruction with the MitraClip implantation is not stabilized by an annuloplasty ring. The EVEREST II (Endovascular Valve Edge-toEdge Repair) High Risk Study (HRS) assessed the safety and effectiveness of the MitraClip device in patients with significant mitral regurgitation at high risk of surgical mortality rate. In 279 patients, the differences between percutaneous and surgical treatment of mitral valve regurgitation were assessed by evaluating major adverse events. In this study, as far as major adverse events are concerned, a favorable outcome for the percutaneous procedure was reported [32]. Major criticism of this study was the impact the transfusion of packed red blood cells had on the number of major adverse events. Interestingly, when transfusion rates were excluded from the major adverse event analysis, no significant difference was observed as far as safety is concerned between the two procedures. Thereby, the safety issue of percutaneous mitral valve repair becomes less important and the durability of such approaches moves to the focus of interest [33 ]. Most studies published within the last year report on 1-year follow-up data with reasonable results [34–38]. However, Mauri et al. [39 ] present a 4-year follow-up of 184 patients treated with the
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MitraClip device. At 4 years, the rate of the composite endpoint of freedom from death, surgery, or mitral regurgitation grade 3 or higher in percutaneously treated patients was 53.4%. Rate of death was 17.4% and mitral regurgitation grade 3 or higher was present in 21.7%.
CONCLUSION Over the past decades, several minimally invasive techniques for mitral valve repair have emerged. These approaches concentrate on reducing surgical trauma by decreasing the size of the skin incision and respecting the integrity of the thoracic bone structure and thereby avoiding the disadvantages of full sternotomy, such as infection, mediastinitis, and sternal instability. Currently, minithoracotomy in the fourth or fifth intercostal space and upper or lower partial sternotomy are the most commonly applied approaches. For these operative approaches, video assistance and the use of a telemanipulator (’robotic mitral valve surgery’) are adjunctive techniques for further decreasing trauma of the surgical access. Due to tremendous costs and the need for intensive surgical training, especially robotic mitral valve repair is currently limited to a few specialized centers. Endovascular therapy for mitral regurgitation (e.g., the MitraClip procedure) currently should be limited to patients who otherwise would not be eligible for surgery. In experienced hands, the minimally invasive approach has excellent results with regard to operative complications and the durability of mitral valve repair, which are at least equal to standard techniques such as full sternotomy. Acknowledgements This work was supported solely by institutional and departmental sources. Conflicts of interest S.M. is a consultant for Medtronic Inc., Minneapolis, Minnesota, USA. H.W. has no conflicts of interest to state.
REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Bailey CP, O’Neill TJ, Glover RP, et al. Surgical repair of mitral insufficiency. Dis Chest 1951; 19:125–137; PubMed PMID: 14813116.
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2. Vahanian A, Alfieri O, Andreotti F, et al. Guidelines on the management of valvular heart disease (version 2012): the Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur J Cardiothorac Surg 2012; 42:S1–S44; PubMed PMID: 22922698. In this publication, the pathways for treatment of mitral valve disease are formulated 3. Bonow RO, Carabello BA, Chatterjee K, et al. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol 2008; 52:e1–e142; PubMed PMID: 18848134. 4. Carpentier A. Cardiac valve surgery: the ‘French correction’. J Thorac Cardiovasc Surg 1983; 86:323–337; PubMed PMID: 6887954. 5. David TE, Armstrong S, McCrindle BW, Manlhiot C. Late outcomes of mitral valve repair for mitral regurgitation due to degenerative disease. Circulation 2013; 127:1485–1492; PubMed PMID: 23459614. 