Flexible or rigid ring in mitral annuloplasty—do the results differ?

Abstract

Introduction Mitral valve annuloplasty has evolved over the decades since its introduction and Carpentier played a major role in developing the technique. Mitral valve repair is preferred over replacement for severe primary mitral regurgitation, as it restores normal life expectancy when successful and does not require lifelong anticoagulation. There is an ongoing debate regarding the choice of ring for mitral valve annuloplasty-rigid or flexible. At present, the choice of ring is based on the availability of the ring and left to the surgeon's discretion. Methodology This is a retrospective study conducted at a tertiary referral centre. Aim To compare the outcomes of mitral valve repair annuloplasty with flexible and rigid rings. The hospital records of 112 patients who underwent mitral valve annuloplasty between January 2010 and December 2014 at our hospital were studied. All patients were followed up for 5 years. The rigid and flexible groups were compared for left ventricular (LV) size regression and the presence of mitral regurgitation (MR). Results One hundred and eight patients had no progression of mitral regurgitation at 5-year follow-up, compared with the immediate postoperative period. The choice of the ring (rigid and flexible) did not affect the recurrence of mitral regurgitation. At 5-year follow-up, three patients (2 patients in the rigid group and 1 patient in the flexible group) had 3+ MR. One of the two patients in the rigid group had poor functional status and underwent mitral valve replacement (MVR). The other two patients (one in the rigid group and one in the flexible group) with 3+ MR had class II NYHA symptoms and were on medical follow-up. The left ventricular internal diameter diastolic (LVIDD) measured 59.1 mm in the flexible ring group and 56.76 mm in the rigid group preoperatively and these values reduced to 48.4 mm and 47.3 mm, at 5-year follow-up respectively. The mean left ventricular internal diameter systolic (LVIDS) size regression at 5 years was 4.5 ± 6.09 mm in the flexible ring group and 3.2 ± 7.17 mm in the rigid ring group and the difference is not statistically significant (p value 0.314). The mean LVIDD size regression at 5 years was 10.62 ± 6.57 mm in the flexible ring group and 9.38 ± 9.29 mm in the rigid ring group and the difference is not statistically significant (p value 0.408). Conclusion The choice of rigid or flexible ring did not have a marked difference on the outcome of mitral valve annuloplasty at midterm follow-up.

Annuloplasty for mitral valve repair in degenerative disease: to be flexible or to be rigid? That’s still the question

“…The study suggests that both rings are safe and effective in treating MV regurgitation with comparable and acceptable 5-year outcome, in keeping with the suggestions from previous studies [3]. One remarkable finding of this study is the reduction in LV size at 5 years in both groups with a trend favouring the flexible ring, although not significant [7], also in keeping with the outcome of the previously cited meta-analysis [4]. More than 30 years ago, Spence and colleagues [8] were already able to compare the effects of rigid and flexible rings in isolated porcine hearts, and found that fixation of the mitral annulus was disadvantageous to the systolic function of the left ventricle.…”

“…It must be emphasized that despite these findings and the available evidence from clinical and translational studies and guidelines, the selection of which ring to use is not regulated and is still typically dictated by surgeon's preference. In the latest issue of the Journal, the paper by Panicker and colleagues [7] provides a valuable and pragmatic contribution to the debate on the appropriateness of using flexible or rigid rings to treat degenerative MV regurgitation. In a retrospective analysis, the authors have followed up 112 young patients undergoing MV repair for primary degenerative MV regurgitation to ascertain the mid-term impact of flexible and rigid rings in terms of recurrent MV regurgitation and LV positive remodelling.…”

3D mitral annulus echocardiography assessment in patients affected by degenerative mitral regurgitation who underwent mitral valve repair with flexible band

“…It has been proved that the use of flexible rings is comparable to rigid rings in terms of mortality and regurgitation recurrence, 11,12 while the flexible band is more effective in preserving the MV area, probably by decreasing the parietal stress and respecting the physiological valve motility. 11,13,14 Accurate diagnosis of DMVD is essential for surgical planning: despite two-dimensional (2D) echocardiography leads the initial assessment of mitral anatomy and regurgitation (MR), specific softwares, that elaborate the three-dimensional (3D) transesophageal echocardiography (TEE) acquisitions, have been developed to assess more accurately the MV geometry and mobility 15,16 ; in particular, the 3D TTE evaluation appeared to be superior to the 2D TEE in providing measurements comparable to the surgical examination.…”

“…It has been proved that the use of flexible rings is comparable to rigid rings in terms of mortality and regurgitation recurrence, 11,12 while the flexible band is more effective in preserving the MV area, probably by decreasing the parietal stress and respecting the physiological valve motility 11,13,14 …”