Mitral Annular Forces and Their Potential Impact on Annuloplasty Ring Selection

Objectives: To provide an overview that describes the characteristics of a mitral annuloplasty device when treating patients with a specific type of mitral regurgitation according to Carpentier's classification of mitral regurgitation.Methods: Starting with the key search term “mitral valve annuloplasty,” a literature search was performed utilising PubMed, Google Scholar, and Web of Science to identify relevant studies. A systematic approach was used to assess all publications.Results: Mitral annuloplasty rings are traditionally categorised by their mechanical compliance in rigid-, semi-rigid-, and flexible rings. There is a direct correlation between remodelling capabilities and rigidity. Thus, a rigid annuloplasty ring will have the highest remodelling capability, while a flexible ring will have the lowest. Rigid- and semi-rigid rings can furthermore be divided into flat and saddled-shaped rings. Saddle-shaped rings are generally preferred over flat rings since they decrease annular and leaflet stress accumulation and provide superior leaflet coaptation. Finally, mitral annuloplasty rings can either be complete or partial.Conclusions: A downsized rigid- or semi-rigid ring is advantageous when higher remodelling capabilities are required to correct dilation of the mitral annulus, as seen in type I, type IIIa, and type IIIb mitral regurgitation. In type II mitral regurgitation, a normosized flexible ring might be sufficient and allow for a more physiological repair since there is no annular dilatation, which diminishes the need for remodelling capabilities. However, mitral annuloplasty ring selection should always be based on the specific morphology in each patient.

Results after Repair of Functional Tricuspid Regurgitation with a Three-Dimensional Annuloplasty Ring

Background: Tricuspid valve (TV) repair is the recommended treatment for severe functional tricuspid regurgitation (fTR) in patients undergoing left-sided surgery. For this purpose, a wide range of annuloplasty devices differing in form and flexibility are available. This study reports the results using a three-dimensional annuloplasty ring (Medtronic, Contour 3D Ring) for TV repair and analysis of risk factors. Methods: A cohort of 468 patients who underwent TV repair (TVr) with a concomitant cardiac procedure from December 2010 to January 2017 was retrospectively analyzed. Results: At follow-up, 96.1% of patients had no/trivial or mild TR. The 30-day mortality was 4.7%; it significantly differed between electively performed operations (2.7%) and urgent/emergent operations (11.7%). Risk factors for recurrent moderate and severe TR were LVEF < 50%, TAPSE < 16 mm, and moderate mitral valve (MV) regurgitation at follow-up. Preoperatively reduced renal function lead to a higher 30-day and overall mortality. Reoperation of the TV was required in six patients (1.6%). Risk factors for TV related reoperations were preoperative TV annulus over 50 mm and an implanted permanent pacemaker. Conclusions: TVr with the Contour 3D annuloplasty ring shows low TR recurrence and reoperation rates. Risk-factor analysis for the recurrence of TR revealed the importance of left- and right-ventricular function.

Successful mitral valve-in-ring repair of mitral annuloplasty ring dehiscence causing severe mitral regurgitation—a case report

Background Annuloplasty failure caused by ring dehiscence can lead to trans-ring and para-ring mitral regurgitation. Transcatheter treatments are available for patients at prohibitive risk of surgery. In patients unsuitable for edge-to-edge repair, valve-in-ring transcatheter mitral valve implantation has been described to treat trans-ring or para-ring jets but not both concurrently. Case summary A 78-year-old male presented with severe mitral regurgitation due to dehiscence of a 34 mm Edwards Physio II mitral annuloplasty ring. Transesophageal echocardiography showed two jets of regurgitation; trans-ring and para- ring. Repair was successfully undertaken with a valve-in-ring procedure (29 mm S3 Edwards Lifesciences). Discussion Patients with failure of mitral valve annuloplasty with trans-ring and para-ring regurgitation can be safely and effectively treated by valve-in-ring transcatheter mitral valve implantation.