6. Adams DH, Kadner A, Chen RH. Artificial mitral valve chordae replacement made simple. Ann Thorac Surg 2001; 71:1377–1378; discussion 8-9. PubMed PMID: 11308205. 7. Kay JH, Egerton WS. The repair of mitral insufficiency associated with ruptured chordae tendineae. Ann Surg 1963; 157:351–360; PubMed PMID: 14031567. Pubmed Central PMCID: 1466378. 8. Alfieri O, Maisano F, De Bonis M, et al. The double-orifice technique in mitral valve repair: a simple solution for complex problems. J Thorac Cardiovasc Surg 2001; 122:674–681; PubMed PMID: 11581597. 9. Frater RW, Vetter HO, Zussa C, Dahm M. Chordal replacement in mitral valve repair. Circulation 1990; 82 (5 Suppl):IV125–IV130; PubMed PMID: 2225397. 10. McClure RS, Athanasopoulos LV, McGurk S, et al. One thousand minimally invasive mitral valve operations: early outcomes, late outcomes, and echocardiographic follow-up. J Thorac Cardiovasc Surg 2013; 145:1199–1206; PubMed PMID: 23353109. 11. De Bonis M, Lapenna E, Lorusso R, et al. Very long-term results (up to 17 years) with the double-orifice mitral valve repair combined with ring annuloplasty for degenerative mitral regurgitation. J Thorac Cardiovasc Surg 2012; 144:1019–1024; PubMed PMID: 22929220. 12. Iung B, Gohlke-Barwolf C, Tornos P, et al. Recommendations on the management of the asymptomatic patient with valvular heart disease. Eur Heart J 2002; 23:1253–1266; PubMed PMID: 12698958. 13. Reichenspurner H, Detter C, Deuse T, et al. Video and robotic-assisted minimally invasive mitral valve surgery: a comparison of the Port-Access and transthoracic clamp techniques. Ann Thorac Surg 2005; 79:485– 490; discussion 90-1. PubMed PMID: 15680820. 14. Luca F, van Garsse L, Rao CM, et al. Minimally invasive mitral valve surgery: a systematic review. Minim Invasive Surg 2013; 2013:179569; PubMed PMID: 23606959. Pubmed Central PMCID: 3625540. 15. Murzi M, Cerillo AG, Miceli A, et al. Antegrade and retrograde arterial perfusion strategy in minimally invasive mitral-valve surgery: a propensity score analysis on 1280 patients. Eur J Cardiothorac Surg 2013; 43:e167–e172; PubMed PMID: 23404687. 16. Grossi EA, Loulmet DF, Schwartz CF, et al. Evolution of operative techniques & and perfusion strategies for minimally invasive mitral valve repair. J Thorac Cardiovasc Surg 2012; 143 (4 Suppl):S68–S70; PubMed PMID: 22285326. Advantages and disadvantages of different perfusion strategies are discussed in this study. 17. Moodley S, Schoenhagen P, Gillinov AM, et al. Preoperative multidetector computed tomography angiography for planning of minimally invasive robotic mitral valve surgery: impact on decision making. J Thorac Cardiovasc Surg 2013; 146:262–268; e1. PubMed PMID: 22841167. 18. Little S, Flynn M, Pettersson GB, et al. Revisiting the dome approach for partial sternotomy/minimally invasive mitral valve surgery. Ann Thorac Surg 2009; 87:694–697; PubMed PMID: 19231372. 19. DiBardino DJ, ElBardissi AW, McClure RS, et al. Four decades of experience with mitral valve repair: analysis of differential indications, technical evolution, and long-term outcome. J Thorac Cardiovasc Surg 2010; 139:76–83; discussion -4. PubMed PMID: 19931098. 20. Vollroth M, Seeburger J, Garbade J, et al. Minimally invasive mitral valve & surgery is a very safe procedure with very low rates of conversion to full sternotomy. Eur J Cardiothorac Surg 2012; 42:e13–e15; discusson e6. PubMed PMID: 22611145. A very large series of patients after minimally invasive mitral valve repair is presented in this study. 21. Santana O, Solenkova NV, Pineda AM, et al. Minimally invasive papillary muscle sling placement during mitral valve repair in patients with functional mitral regurgitation. J Thorac Cardiovasc Surg 2014; 147:496–499. doi: 10.1016/j.jtcvs.2013.03.006. 22. Mihos CG, Santana O, Brenes JC, Lamelas J. Outcomes of transaortic edgeto-edge repair of the mitral valve in patients undergoing minimally invasive aortic valve replacement. J Thorac Cardiovasc Surg 2013; 145:1412–1413; PubMed PMID: 23312971.
