ARTIFICIAL CHORDAE FOR ANTERIOR LEAFLET PROLAPSE: ARE ALL THE ROADS LEADING TO ROME?Antonio Maria Calafiore (a), MD, Antonio Totaro (a), MD, Sotirios Prapas (b), MD, Diego Magnano, MD (a), Stefano Guarracini (c), PhD, Massimo Di Marco (d), MD, Michele Di Mauro (c,e), PhDDepartment of Cardiovascular Diseases, Gemelli Molise, Campobasso, ItalyDivision of Cardiac Surgery A, Henry Dunant Hospital, Athens, GreeceDepartment of Cardiology, “Pierangeli” Hospital, Pescara, ItalyDepartment of Cardiology, “S Spirito” Hospital, Pescara, ItalyCardio‐Thoracic Surgery Department, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands

Based on Carpentier’s classification and principles, the techniques for mitral valve repair continue to evolve. We herein report our experience with the morpho-functional echocardiographic analysis of single mitral leaflets, as different anatomic features, even if conflicting, may coexist not only in the two leaflets, but in the same leaflet as well. A classification is proposed, based on the length (normal, short, or long) and mobility (normal, restricted, or excessive) of mitral leaflets. The surgical techniques adopted for mitral valve repair are the direct consequence of this analysis.

The chordae tendinae connect the papillary muscles to the mitral valve. While the first-order chordae serve to secure the leaflets to maintain valve closure and prevent mitral valve prolapse, the second-order chordae are believed that they play a role in maintaining normal LV size and geometry. The papillary muscles, from where the chordae tendinae originate, function as shock absorbers that compensate for the geometric changes of the left ventricular wall. The second-order chordae connect the PMs to both trigons under tension. The tension distributed towards the second-order chordae has been demonstrate to be more than three-fold that in the first-order counterpart. Cutting the second-order chordae puts all the tension on the first-order chordae, that can go closer to their rupture point. However, it has been experimentally demonstrated that the tension where the first-order chordae break is 6.8 N, by far higher than the maximal tension reached, that is 0.4 N. Even if the clinical reports have been favorable, the importance of cutting the second-order chordae to recover curvature of the anterior leaflet and increasing the coaptation length between the mitral leaflet has been slowly absorbed by the surgical world. Nevertheless, there are progressive demonstrations that chordal tethering affects the anterior leaflet not only in secondary, but also in primary mitral regurgitation, having a not negligeable role in the long-term outcome of mitral repair.

Background and aim of the study. Wrapping of the ascending aorta (AA), isolated or associated with aortoplasty, has never been completely accepted. Some complications, as folding of the aortic wall, compression of the vasa vasorum and changes in the flow pattern, with consequent dilatation of the proximal arch, have been described. We used fresh autologous pericardium (FAP), so far never reported, to wrap the AA, with the aim to stabilize its size when moderately dilated, maintaining the preoperative dimension or limiting the reduction to a few mm. Material and Methods. From 2015 to 2019, 10 patients, who were operated on for valve or coronary surgery or both, underwent wrapping of the AA with FAP. Mean age was 69±7 years and ESII 3.5±1.7. Four patients had moderately impaired ejection fraction (35-49%). Results. There was no early or late mortality. One patient was reoperated on after 48 months for severe mitral regurgitation. At a follow up of 53±14 months, a transthoracic echocardiogram showed that the AA size reduced slightly but significantly, from 45.2±2.0 to 42.5±4.1 mm, p=0.03. The diameter of the proximal arch remained unchanged, from 37.1±1.6 to 36.3±2.9 mm, p=0.20. Conclusions. In presence of moderately dilated AA wrapping can be a reasonable option. The use of FAP stabilizes the size of the aorta after a follow up of 53 months. Maintaining a size similar to the preoperative one avoids the complications related to the procedure.

