- Email: [email protected]
Reoperation rate for recurrent mitral disease is low after robotically assisted mitral valve repair
Accepted Manuscript Reoperation Rate for Recurrent Mitral Disease is Low Following Robotically-Assisted Mitral Valve Repair Amit Taggarse, MD, Joseph A. Dearani, MD, Richard C. Daly, MD, Lucman A. Anwer, MD, Wooseok Choi, MD, Hector I. Michelena, MD, William J. Mauermann, MD, Simon Maltais, MD, PhD PII:
S0022-5223(17)31901-3
DOI:
10.1016/j.jtcvs.2017.08.126
Reference:
YMTC 11954
To appear in:
The Journal of Thoracic and Cardiovascular Surgery
Received Date: 5 May 2017 Revised Date:
3 August 2017
Accepted Date: 24 August 2017
Please cite this article as: Taggarse A, Dearani JA, Daly RC, Anwer LA, Choi W, Michelena HI, Mauermann WJ, Maltais S, Reoperation Rate for Recurrent Mitral Disease is Low Following RoboticallyAssisted Mitral Valve Repair, The Journal of Thoracic and Cardiovascular Surgery (2017), doi: 10.1016/ j.jtcvs.2017.08.126. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
1
Title: Reoperation Rate for Recurrent Mitral Disease is Low Following Robotically-Assisted
2
Mitral Valve Repair
3 Authors: Amit Taggarse, MD1*, Joseph A. Dearani, MD1, Richard C. Daly, MD1, Lucman A.
5
Anwer, MD1,2*, Wooseok Choi, MD1, Hector I. Michelena, MD3, William J. Mauermann, MD4,
6
Simon Maltais, MD, PhD1. * co-first authors
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7
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1. Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, United States
9
2. Department of General Surgery, University of Illinois/Metropolitan Group of Hospitals,
10
Chicago, IL, United States
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3. Department of Cardiology, Mayo Clinic, Rochester, MN, United States
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4. Department of Cardiac Anesthesiology, Mayo Clinic, Rochester, MN, United States
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Disclosures:
15
The authors report no conflict of interest or relevant source of funding.
EP
16 Corresponding Author:
18
Dr. Simon Maltais, MD, PhD
19
Department of Cardiovascular Surgery
20
Mayo Clinic, 200 First St SW, Rochester, MN, 55905
21
Email: [email protected]
22
Telephone: 507-255-7067
23
Word Count: 887 words
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1
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Central Message:
25
Reoperation rate in robotic MVr patients is low and continues to decline. Series assessing
26
outcomes and complications will continue to improve results for this innovative technique for
27
MV repair.
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24
28
Central Picture Legend. Robotic Team at Mayo: Richard C. Daly, Joseph A. Dearani, Simon
30
Maltais (left to right)
SC
29
M AN U
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Video Legend:
33
Complex Bileaflet Barlow repair. Repair was performed using neochords and
34
resection/plication of posterior mitral leaflet.
40 41 42 43
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36 37 38 39
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44 45 46
2
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The last few decades have seen significant progress in mitral valve repair (MVr) surgery. With a
48
growing trend towards minimally invasive cardiac surgery (MICS), robotically-assisted MVr
49
(RA-MVr) has become an increasingly popular alternative approach. MVr is a common
50
procedure, and several authors have previously discussed mechanisms of repair failure and
51
reoperation for recurrent mitral disease.1-3 Suri et al. recently applied the time-tested techniques
52
of open MVr through a robotically-assisted approach and demonstrated excellent mid-term
53
outcomes for severe degenerative mitral regurgitation (MR) with a very low reoperation rate.4 In
54
this report, we further shed light on reoperation for recurrent mitral valve (MV) disease in
55
patients undergoing RA-MVr. We detail causes for reoperation and individually assess their
56
impact on outcomes.
M AN U
SC
RI PT
47
57 Clinical Summary:
59
Following approval from the Mayo Clinic Institutional Review Board, we retrospectively
60
reviewed RA-MVr patients between January 2008 to September 2016 at our institution. From a
61
total cohort of 619 consenting consecutive patients, 12 (1.9%) patients developed moderate or
62
greater recurrent MR. Of these, five patients required a reoperation; three patients had a ruptured
63
anterior mitral leaflet (AML) chord, one had an annuloplasty band dehiscence (ABD) in addition
64
to a ruptured AML chord, and one had an elongated posterior mitral leaflet chord in addition to
65
an ABD. Of note, all chord failures occurred at the leaflet edge. During follow-up, another two
66
patients required re-intervention for indications other than recurrent MR; one patient had MV
67
infective endocarditis and one had a left atrial mass in the vicinity of the MV.