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Minimally invasive mitral valve repair strategies Welp and Martens 23. Lamelas J, Mihos CG, Santana O. Minimally invasive transaortic edge-to-edge repair of the mitral valve. J Heart Valve Dis 2013; 22:11–13; PubMed PMID: 23610982. 24. Mazine A, Pellerin M, Lebon JS, et al. Minimally invasive mitral valve surgery: influence of aortic clamping technique on early outcomes. Ann Thorac Surg 2013; 96:2116–2122. doi: 10.1016/j.athoracsur.2013.07.015. 25. Seeburger J, Eifert S, Pfannmuller B, et al. Gender differences in mitral valve surgery. Thorac Cardiovasc Surg 2013; 61:42–46; PubMed PMID: 23258762. 26. Holzhey DM, Shi W, Borger MA, et al. Minimally invasive versus sternotomy approach for mitral valve surgery in patients greater than 70 years old: a propensity-matched comparison. Ann Thorac Surg 2011; 91:401–405. doi: 10.1016/j.athoracsur.2010.08.006. PMID: 21256279. 27. Yoo JS, Kim JB, Jung SH, et al. Echocardiographic assessment of mitral durability in the late period following mitral valve repair: minithoracotomy versus conventional sternotomy. J Thorac Cardiovasc Surg 2013; pii: S00225223(13)00607-7. doi: 10.1016/j.jtcvs.2013.05.042. [Epub ahead of print] 28. Goldstone AB, Atluri P, Szeto WY, et al. Minimally invasive approach provides at least equivalent results for surgical correction of mitral regurgitation: a propensity-matched comparison. J Thorac Cardiovasc Surg 2013; 145:748– 756; PubMed PMID: 23414991. 29. Mihaljevic T, Pattakos G, Gillinov AM, et al. Robotic posterior mitral leaflet repair: neochordal versus resectional techniques. Ann Thorac Surg 2013; 95:787–794; PubMed PMID: 23103008. 30. Stevens LM, Rodriguez E, Lehr EJ, et al. Impact of timing and surgical approach on outcomes after mitral valve regurgitation operations. Ann Thorac Surg 2012; 93:1462–1468; PubMed PMID: 22421591. 31. Nifong LW, Rodriguez E, Chitwood WR Jr. 540 consecutive robotic mitral valve repairs including concomitant atrial fibrillation cryoablation. Ann Thorac Surg 2012; 94:38–42; discussion 3. PubMed PMID: 22560967. 32. Feldman T, Foster E, Glower DD, et al. Percutaneous repair or surgery for mitral regurgitation. N Engl J Med 2011; 364:1395–1406; PubMed PMID: 21463154.
33. LaPar DJ, Mulloy DP, Crosby IK, et al. Contemporary outcomes for surgical mitral valve repair: a benchmark for evaluating emerging mitral valve technology. J Thorac Cardiovasc Surg 2012; 143 (4 Suppl):S12–S16; PubMed PMID: 22326424. Pubmed Central PMCID: 3617492. Current long and short-term results of mitral valve surgery are discussed in this paper. 34. Grasso C, Capodanno D, Scandura S, et al. One- and twelve-month safety and efficacy outcomes of patients undergoing edge-to-edge percutaneous mitral valve repair (from the GRASP Registry). Am J Cardiol 2013; 111:1482–1487; PubMed PMID: 23433761. 35. Maisano F, Franzen O, Baldus S, et al. Percutaneous mitral valve interventions in the real world: early and one year results from the ACCESS-EU, a prospective, multicenter non-randomized post-approval study of the MitraClip(R) Therapy in Europe. J Am Coll Cardiol 2013; 62:1052–1061; PubMed PMID: 23747789. 36. Reichenspurner H, Schillinger W, Baldus S, et al. Clinical outcomes through 12 months in patients with degenerative mitral regurgitation treated with the MitraClip device in the ACCESS-EUrope Phase I trial. Eur J Cardiothorac Surg 2013; 44:e280–e288; PubMed PMID: 23864216. 37. Munkholm-Larsen S, Wan B, Tian DH, et al. A systematic review on the safety and efficacy of percutaneous edge-to-edge mitral valve repair with the MitraClip system for high surgical risk candidates. Heart 2013. [Epub ahead of print] 38. Whitlow PL, Feldman T, Pedersen WR, et al. Acute and 12-month results with catheter-based mitral valve leaflet repair: the EVEREST II (Endovascular Valve Edge-to-Edge Repair) High Risk Study. J Am Coll Cardiol 2012; 59:130– 139; PubMed PMID: 22222076. 39. Mauri L, Foster E, Glower DD, et al. 4-year results of a randomized controlled & trial of percutaneous repair versus surgery for mitral regurgitation. J Am Coll Cardiol 2013; 62:317–328; PubMed PMID: 23665364. Four-year follow-up data on percutaneous mitral valve repair are presented in this study. &
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Minimally invasive mitral valve repair Henryk Welp and Sven Martens
Purpose of review Meanwhile mitral valve insufficiency is probably the second most common heart valve disease represented in cardiac surgery. Due to low perioperative morbidity and mortality, nowadays mitral valve repair can even be considered in asymptomatic patients. The enhancements of minimally invasive surgical techniques led to a decrease in surgical trauma and accelerated postoperative recovery, resulting in increased acceptance of these operating techniques. Therefore, the present review focuses on the different surgical access ways to the mitral valve and their significance for mitral valve repair. Recent findings The emergence of transcatheter approaches to mitral valve repair has focused attention on outcomes after surgical mitral valve repair. Results from the EVEREST II trial demonstrated worse short-term major adverse event rates for surgical repair. Recently, several studies were published analyzing contemporary outcomes, morbidity, mortality, and quality of life after conventional and minimally invasive surgical mitral valve repair to establish benchmarks for future therapeutic comparisons. Summary Today mitral valve repair is the gold standard for treatment of significant mitral valve regurgitation with low perioperative morbidity and mortality and excellent long-term results. It can be performed through minimally invasive surgical techniques without compromising long-term durability of repair results, but with a decrease in surgical trauma and accelerated postoperative recovery. Currently, endovascular therapy for mitral regurgitation (e.g., the MitraClip procedure) should be limited to patients who otherwise would not be eligible for surgery. Keywords long-term results, minimally invasive, mitral valve repair