Severe hemolytic anemia and acute renal failure after mitral valve repair associated with non-endothelialization of artificial chordae tendinae: case report

Background Mechanical hemolytic anemia and acute renal failure are rare complications of mitral valve repair. Case presentation We report a unique case of severe hemolytic anemia and severe acute renal failure after mitral valve repair using artificial chordae tendinae. Conservative therapy including plasmapheresis and blood transfusion was not effective. The major cause of the mechanical hemolysis was mild mitral regurgitation originating from the centre of the valve and striking the annuloplasty ring. The hemolytic anemia resolved gradually after the replacement of mitral valve. The new artificial chordae tendinae was found to be completely non-endothelialized in the surgery. Non-endothelialization of artificial chordae tendinae may also play a role in the genesis of mechanical anemia. Conclusions The major cause of the mechanical hemolysis was mild mitral regurgitation originating from the centre of the valve and striking the annuloplasty ring. Non-endothelialization of foreign materials might be another mechanism of hemolysis after mitral repair.

Severe Hemolytic Anemia and Acute Renal Failure After Mitral Valve Repair Associated With Non-endothelialization of Artificial Chordae Tendinae: Case Report

Background: Mechanical hemolytic anemia and acute renal failure are rare complication sof mitral valve repair.Case presentation: We report a unique case of severe hemolytic anemia and severe acute renal failure after mitral valve repair using artificial chordae tendinae. Conservative therapy including plasmapheresis and blood transfusion was not effective. The major cause of the mechanical hemolysis was mild mitral regurgitation originating from the centre of the valve and striking the annuloplasty ring. The hemolytic anemia resolved gradually after the replacement of mitral valve. The new artificial chordae tendinae was found to be completely non-endothelialized in the surgery. Non-endothelialization of artificial chordae tendinae may also play a role in the genesis of mechanical anemia. Conclusions: The major cause of the mechanical hemolysis was mild mitral regurgitation originating from the centre of the valve and striking the annuloplasty ring. Non-endothelialization of foreign materials might be another mechanism of hemolysis after mitral repair.

Solid aortic annuloplasty opening up for new valve sparing options

We have read with great interest the article by Papakonstantinou et al. providing a single-center analysis of the contemporary approach to tricuspid aortic valve (TAV) insufficiency with the use of HAART 300 annuloplasty ring [1].We believe that the presented concept of a robust circumferential aortic annuloplasty with separate sinus replacement, avoiding coronary re-implantations when allowed, can be successfully applied to many cases, including BAV.

Early and Mid-Term Results After Repair of Ischaemic Mitral Regurgitation with Complete Annuloplasty Ring and Incomplete Ring

Background: The choice of ring type for mitral valve (MV) repair is still debatable and usually is left to the surgeon's discretion. Aim: The aim of this study was to compare the early and mid-term results after repair of ischaemic mitral regurgitation (MR) with complete and incomplete annuloplasty rings. Methods: Collected data included preoperative assessment (age, sex, comorbidities, clinical status, NYHA grade, and the EURO score); intraoperative details (echocardiography, degree of MR, and cross-clamp time); and results (the length of ICU and hospital stay, duration and need for inotropes, duration of mechanical ventilation, and postoperative adverse events). Follow up after discharge included assessment of dyspnea status, the degree and progression of MR, and left ventricular function and dimensions. Results: The present study included 133 patients: 61 with incomplete rings and 72 with complete rings inserted. There was no significant difference in the rate of postoperative complications between the two groups, apart from a significantly higher percentage of patients with incomplete ring who required prolonged ventilation >24 hours (P = 0.002). There were no significant differences between the two groups, regarding the grade of residual MR (P = 0.464), postoperative dyspnea status (P = 0.723), 30-day mortality rate (P = 0.687), and mean duration of survival (P = 0.276). Conclusion: The choice of incomplete or complete annuloplasty ring was not associated with a marked difference in the early and midterm results of ischaemic MV repair.