Mitral repair best practice: proposed standards

Bridgewater, Ben; Hooper, Timothy L.; Munsch, Christopher; Hunter, Steven; Oppell, Ulrich Von; Livesey, Steven; Keogh, Bruce; Wells, F. C.; Patrick, M.; Kneeshaw, J.; Chambers, John; Masani, Navroz; Ray, Simon

doi:10.1136/hrt.2005.076109

Cited by 119 publications

(72 citation statements)

References 39 publications

(42 reference statements)

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“…It is not clear if every thoracic surgery department can prove that they meet the standard for MV repair. [13]. If an MV repair fails, and a MV prosthesis is implanted, the overall outcome of this patient group has proven to be associated with worse outcome [2].…”

Section: Discussionmentioning

confidence: 99%

“…Surgery MV repair will be performed in centres meeting the standards for best practice regarding MV surgery: low perioperative mortality (<1%), repair rate of >95% in these patients, low reoperation rate after 5 years (<5%), >25 MV repair procedures/year/surgeon and >50/centre [13]. In principle, common daily practice and referring patterns can be followed, if they meet the aforementioned criteria and pending METC approval.…”

Section: Randomisationmentioning

confidence: 99%

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Early mitral valve repair versus watchful waiting in patients with severe asymptomatic organic mitral regurgitation; rationale and design of the Dutch AMR trial, a multicenter, randomised trial

et al. 2012

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Background Asymptomatic severe mitral valve (MV) regurgitation with preserved left ventricular function is a challenging clinical entity as data on the recommended treatment strategy for these patients are scarce and conflicting. For asymptomatic patients, no randomised trial has been performed for objectivising the best treatment strategy. Methods The Dutch AMR (Asymptomatic Mitral Regurgitation) trial is a multicenter, prospective, randomised trial comparing early MV repair versus watchful waiting in asymptomatic patients with severe organic MV regurgitation. A total of 250 asymptomatic patients (18-70 years) with preserved left ventricular function will be included. Intervention will be either watchful waiting or MV surgery. Follow-up will be 5 years. Primary outcome measures are all-cause mortality and a composite endpoint of cardiovascular mortality, congestive heart failure, and hospitalisation for non-fatal cardiovascular and cerebrovascular events. Secondary outcome measures are total costs, cost-effectiveness, quality of life, echocardiographic and cardiac magnetic resonance parameters, exercise tests, asymptomatic atrial fibrillation and brain natriuretic peptide levels. Additionally, the complication rate in the surgery group and rate of surgery in the watchful waiting group will be determined. Implications The Dutch AMR trial will be the first multicenter randomised trial on this topic. We anticipate that the results of this study are highly needed to elucidate the best treatment strategy and that this may prove to be an international landmark study.

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Section: Discussionmentioning

confidence: 99%

Section: Randomisationmentioning

confidence: 99%

Early mitral valve repair versus watchful waiting in patients with severe asymptomatic organic mitral regurgitation; rationale and design of the Dutch AMR trial, a multicenter, randomised trial

et al. 2012

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“…Recent reports indicate that recurrent MR is very uncommon, 92-94 but some cite a significant incidence of late 3 or 4ϩ MR. [95][96][97] The early surgical literature did not investigate or report this discrepancy, but it is now becoming a routine part of mitral valve repair publications. 98,99 It should be kept in mind that reports of late follow-up also reflect an era when the use of intraoperative echocardiography was not routine, so residual MR may have been undetected; some techniques have been largely abandoned (eg, chord shortening); and in general, repair techniques and rings were not as well developed. Recent reports of recurrent 3 to 4ϩ MR range from 1% 72 to 4.8%, 94 5%, 92 9%, 96 and 29%.…”

Section: Contemporary Results Of Surgical Mitral Valve Repairmentioning

confidence: 99%

Evolving Concepts and Technologies in Mitral Valve Repair

Fedak

McCarthy

Bonow³

2008

Circulation

151

109

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“…In England, Bridgewater et al 28 went so far as to make explicit suggestions for criteria about surgical training, the use of intraoperative echocardiography, and surgery for associated atrial fibrillation. In a controversial recommendation, they suggested volume thresholds so that surgeons undertaking mitral repair surgery should be doing >25 repairs each year and that hospitals undertaking mitral repair should be doing >50 repairs each year.…”

Section: Why Is This Important?mentioning

confidence: 99%

Three-dimensional Echocardiography Is Not Essential for Intraoperative Assessment of Mitral Regurgitation

McCarthy

2013

Circulation

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T he problem is not what you see on intraoperative echocardiography; it is what you do not see. Intraoperative transesophageal echocardiography and 3-dimensional (3D) echocardiography provide useful information for the surgeon performing mitral valve surgery, but they are not indispensable. We should consider the outstanding results of the pioneer of mitral valve repair, Professor Alain Carpentier. A report of very late results (>20 years) of the earliest series (1970)(1971)(1972)(1973)(1974)(1975)(1976)(1977)(1978)(1979)(1980)(1981)(1982)(1983)(1984) of mitral valve repair is informative.1 Even without the availability of intraoperative transesophageal echocardiography, the late results were outstanding. At 20 years, freedom from reoperation was 96.9% for patients with posterior leaflet prolapse and 86.2% for patients with anterior prolapse. At the last follow-up (median, 17 years) 15% had moderate or worse mitral regurgitation. An experienced mitral valve surgeon can achieve durable high-quality results without any echocardiography, so 3D echocardiography is not essential. Response by Tsang and Lang on p 658What is essential for mitral valve surgery? The fundamental elements from the surgical standpoint are the same whether the procedure is performed through a sternotomy or a minimally invasive incision or is robotically assisted. Achieving good surgical exposure is paramount.2 Numerous surgical techniques, including the type and location of venous cannulation, the atrial incision, retraction of the atrial wall, sutures to help rotate the valve and improve visualization, and occasionally the use of an instrument pushing from outside the heart to facilitate exposure of commissures or the anterior leaflet, are routine practice to optimally visualize the valve. Unless the surgeon is expert in the first step of the procedure, results will be compromised. A perfect 3D echocardiography image of the valve will not compensate for poor exposure. Although realtime 3D color echocardiography is useful, there is nothing more realistic than real-time 3D color visualization through 2.5-power loupes by the operating surgeon. In addition, the entire subvalvular apparatus can be examined by the surgeon, including subtle pathology of the chords and leaflet that may not be apparent on 3D echocardiography. Three-dimensional echocardiography can visualize the valve during the entire cardiac cycle, but for patients with mitral regurgitation, the surgeon is concerned primarily with the appearance and function of the valve in systole. Inspection of the valve with the saline test, that is, pressurizing the left ventricle with saline (or cardioplegia), is therefore paramount. Once the ventricle is pressurized, the abnormal areas of coaptation become evident. Along with exposure and careful inspection, a thorough understanding of the pathology such as the Carpentier

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Mitral repair best practice: proposed standards

Cited by 119 publications

References 39 publications

Early mitral valve repair versus watchful waiting in patients with severe asymptomatic organic mitral regurgitation; rationale and design of the Dutch AMR trial, a multicenter, randomised trial

Early mitral valve repair versus watchful waiting in patients with severe asymptomatic organic mitral regurgitation; rationale and design of the Dutch AMR trial, a multicenter, randomised trial

Evolving Concepts and Technologies in Mitral Valve Repair

Three-dimensional Echocardiography Is Not Essential for Intraoperative Assessment of Mitral Regurgitation

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