INTRODUCTION One of the first surgeons to report a successful repair of the mitral valve through a left thoracotomy was C. P. Bailey in 1951 [1]. He repaired the valve by narrowing the annulus through an external constriction of the base of the heart. Since then mitral valve insufficiency has become probably the second-most common heart valve disease represented in cardiac surgery. With the publication of the landmark article ‘The French correction’ in 1983 by Alain Carpentier, surgical repair of the mitral valve became gold standard therapy for mitral valve incompetence with superior acute and long-term outcomes compared with prosthetic valve replacement [2 ,3–5]. This publication forms the fundament for mitral valve repair and describes the majority of the correction techniques, such as sliding plasty and quadrangular resection depending on the integrity of the anterior leaflet to maintain mitral valve competence. In order to extend reconstructive mitral valve &&
surgery to disorders of the anterior leaflet, the edgeto-edge technique and the implantations of artificial chordae expand the spectrum of surgical repair options [6–10]. Recently, a study with 174 patients who underwent mitral valve repair with the edge-to-edge technique reported more than 85% survival at 14 years. Freedom rates from cardiac death of approximately 95% and freedom rates from reoperation of approximately 90% were reported, demonstrating
Division of Cardiac Surgery, Department of Cardiac and Thoracic Surgery, University Hospital Mu¨nster, Mu¨nster, Germany Correspondence to Dr med. Henryk Welp, Division of Cardiac Surgery, Department of Cardiac Surgery, University Hospital Mu¨nster, AlbertSchweitzer Campus 1, Building A1, 48149 Mu¨nster, Germany. Tel: +49 251 83 47401; fax: +49 251 83 48316; e-mail: henryk.welp@ ukmuenster.de Curr Opin Anesthesiol 2014, 27:65–71 DOI:10.1097/ACO.0000000000000038
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KEY POINTS Mitral valve repair currently is the gold standard for treatment of significant mitral valve regurgitation with low perioperative morbidity and mortality and excellent long-term results. Minimally invasive surgical techniques lead to decreased surgical trauma and accelerated postoperative recovery without compromising long-term durability of repair results. Currently, endovascular therapy for mitral regurgitation (e.g., the MitraClip procedure) should be limited to patients who otherwise would not be eligible for surgery.
very satisfactory long-term results of this repair technique [11]. As a consequence, due to low perioperative morbidity and mortality, nowadays mitral valve repair can even be considered in asymptomatic patients [12]. The enhancements of minimally invasive surgical techniques led to a decrease in surgical trauma and accelerated postoperative recovery, resulting in increased acceptance of these operating techniques among cardiac surgeons as well as patients [13]. Therefore, the present review focuses on the different surgical access ways (for an overview, see Table 1. Modified according to [14]) to the mitral valve and their significance for mitral valve repair.
SURGICAL APPROACH Basically for all minimally invasive approaches to mitral valve surgery, two different perfusion strategies are available. With the antegrade perfusion route, direct cannulation of the ascending aorta is performed. Venous drainage is usually achieved through the
femoral vein, which is percutaneously accessed. Percutaneous cannulation of the superior vena cava can also be instituted to maximize venous drainage. With the retrograde route, cardiopulmonary bypass can be initiated by way of the femoral artery and vein cannulation. The femoral artery is connected to the extracorporeal circulation either directly or by sewing an 8-mm tube graft to the femoral artery, which is attached to the arterial cannula. With this perfusion strategy, the blood flow in the iliac arteries and aorta is subsequently reversed for brain perfusion. In patients with aortoiliac atherosclerotic disease, peripheral cannulation and flow reversal has been shown to be associated with an increased risk of embolic cerebrovascular complications. In a propensity score analysis on 1280 patients undergoing minimally invasive mitral valve surgery, Murzi et al. [15] showed that retrograde arterial perfusion was associated with a higher incidence of stroke, postoperative delirium, and aortic dissection. They identified retrograde arterial perfusion as an independent risk factor. Thus, it would be important to understand the atherosclerotic burden in patients being considered for retrograde brain perfusion during cardiac surgery [16 ]. Preoperative multidetector computed tomography angiography might serve to reduce complications of this approach in the future [17]. &
HEMISTERNOTOMY Surgical access can be achieved either through a lower or upper hemisternotomy. For lower hemisternotomy, a 6-cm skin incision, two fingerbreadths distal to the manubrium, is extended distal to a level of two fingerbreadths proximal to the xiphoid process. A hemisternotomy is performed from the xiphoid to the second intercostal space and extended into the second intercostal space on the right.