AC C
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58
68
Median time from RA-MVr to reoperation was 182 days (range, 2-1834 days). Only one
69
patient required reoperation within the early postoperative period. Incidentally, this was the only
3
ACCEPTED MANUSCRIPT
70
patient who underwent a robotic re-intervention; all others were approached through a median
71
sternotomy. Of the five patients with recurrent MR, successful MV re-repair was achieved in
72
three patients and the other two underwent MV replacements (Table).
RI PT
73 Discussion:
75
With a growing use of the robotic technology for MVr, an increased understanding of the
76
determinants of success and causes for recurrent MR after primary RA-MVr is essential to
77
continue to improve patient management. Similar to conventional MVr3, 5, our series
78
demonstrates that the most prevalent cause for recurrent MR is indeed native MV disease
79
progression (4/5 recurrent MR reoperations).
M AN U
80
SC
74
Early landmark studies in RA-MVr patients have reported MV related reoperation rates of 3-5%.6-8 In 2014, Yoo et al. described a non-bleeding related reoperation rate of only 1%
82
(2/200).9 In our current Mayo Clinic experience, we also report a similar reoperation rate of 1.1
83
% (7/619). Importantly, reoperation based only on recurrent MR was observed in 0.8% of
84
patients, highlighting the technical success of the procedure. Compared to conventional MVr series which have reported freedom from reoperation
EP
85
TE D
81
rates ranging from 92-94 % at 1 year10, 11 and 79-95% at 5-years10-14, freedom from reoperation
87
in our RA-MVr cohort was 99.2% and 98.6% at 1 and 5-years, respectively. We believe a
88
standardized technique for initial MVr has been a major reason behind our success. We typically
89
utilized a simplified approach to the repair with limited resection and plication as needed. We
90
utilized neochords or chordal transfers for anterior-directed problems. Our annuloplasty strategy
91
includes, in most cases, a one-size fits all 63mm posterior flexible annuloplasty band placed from
92
trigone to trigone.
AC C
86
4
ACCEPTED MANUSCRIPT
93
Improvements in overall RA-MVr outcomes have allowed for an increasing number of complex mitral repairs in recent years; we performed a complex repair in 257/619 (42%)
95
patients. Nevertheless, in accordance with published literature15, the reoperation rate in these
96
patients was still higher than for simple repairs; 4 out of 5 of patients requiring re-intervention
97
for recurrent MR in our cohort had an initial complex repair.
99
Previous studies in conventional MVr patients have demonstrated earlier and improved LV remodeling and a survival benefit in patients with mitral re-repair vs. replacement.3 Mitral re-
SC
98
RI PT
94
repair is often considered technically more challenging but can be accomplished when the
101
mechanism of MR is well understood and is amenable to repair.5 Therefore, MVr patients with
102
recurrent MR should be thoroughly evaluated by transesophageal echocardiography (TEE) for
103
accurate determination of the regurgitation mechanism and candidacy for re-repair.5
104
M AN U
100
As our familiarity and mastery of the various MICS procedures grows, we believe the proportion of re-repair vs. MVR is likely to increase. Technical failures such as ring dehiscence
106
could be proactively addressed by reinforcing annuloplasty sutures in perceived higher risk
107
patients, as well as careful post bypass intra-operative TEE evaluation. Ruptured chords early in
108
the postoperative period can be prevented by improved intraoperative identification of pathology
109
using 3D echocardiographic assessment, allowing for increased utilization of neochords or
110
chordal transfers for flailed or elongated segments and perhaps resulting in a decreased early
111
failure rate. In addition, intra-operative TEE residual MR severity assessment under physiologic
112
blood pressure conditions should be performed, as greater than mild residual MR continues to be
113
an independent predictor of recurrent MR.16
114 115
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105
Supported by encouraging early and mid-term outcomes, RA-MVr continues to be a promising alternative to the conventional sternotomy approach. Reoperation rate in these patients
5
ACCEPTED MANUSCRIPT
is low and with further experience, it is likely to decrease further. Re-repair should be offered as
117
the initial procedure of choice, provided the mechanism of MR is understood and native tissues
118
can withstand re-repair. Results of ongoing comparative studies assessing long-term outcomes
119
for contemporary MVr techniques versus conventional ones will determine the gold standard for
120
this population.