Resection or exclusion of scars following a myocardial infarction on the LAD territory started even before the beginning of the modern era of cardiac surgery. Many techniques were developed, but there is still confusion on who did what. The original techniques underwent modifications that brought to a variety of apparently new procedures that, however, were only a “revisitation” of what described before. In some case old techniques were reproposed and renamed, without giving credit to the surgeon that was the original designer. Herein we try to describe which are the seminal procedures and some of the most important modifications, respecting however the merit of who first communicated the procedure to the scientific world.

The meta-analysis by Di Tommaso et al demonstrated as elderly patients with mitral regurgitation (MR) undergoing mitral valve repair (MVr) had lower short-term mortality and higher long-term survival with respect to patients undergoing mitral valve replacement (MVR). The benefit of repair is such, that initial surgical strategy is advisable in the elderly even in case of mild symptoms if compared with conservative management. However, even if repair can be performed in presence of some specific etiologies, as degenerative MR or secondary MR, there are always cases where a replacement can be an acceptable solution compared to a repair with uncertain future, regardless of our believes and our technical ability. In this subset of patients, the literature does not show any improvement in outcome of transcatheter mitral repair. Mitral valve repair has to be always done, but look at the etiologies and to the consequences that what is done today can cause tomorrow.

OBJECTIVE. For many years, functional tricuspid regurgitation (FTR) was considered negligible after treatment of left-sided heart valve surgery. The aim of the present network meta-analysis is to summarize the results of four approaches in order to establish the possible gold standard. METHODS A systematic search was performed to identify all publications reporting the outcomes of four approach for FTR, not tricuspid annuloplasty (no TA), suture annuloplasty (SA), flexible (FRA), rigid rings (RRA). All studies reporting at least one the four endpoints (early and late mortality, early and late moderate or more TFR) were included in a Bayesian network meta-analysis. RESULTS There were 31 included studies with 9,663 patients. Aggregate early mortality was 5.3% no TA, 7.2% SA, 6.6% FRA and 6.4% RRA; Early TR moderate-or-more was 9.6%, 4.8%, 4.6% and 3.8%; Late mortality was 22.5%, 18.2%, 11.9% and 11.9%; Late TR moderate-or-more was 27.9%, 18.3%, 14.3% and 6.4%. Rigid or semirigid ring annuloplasty was the most effective approach for decreasing the risk of late moderate or more FTR (–85% vs. no TA; –64% vs. SA; –32% vs. FRA). Concerning late mortality, no significant differences were found among different surgical approaches, however, flexible or rigid rings reduced significantly the risk of late mortality (78% and 47%, respectively) compared with not performing TA mortality. No differences were found for early outcomes. CONCLUSIONS. Ring annuloplasty seems to offer better late outcomes compare to either suture annuloplasty or not performing TA. In particular rigid or semirigid rings provides more stable FTR across time.

Mitral valve (MV) repair for mitral regurgitation (MR) due to posterior leaflet (PL) prolapse is achieved nowadays with a great success rate and a good survival, similar, in certain subgroups. In this paper, Sakaguchi et al describe their results in two groups of patients with PL prolapse. Some patients underwent resection (resection group) and others chordal replacement with/out limited resection (respect group). Results were similar in terms of survival and MR recurrence. Our goal is to eliminate, as much as possible, MR when a patient with degenerative MR is operated on. Reduction of the mitral orifice and consequently an increase of the transmitral gradient is the rule. MV repair for degenerative MR provides great results, but there is not a single surgical technique. A close evaluation of the anatomical findings will allow us to choose the best strategy for the individual patient. An open mind is the most important characteristic that a surgeon should have to repair a prolapsing PL without residual regurgitation and dangerous gradients.