Table 1. An overview on possible access ways to minimally invasive mitral valve surgery Thoracotomy
Partial sternotomy
Robot-assisted
Video-assisted
Right anterior (second and third intercostal spaces)
Upper sternotomy:
AESOP 3000
Port access
Right anterior (fourth and fifth intercostal spaces)
J or reversed L-shaped partial upper sternotomy
Da Vinci
Left lateral
L-shaped partial upper sternotomy
Zeus
Left posterior
Inverted T sternotomy
Right vertical infra-axillary
Lower sternotomy:
Parasternal incision
T mini sternotomy V incision
Most commonly used access ways are marked in bold letters. Modified with permission from [14].
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For upper hemisternotomy through an 8-cm midline skin incision, a J-shaped partial upper sternotomy with extension into the fourth left intercostal space is performed (Fig. 1). Usually when hemisternotomy is used, the valve is approached through an extended transseptal incision. With this approach to the valve, the incision to the heart is often longer than the skin incision. Consequently, Little et al. [18] presented a series of 42 patients in whom the left atrial incision was limited to the dome. In all cases, the operation was completed without extending the sternotomy or atrial incision. They reported a repair rate of 71% without observing any operative deaths. In a review of the Brigham Cardiac Valve database, McClure et al. [10] analyzed the echocardiographic outcomes of 1000 patients who were operated via a minimally invasive access to the
(a)
(b)
FIGURE 1. Intraoperative access through an upper hemisternotomy (a) for mitral valve repair and the repaired valve (b) after a quadrangular resection and a sliding plasty of the posterior leaflet are displayed. Repair result is stabilized by an annuloplasty ring.
mitral valve. In this series, the predominant surgical access was through a lower hemisternotomy (75%). They reported a repair rate of 92.3% with the predominant underlying mitral valve pathology being myxomatous degenerative disease. Perioperative mortality was 0.8% and overall survival at 15 years was 79% with a freedom rate from reoperation of 90% for patients with mitral valve repairs. Echocardiographic data after 10 years showed that almost 70% of the repaired valves had a regurgitation of under grade 3. In a series of 1503 patients, DiBardino et al. [19] reported on long-term outcomes of mitral valve repair for different diseases. The incision types included in this retrospective study consisted of full sternotomy (57%), right thoracotomy (1%), right parasternal (9%), and hemisternotomy (33%). They reported a conversion rate to full sternotomy in the hemisternotomy group of 1.2% for the inability to defibrillate in two cases, poor exposure in three cases, and an acute dissection of the ascending aorta, which is comparable to the findings of Vollroth et al. [20 ] for the thoracotomy approach. In the cohort reported by DiBardino et al., an overall 30-day mortality of 1.3% was reported. Their longterm follow-up data up to 36 years demonstrated that the cause of mitral valve regurgitation strongly determined survival and durability of mitral valvuloplasty. Patients with rheumatic valve disease survived more than 20 years without requiring reoperation. However, functional mitral regurgitation carries the highest short-term and long-term mortality rates and lowest freedom from reoperation. Mitral valvuloplasty for myxomatous valves demonstrates the longest durability, with many patients free from reoperation at 30 years. However, survival data were not stratified according to the surgical approach [19]. Furthermore, even more complex repair strategies can be performed through this limited access. Santana et al. [21] report on a series of 19 consecutive patients undergoing minimally invasive mitral valve repairs with papillary muscle sling placement for severe functional mitral regurgitation. In this small study population, there were no reoperations for bleeding or any cerebrovascular accidents or early deaths observed. A follow-up echocardiogram, obtained at a median of 3 months, demonstrated none to trivial mitral regurgitation in all patients. However, long-term data to evaluate the effects on left ventricular remodeling and to assess the durability of the repair are still lacking for this approach. Mihos and coworkers [22,23] report on a total of 24 consecutive patients who underwent a transaortic edge-to-edge repair of the mitral valve in
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combination with concomitant aortic valve replacement. In this study, a 4% operative mortality was observed. Mitral valve regurgitation grade was reduced by at least two degrees.