RI PT
116
121
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122 123
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131 132 133 134 135 136
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References: 1. Cerfolio RJ1, Orzulak TA, Pluth JR, Harmsen WS, Schaff HV. Reoperation after valve repair for mitral regurgitation: early and intermediate results. J Thorac Cardiovasc Surg.
142
1996 Jun;111(6):1177-83; discussion 1183-4.
143
RI PT
141
2. Gillinov AM1, Cosgrove DM, Lytle BW, Taylor PC, Stewart RW, McCarthy PM, et al. Reoperation for failure of mitral valve repair. J Thorac Cardiovasc Surg. 1997
145
Mar;113(3):467-73; discussion 473-5.
146
SC
144
3. Suri RM, Schaff HV, Dearani JA, Sundt TM 3rd, Daly RC, Mullany CJ, et al. Recurrent mitral regurgitation after repair: should the mitral valve be re-repaired? J Thorac
148
Cardiovasc Surg. 2006 Dec;132(6):1390-7.
149
M AN U
147
4. Suri RM, Taggarse A, Burkhart HM, Daly RC, Mauermann W, Nishimura RA, et al. Robotic Mitral Valve Repair for Simple and Complex Degenerative Disease: Midterm
151
Clinical and Echocardiographic Quality Outcomes. Circulation. 2015 Nov
152
24;132(21):1961-8.
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150
5. Spoon JN, Nkomo VT, Suri RM, Pislaru SV, Spoon DB, Michelena HI, et al. Mechanisms
154
of Mitral Valve Dysfunction Following Mitral Valve Repair for Degenerative Disease.
155
JACC Cardiovasc Imaging. 2015 Oct;8(10):1223-7.
157 158 159
6. Nifong LW, Chitwood WR, Pappas PS, Smith CR, Argenziano M, Starnes VA, et al.
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156
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153
Robotic mitral valve surgery: a United States multicenter trial. J Thorac Cardiovasc Surg. 2005 Jun;129(6):1395-404.
7. Cheng W, Fontana GP, De Robertis MA, Mirocha J, Czer LS, Kass RM, et al. Is robotic
160
mitral valve repair a reproducible approach? J Thorac Cardiovasc Surg. 2010
161
Mar;139(3):628-33.
7
ACCEPTED MANUSCRIPT
162
8. Nifong LW, Rodriguez E, Chitwood WR Jr. 540 consecutive robotic mitral valve repairs
163
including concomitant atrial fibrillation cryoablation. Ann Thorac Surg. 2012
164
Jul;94(1):38-42; discussion 43. 9. Yoo JS, Kim JB1, Jung SH. Mitral durability after robotic mitral valve repair: analysis of
RI PT
165 166
200 consecutive mitral regurgitation repairs. J Thorac Cardiovasc Surg. 2014
167
Dec;148(6):2773-9.
10. Zhou YX, Leobon B, Berthoumieu P, Roux D, Glock Y, Mei YQ, et al. Long-term
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168
outcomes following repair or replacement in degenerative mitral valve disease. Thorac
170
Cardiovasc Surg. 2010; 58:415–21.
M AN U
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171
11. Gillinov AM, Faber C, Houghtaling PL, Blackstone EH, Lam BK, Diaz R, et al. Repair
172
versus replacement for degenerative mitral valve disease with coexisting ischemic heart
173
disease. J Thorac Cardiovasc Surg. 2003; 125:1350–62.
12. Suri RM, Schaff HV, Dearani JA, Sundt TM 3rd, Daly RC, Mullany CJ, et al. Survival
175
advantage and improved durability of mitral repair for leaflet prolapse subsets in the
176
current era. Ann Thorac Surg. 2006; 82:819–26. 13. Mohty D, Orszulak TA, Schaff HV, Avierinos JF, Tajik JA, Enriquez-Sarano M. Very
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long-term survival and durability of mitral valve repair for mitral valve
179
prolapse. Circulation. 2001;104(12) Suppl 1 :11–7.
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180
14. Gillinov AM, Blackstone EH, Nowicki ER, Slisatkorn W, Al-Dossari G, Johnston DR, et
181
al. Valve repair versus valve replacement for degenerative mitral valve disease. J Thorac
182
Cardiovasc Surg. 2008; 135:885–93.