Large studies demonstrated that moderate or severe patient-prosthesis mismatch (PPM) occurs in 44.2% to 65% of patients undergoing aortic valve replacement. If there is general agreement that patients with PPM have worse outcome than patients without, it is difficult to understand how to prevent this dangerous complication. The formula used to calculate the effective orifice area (EOA) of an implanted aortic prosthesis has many weak points that produce inconsistent results using the same prosthetic valve (type and size). The observed EOA (3 to 6 months postoperatively) of a #23 biological prosthesis can range from 0.9 to 3.5 cm², making PPM prevention impossible using projected EOA, where only the mean value is reported (1.83 cm² for the same #23 biological prosthesis). An EACTS-STS-AATS Valve Labelling Task Force has been established to suggest the manufacturers to present essential information on valvular prosthesis characteristics in standardized Valve Charts. For valves used in the aortic position, Valve Charts should include a standardized PPM chart to assess the probability of PPM after implantation. This will not solve completely the conundrum of prevention, but most likely it will be a step ahead.

In the last decades, the overlapping areas of intervention between cardiac surgeons and interventional cardiologists are rocketing, especially in the field of treatment of heart valve disease. But, while for the aortic valve the competition, even for non-high risk patients, has become tightened, in the context of mitral regurgitation, the surgery seems to not have competitors .In fact looking the results of studies published so far, a question arises: Is surgery the fair competitor for the Mitraclip? The meta-analysis by Abdul Khader et al summarized few evidences present in this field, only 11 observational studies and 1 randomized trial, providing an awesome response: “NO”. Is therefore not a case if recently two trials, MITRA-FR and COAPT, chose to use as competitor for MitraClip, more rightly, medical therapy instead of surgery. In conclusions, in case of mitral regurgitation, surgery is still largely the gold standard treatment and so MitraClip cannot be mention at all as competitor of surgery. It can be the right choice of case of primary MR where patients showed high risk for surgery. In case of secondary MR, especially with large and poor left ventricle we should wait for a clear answer on its role, yet.

In secondary mitral regurgitation, the concept that the mitral valve (MV) is an innocent bystander, has been challenged by many studies in the last decades. The MV is a living structure with an intrinsic plasticity that reacts to changes in stretch or in mechanical stress activating bio-humoral mechanisms that have, as purpose, the adaptation of the valve to the new environment. If the adaptation is balanced, the leaflets increase both surface and length and the chordae tendinae lengthen: the result is a valve with different characteristics, but able to avoid or to limit the regurgitation. However, if the adaptation is unbalanced, the leaflets and the chords do not change their size, but become stiffer and rigid, with moderate or severe regurgitation. These changes are mediated mainly by a cytokine, the transforming growth factor β (TGF-β), which is able to promote the changes that the MV needs to adapt to a new hemodynamic environment. In general, mild TGF-β activation facilitates leaflet growth, excessive TGF-β activation, as after a myocardial infarction, results in profibrotic changes in the leaflets, with increased thickness and stiffness. The MV is then a plastic organism, that reacts to the external stimuli, trying to maintain its physiologic integrity. This review has the goal to unveil the secret life of the MV, to understand which stimuli can trigger its plasticity and to explain why the equation “large heart=moderate/severe mitral regurgitation” and “small heart=no/mild mitral regurgitation” does not work into the clinical practice.

Left ventricular surgical remodeling (LVSR) has been, for long time, the procedure applied for large dyskinetic, or akinetic, areas as a consequence of a myocardial infarction, manly located in the left anterior descending area. Many surgical techniques were developed, aimed to a pure reduction of the volume of the left ventricular cavity or to add to volume reduction a more physiologic conical shape. The expansion of interventional procedures invaded most of the fields before treated only by cardiac surgeons. In this issue, Pillay describes an hybrid technique, involving both interventional cardiologists and cardiac surgeons, aimed to LV volume reduction after an anterior myocardial infarction. A series of internal (right ventricular septum) and external (anterior wall) anchors are implanted to approximate the LV free wall to the anterior septum, consequently excluding the scarred myocardium. Although some limitations of this study, the Authors have to be commended for having revitalized a procedure almost eliminated from the surgical scenario