(a)
MINITHORACOTOMY/VIDEO-ASSISTED ACCESS Today, the standard access via minithoracotomy is primarily through the fourth or fifth intercostal space by way of a 6-cm skin incision made either just below the mammillae or within the inframammary crease for men and women, respectively (Fig. 2). In addition to perioperative morbidity and mortality with a minimally invasive approach to mitral valve repair, two other key issues, namely the conversion rate to full sternotomy and the long-term durability of the repair come to the focus of interest. Most studies investigating the outcome of minimally invasive mitral valve procedures report a significantly longer operating and cross-clamp time compared with procedures performed via full sternotomy [10,24,25]. Vollroth et al. [20 ] report on a total of 3125 patients undergoing mitral valve repair through a right lateral minithoracotomy. They found that conversion to full sternotomy was required in only 1.0% of all patients. As the main reasons for conversion, they specified major bleeding, severe pulmonary adhesions, and aortic dissection. When a conversion to full sternotomy was indicated, it was associated with a high 30-day mortality of 23.5%. In a study by Holzhey et al. [26], the outcome after mitral valve surgery through either standard sternotomy or right lateral minithoracotomy in elderly patients with higher perioperative risk was examined in 1027 patients. The minimally invasive approach led to longer duration of surgery, cardiopulmonary bypass time, and cross-clamp time. There were no differences between the matched groups in 30-day mortality (7.7 vs. 6.3%), combined major adverse cardiac and cerebrovascular events (11.2 vs. 12.6%), or other postoperative outcome. In a series of 299 patients, Yoo et al. [27] report on long-term results of mitral valve repair via minithoracotomy compared with conventional repair by full sternotomy. In this series, 210 patients were operated through a right-sided minithoracotomy. No significant differences in 30-day mortality were observed. After a risk adjustment, the minithoracotomy group had similar risks for major adverse cardiac events compared with a control group of conventionally operated patients. Long-term echocardiographic evaluation of mitral valve function
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(c)
FIGURE 2. Thoracoscopic mitral valve repair: operative setting (a), access through a window access retractor (b), and intraoperative view on the anterior mitral valve leaflet (c). By courtesy of Dr A. Rukosujew.
after 5 years showed similar rates for freedom from significant mitral regurgitation in the conventionally operated group (86.1%) and in those patients operated through a minithoracotomy (85.3%). By propensity-matched groups, Goldstone et al. [28] compared 455 mitral valve repair operations performed through full sternotomy to 556 repairs Volume 27 Number 1 February 2014
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performed through right minithoracotomy. In-hospital mortality was similar between propensitymatched groups. Incidence of stroke, infection, myocardial infarction, exploration for postoperative hemorrhage, renal failure, and atrial fibrillation were also comparable. Transfusion was less frequent in the minimally invasive groups (11.8 vs. 20.3%), but time to extubation and discharge was similar. A 99% repair rate was achieved in the overall population and a minimally invasive approach did not significantly increase the likelihood of a failed repair resulting in mitral valve replacement. Patients undergoing minimally invasive mitral repair were more likely to have no residual mitral regurgitation. Over 9 years of follow-up, there was no significant difference in long-term survival between the groups.
ROBOTIC APPROACH The use of telemanipulative robotic arms with near three-dimensional valve visualization has allowed for near complete endoscopic robotic assisted mitral valve surgery, providing increased patient satisfaction and cosmesis. Today, most robotic procedures are performed with the three-dimensional da Vinci telesurgical system. Mihaljevic et al. [29] report on a series of 443 patients who underwent robotic mitral valve repair for degenerative disease. In 248 patients, resectional techniques were employed and in 86 patients, the valve was reconstructed by implantation of neochordae. In both groups, no in-hospital mortality was observed. In addition, outcomes concerning perioperative morbid events, especially permanent stroke and perioperative myocardial infarction, were similar. Stevens et al. [30] presented their experiences with 2255 patients who underwent mitral valve operations (1305 isolated repairs). Surgical approaches were sternotomy in 377, video-assisted right minithoracotomy in 481, or robot-assisted in 447 patients. The robotic approach led to a higher mitral valve repair rate and increased use of leaflet/chordal procedures, but had longer cardiopulmonary bypass and aortic cross-clamp times. The 30-day mortality for isolated mitral valve repair was similar for all approaches. Fewer neurological events were observed in the videoscopic and robotic groups. At present, mitral valve repair can be combined with atrial fibrillation cryoablation using a robotic approach. Nifong et al. [31] report on a series of 540 patients with either grade 3 or grade 4 mitral insufficiencies who underwent mitral valve repair. Of those, 84.1% underwent robotic mitral valve repair and 15.9% underwent robotic mitral valve repair and cryoablation.
Postrepair transesophageal echocardiography showed 82.8% patients with no mitral insufficiency, 14.8% with trivial, 2.2% with mild, and 0.6% with moderate mitral insufficiency. In those who underwent robotic mitral valve repair and cryoablation, freedom from atrial fibrillation without taking antiarrhythmic drugs or warfarin was achieved in 96.5% of patients [31].