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15. Rodriguez E, Nifong LW, Chu MW, Wood W, Vos PW, Chitwood WR. Robotic mitral
184
valve repair for anterior leaflet and bileaflet prolapse. Ann Thorac Surg. 2008
185
Feb;85(2):438-44; discussion 444. 16. Suri RM, Clavel MA, Schaff HV, Michelena HI, Huebner M, Nishimura RA, et al. Effect
187
of Recurrent Mitral Regurgitation Following Degenerative Mitral Valve Repair: Long-
188
Term Analysis of Competing Outcomes. J Am Coll Cardiol. 2016 Feb 9;67(5):488-98.
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Tables:
2
Table. Patient characteristics: Robotic MVr patients requiring a reoperation. Reoperation for Recurrent MR Age/
1st operation
Original pathology
Symptoms/ Degree of MR
Reoperation – time from 1st surgery
Reason for Reoperation (technical failure/new pathology/mixed)
Reintervention approach
Procedure performed
New PML chord elongation + ABD (Mixed)
Median Sternotomy
Re-repaired with neochords to PML, new annuloplasty band and ALC
New AML chord rupture. Neochords were intact (New pathology)
Median Sternotomy
Bioprosthetic MVR
Sex
SC
#
RI PT
1
65M
Triangular P2 resection + PAB
Simple
Asymptomatic, severe MR
1835 days
2
76M
Neochordae to AML + ALC + PAB
Complex
Symptomatic, severe MR
55 days
3
48M
Neochordae to AML + ALC + PMC + PAB
Complex
Symptomatic, moderate MR
2 days
Neochord + native chord rupture (Mixed)
Robotically Assisted
Re-repaired with additional neochords
4
44M
PAB / Severe myxomatous disease
Complex
Symptomatic, severe MR
63 days
New AML chord rupture + ABD (Mixed)
Median Sternotomy
Mechanical MVR
5
53M
Neochordae to AML + PMC + PAB
Complex
Symptomatic, severe MR
624 days
Neochord to AML rupture (Technical failure)
Median Sternotomy
Re-repaired with PMC and cleft closure in PML
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Reoperation for reasons other than Recurrent MR
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Triangular PML resection + PMC + PAB
Complex
-
182 days
Infective Endocarditis
7
46M
Triangular PML resection + PAB
Simple
-
410 days
Left Atrial Mass/Thrombus
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64M
Median Sternotomy
Bioprosthetic MVR
Median Sternotomy
Mass Removal
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MR=Mitral regurgitation; AML=Anterior mitral leaflet; PML=Posterior mitral leaflet; ABD=Annuloplasty band dehiscence; MVR=Mitral Valve Replacement; AAB=Anterior Annuloplasty Band; PAB=Posterior Annuloplasty Band; ALC=Anterolateral Commisuroplasty; PMC=Posteromedial Commisuroplasty
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2
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S0022-5223(17)31901-3
DOI:
10.1016/j.jtcvs.2017.08.126
Reference:
YMTC 11954
To appear in:
The Journal of Thoracic and Cardiovascular Surgery
Received Date: 5 May 2017 Revised Date:
3 August 2017
Accepted Date: 24 August 2017
Please cite this article as: Taggarse A, Dearani JA, Daly RC, Anwer LA, Choi W, Michelena HI, Mauermann WJ, Maltais S, Reoperation Rate for Recurrent Mitral Disease is Low Following RoboticallyAssisted Mitral Valve Repair, The Journal of Thoracic and Cardiovascular Surgery (2017), doi: 10.1016/ j.jtcvs.2017.08.126. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
1
Title: Reoperation Rate for Recurrent Mitral Disease is Low Following Robotically-Assisted
2
Mitral Valve Repair
3 Authors: Amit Taggarse, MD1*, Joseph A. Dearani, MD1, Richard C. Daly, MD1, Lucman A.
5
Anwer, MD1,2*, Wooseok Choi, MD1, Hector I. Michelena, MD3, William J. Mauermann, MD4,
6
Simon Maltais, MD, PhD1. * co-first authors
SC
7
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4
1. Department of Cardiovascular Surgery, Mayo Clinic, Rochester, MN, United States
9
2. Department of General Surgery, University of Illinois/Metropolitan Group of Hospitals,
10
Chicago, IL, United States
M AN U
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11
3. Department of Cardiology, Mayo Clinic, Rochester, MN, United States
12
4. Department of Cardiac Anesthesiology, Mayo Clinic, Rochester, MN, United States
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13 14
Disclosures:
15
The authors report no conflict of interest or relevant source of funding.
EP
16 Corresponding Author:
18
Dr. Simon Maltais, MD, PhD
19
Department of Cardiovascular Surgery
20
Mayo Clinic, 200 First St SW, Rochester, MN, 55905
21
Email: [email protected]
22
Telephone: 507-255-7067
23
Word Count: 887 words
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1
ACCEPTED MANUSCRIPT
Central Message:
25
Reoperation rate in robotic MVr patients is low and continues to decline. Series assessing
26
outcomes and complications will continue to improve results for this innovative technique for
27
MV repair.
RI PT
24
28
Central Picture Legend. Robotic Team at Mayo: Richard C. Daly, Joseph A. Dearani, Simon
30
Maltais (left to right)
SC
29
M AN U
31
Video Legend:
33
Complex Bileaflet Barlow repair. Repair was performed using neochords and
34
resection/plication of posterior mitral leaflet.
40 41 42 43
EP
36 37 38 39
AC C
35
TE D
32
44 45 46
2
ACCEPTED MANUSCRIPT
The last few decades have seen significant progress in mitral valve repair (MVr) surgery. With a
48
growing trend towards minimally invasive cardiac surgery (MICS), robotically-assisted MVr
49
(RA-MVr) has become an increasingly popular alternative approach. MVr is a common
50
procedure, and several authors have previously discussed mechanisms of repair failure and
51
reoperation for recurrent mitral disease.1-3 Suri et al. recently applied the time-tested techniques
52
of open MVr through a robotically-assisted approach and demonstrated excellent mid-term
53
outcomes for severe degenerative mitral regurgitation (MR) with a very low reoperation rate.4 In
54
this report, we further shed light on reoperation for recurrent mitral valve (MV) disease in
55
patients undergoing RA-MVr. We detail causes for reoperation and individually assess their
56
impact on outcomes.
M AN U
SC
RI PT
47
57 Clinical Summary:
59
Following approval from the Mayo Clinic Institutional Review Board, we retrospectively
60
reviewed RA-MVr patients between January 2008 to September 2016 at our institution. From a
61
total cohort of 619 consenting consecutive patients, 12 (1.9%) patients developed moderate or
62
greater recurrent MR. Of these, five patients required a reoperation; three patients had a ruptured
63
anterior mitral leaflet (AML) chord, one had an annuloplasty band dehiscence (ABD) in addition
64
to a ruptured AML chord, and one had an elongated posterior mitral leaflet chord in addition to
65
an ABD. Of note, all chord failures occurred at the leaflet edge. During follow-up, another two
66
patients required re-intervention for indications other than recurrent MR; one patient had MV
67
infective endocarditis and one had a left atrial mass in the vicinity of the MV.
AC C
EP
TE D
58
68
Median time from RA-MVr to reoperation was 182 days (range, 2-1834 days). Only one
69
patient required reoperation within the early postoperative period. Incidentally, this was the only
3
ACCEPTED MANUSCRIPT
70
patient who underwent a robotic re-intervention; all others were approached through a median
71
sternotomy. Of the five patients with recurrent MR, successful MV re-repair was achieved in
72
three patients and the other two underwent MV replacements (Table).
RI PT
73 Discussion:
75
With a growing use of the robotic technology for MVr, an increased understanding of the
76
determinants of success and causes for recurrent MR after primary RA-MVr is essential to
77
continue to improve patient management. Similar to conventional MVr3, 5, our series
78
demonstrates that the most prevalent cause for recurrent MR is indeed native MV disease
79
progression (4/5 recurrent MR reoperations).
M AN U
80
SC
74
Early landmark studies in RA-MVr patients have reported MV related reoperation rates of 3-5%.6-8 In 2014, Yoo et al. described a non-bleeding related reoperation rate of only 1%
82
(2/200).9 In our current Mayo Clinic experience, we also report a similar reoperation rate of 1.1
83
% (7/619). Importantly, reoperation based only on recurrent MR was observed in 0.8% of
84
patients, highlighting the technical success of the procedure. Compared to conventional MVr series which have reported freedom from reoperation
EP
85
TE D
81
rates ranging from 92-94 % at 1 year10, 11 and 79-95% at 5-years10-14, freedom from reoperation
87
in our RA-MVr cohort was 99.2% and 98.6% at 1 and 5-years, respectively. We believe a
88
standardized technique for initial MVr has been a major reason behind our success. We typically
89
utilized a simplified approach to the repair with limited resection and plication as needed. We
90
utilized neochords or chordal transfers for anterior-directed problems. Our annuloplasty strategy
91
includes, in most cases, a one-size fits all 63mm posterior flexible annuloplasty band placed from
92
trigone to trigone.