PERCUTANEOUS APPROACH With more than 6000 implantations performed worldwide so far, to date the MitraClip (Abbott Vascular, Santa Clara, California, USA) is probably the only relevant percutaneous approach to mitral valve repair. So far it seems to be the only interventional method, which might have an influence on the morphology of the mitral valve as well as on the configuration of the mitral annulus. Basically, the procedure resembles the operative edge-to-edge repair for mitral valve insufficiency, first introduced by Otavio Alfieri [8]. Briefly, portions of the anterior and posterior leaflet are attached to the clip and moved toward each other. Thereby, a double orifice mitral valve is created and the mitral annulus is gathered together. In contrast to the procedure described by Alfieri et al., the result of the reconstruction with the MitraClip implantation is not stabilized by an annuloplasty ring. The EVEREST II (Endovascular Valve Edge-toEdge Repair) High Risk Study (HRS) assessed the safety and effectiveness of the MitraClip device in patients with significant mitral regurgitation at high risk of surgical mortality rate. In 279 patients, the differences between percutaneous and surgical treatment of mitral valve regurgitation were assessed by evaluating major adverse events. In this study, as far as major adverse events are concerned, a favorable outcome for the percutaneous procedure was reported [32]. Major criticism of this study was the impact the transfusion of packed red blood cells had on the number of major adverse events. Interestingly, when transfusion rates were excluded from the major adverse event analysis, no significant difference was observed as far as safety is concerned between the two procedures. Thereby, the safety issue of percutaneous mitral valve repair becomes less important and the durability of such approaches moves to the focus of interest [33 ]. Most studies published within the last year report on 1-year follow-up data with reasonable results [34–38]. However, Mauri et al. [39 ] present a 4-year follow-up of 184 patients treated with the
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MitraClip device. At 4 years, the rate of the composite endpoint of freedom from death, surgery, or mitral regurgitation grade 3 or higher in percutaneously treated patients was 53.4%. Rate of death was 17.4% and mitral regurgitation grade 3 or higher was present in 21.7%.
CONCLUSION Over the past decades, several minimally invasive techniques for mitral valve repair have emerged. These approaches concentrate on reducing surgical trauma by decreasing the size of the skin incision and respecting the integrity of the thoracic bone structure and thereby avoiding the disadvantages of full sternotomy, such as infection, mediastinitis, and sternal instability. Currently, minithoracotomy in the fourth or fifth intercostal space and upper or lower partial sternotomy are the most commonly applied approaches. For these operative approaches, video assistance and the use of a telemanipulator (’robotic mitral valve surgery’) are adjunctive techniques for further decreasing trauma of the surgical access. Due to tremendous costs and the need for intensive surgical training, especially robotic mitral valve repair is currently limited to a few specialized centers. Endovascular therapy for mitral regurgitation (e.g., the MitraClip procedure) currently should be limited to patients who otherwise would not be eligible for surgery. In experienced hands, the minimally invasive approach has excellent results with regard to operative complications and the durability of mitral valve repair, which are at least equal to standard techniques such as full sternotomy. Acknowledgements This work was supported solely by institutional and departmental sources. Conflicts of interest S.M. is a consultant for Medtronic Inc., Minneapolis, Minnesota, USA. H.W. has no conflicts of interest to state.
REFERENCES AND RECOMMENDED READING Papers of particular interest, published within the annual period of review, have been highlighted as: & of special interest && of outstanding interest 1. Bailey CP, O’Neill TJ, Glover RP, et al. Surgical repair of mitral insufficiency. Dis Chest 1951; 19:125–137; PubMed PMID: 14813116.
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2. Vahanian A, Alfieri O, Andreotti F, et al. Guidelines on the management of valvular heart disease (version 2012): the Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS). Eur J Cardiothorac Surg 2012; 42:S1–S44; PubMed PMID: 22922698. In this publication, the pathways for treatment of mitral valve disease are formulated 3. Bonow RO, Carabello BA, Chatterjee K, et al. 2008 focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/ American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1998 guidelines for the management of patients with valvular heart disease). Endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. 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A very large series of patients after minimally invasive mitral valve repair is presented in this study. 21. Santana O, Solenkova NV, Pineda AM, et al. Minimally invasive papillary muscle sling placement during mitral valve repair in patients with functional mitral regurgitation. J Thorac Cardiovasc Surg 2014; 147:496–499. doi: 10.1016/j.jtcvs.2013.03.006. 22. Mihos CG, Santana O, Brenes JC, Lamelas J. Outcomes of transaortic edgeto-edge repair of the mitral valve in patients undergoing minimally invasive aortic valve replacement. J Thorac Cardiovasc Surg 2013; 145:1412–1413; PubMed PMID: 23312971.
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Minimally invasive mitral valve repair strategies Welp and Martens 23. Lamelas J, Mihos CG, Santana O. Minimally invasive transaortic edge-to-edge repair of the mitral valve. J Heart Valve Dis 2013; 22:11–13; PubMed PMID: 23610982. 24. Mazine A, Pellerin M, Lebon JS, et al. Minimally invasive mitral valve surgery: influence of aortic clamping technique on early outcomes. Ann Thorac Surg 2013; 96:2116–2122. doi: 10.1016/j.athoracsur.2013.07.015. 25. Seeburger J, Eifert S, Pfannmuller B, et al. Gender differences in mitral valve surgery. Thorac Cardiovasc Surg 2013; 61:42–46; PubMed PMID: 23258762. 26. Holzhey DM, Shi W, Borger MA, et al. Minimally invasive versus sternotomy approach for mitral valve surgery in patients greater than 70 years old: a propensity-matched comparison. Ann Thorac Surg 2011; 91:401–405. doi: 10.1016/j.athoracsur.2010.08.006. PMID: 21256279. 27. Yoo JS, Kim JB, Jung SH, et al. Echocardiographic assessment of mitral durability in the late period following mitral valve repair: minithoracotomy versus conventional sternotomy. J Thorac Cardiovasc Surg 2013; pii: S00225223(13)00607-7. doi: 10.1016/j.jtcvs.2013.05.042. [Epub ahead of print] 28. Goldstone AB, Atluri P, Szeto WY, et al. Minimally invasive approach provides at least equivalent results for surgical correction of mitral regurgitation: a propensity-matched comparison. J Thorac Cardiovasc Surg 2013; 145:748– 756; PubMed PMID: 23414991. 29. Mihaljevic T, Pattakos G, Gillinov AM, et al. Robotic posterior mitral leaflet repair: neochordal versus resectional techniques. Ann Thorac Surg 2013; 95:787–794; PubMed PMID: 23103008. 30. Stevens LM, Rodriguez E, Lehr EJ, et al. Impact of timing and surgical approach on outcomes after mitral valve regurgitation operations. Ann Thorac Surg 2012; 93:1462–1468; PubMed PMID: 22421591. 31. Nifong LW, Rodriguez E, Chitwood WR Jr. 540 consecutive robotic mitral valve repairs including concomitant atrial fibrillation cryoablation. Ann Thorac Surg 2012; 94:38–42; discussion 3. PubMed PMID: 22560967. 32. Feldman T, Foster E, Glower DD, et al. Percutaneous repair or surgery for mitral regurgitation. N Engl J Med 2011; 364:1395–1406; PubMed PMID: 21463154.
33. LaPar DJ, Mulloy DP, Crosby IK, et al. Contemporary outcomes for surgical mitral valve repair: a benchmark for evaluating emerging mitral valve technology. J Thorac Cardiovasc Surg 2012; 143 (4 Suppl):S12–S16; PubMed PMID: 22326424. Pubmed Central PMCID: 3617492. Current long and short-term results of mitral valve surgery are discussed in this paper. 34. Grasso C, Capodanno D, Scandura S, et al. One- and twelve-month safety and efficacy outcomes of patients undergoing edge-to-edge percutaneous mitral valve repair (from the GRASP Registry). Am J Cardiol 2013; 111:1482–1487; PubMed PMID: 23433761. 35. Maisano F, Franzen O, Baldus S, et al. Percutaneous mitral valve interventions in the real world: early and one year results from the ACCESS-EU, a prospective, multicenter non-randomized post-approval study of the MitraClip(R) Therapy in Europe. J Am Coll Cardiol 2013; 62:1052–1061; PubMed PMID: 23747789. 36. Reichenspurner H, Schillinger W, Baldus S, et al. Clinical outcomes through 12 months in patients with degenerative mitral regurgitation treated with the MitraClip device in the ACCESS-EUrope Phase I trial. Eur J Cardiothorac Surg 2013; 44:e280–e288; PubMed PMID: 23864216. 37. Munkholm-Larsen S, Wan B, Tian DH, et al. A systematic review on the safety and efficacy of percutaneous edge-to-edge mitral valve repair with the MitraClip system for high surgical risk candidates. Heart 2013. [Epub ahead of print] 38. Whitlow PL, Feldman T, Pedersen WR, et al. Acute and 12-month results with catheter-based mitral valve leaflet repair: the EVEREST II (Endovascular Valve Edge-to-Edge Repair) High Risk Study. J Am Coll Cardiol 2012; 59:130– 139; PubMed PMID: 22222076. 39. Mauri L, Foster E, Glower DD, et al. 4-year results of a randomized controlled & trial of percutaneous repair versus surgery for mitral regurgitation. J Am Coll Cardiol 2013; 62:317–328; PubMed PMID: 23665364. Four-year follow-up data on percutaneous mitral valve repair are presented in this study. &
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