AC C
86
4
ACCEPTED MANUSCRIPT
93
Improvements in overall RA-MVr outcomes have allowed for an increasing number of complex mitral repairs in recent years; we performed a complex repair in 257/619 (42%)
95
patients. Nevertheless, in accordance with published literature15, the reoperation rate in these
96
patients was still higher than for simple repairs; 4 out of 5 of patients requiring re-intervention
97
for recurrent MR in our cohort had an initial complex repair.
99
Previous studies in conventional MVr patients have demonstrated earlier and improved LV remodeling and a survival benefit in patients with mitral re-repair vs. replacement.3 Mitral re-
SC
98
RI PT
94
repair is often considered technically more challenging but can be accomplished when the
101
mechanism of MR is well understood and is amenable to repair.5 Therefore, MVr patients with
102
recurrent MR should be thoroughly evaluated by transesophageal echocardiography (TEE) for
103
accurate determination of the regurgitation mechanism and candidacy for re-repair.5
104
M AN U
100
As our familiarity and mastery of the various MICS procedures grows, we believe the proportion of re-repair vs. MVR is likely to increase. Technical failures such as ring dehiscence
106
could be proactively addressed by reinforcing annuloplasty sutures in perceived higher risk
107
patients, as well as careful post bypass intra-operative TEE evaluation. Ruptured chords early in
108
the postoperative period can be prevented by improved intraoperative identification of pathology
109
using 3D echocardiographic assessment, allowing for increased utilization of neochords or
110
chordal transfers for flailed or elongated segments and perhaps resulting in a decreased early
111
failure rate. In addition, intra-operative TEE residual MR severity assessment under physiologic
112
blood pressure conditions should be performed, as greater than mild residual MR continues to be
113
an independent predictor of recurrent MR.16
114 115
AC C
EP
TE D
105
Supported by encouraging early and mid-term outcomes, RA-MVr continues to be a promising alternative to the conventional sternotomy approach. Reoperation rate in these patients
5
ACCEPTED MANUSCRIPT
is low and with further experience, it is likely to decrease further. Re-repair should be offered as
117
the initial procedure of choice, provided the mechanism of MR is understood and native tissues
118
can withstand re-repair. Results of ongoing comparative studies assessing long-term outcomes
119
for contemporary MVr techniques versus conventional ones will determine the gold standard for
120
this population.
RI PT
116
121
SC
122 123
M AN U
124 125 126 127
131 132 133 134 135 136
EP
130
AC C
129
TE D
128
137 138
6
ACCEPTED MANUSCRIPT
139 140
References: 1. Cerfolio RJ1, Orzulak TA, Pluth JR, Harmsen WS, Schaff HV. Reoperation after valve repair for mitral regurgitation: early and intermediate results. J Thorac Cardiovasc Surg.
142
1996 Jun;111(6):1177-83; discussion 1183-4.
143
RI PT
141
2. Gillinov AM1, Cosgrove DM, Lytle BW, Taylor PC, Stewart RW, McCarthy PM, et al. Reoperation for failure of mitral valve repair. J Thorac Cardiovasc Surg. 1997
145
Mar;113(3):467-73; discussion 473-5.
146
SC
144
3. Suri RM, Schaff HV, Dearani JA, Sundt TM 3rd, Daly RC, Mullany CJ, et al. Recurrent mitral regurgitation after repair: should the mitral valve be re-repaired? J Thorac
148
Cardiovasc Surg. 2006 Dec;132(6):1390-7.
149
M AN U
147
4. Suri RM, Taggarse A, Burkhart HM, Daly RC, Mauermann W, Nishimura RA, et al. Robotic Mitral Valve Repair for Simple and Complex Degenerative Disease: Midterm
151
Clinical and Echocardiographic Quality Outcomes. Circulation. 2015 Nov
152
24;132(21):1961-8.
TE D
150
5. Spoon JN, Nkomo VT, Suri RM, Pislaru SV, Spoon DB, Michelena HI, et al. Mechanisms
154
of Mitral Valve Dysfunction Following Mitral Valve Repair for Degenerative Disease.
155
JACC Cardiovasc Imaging. 2015 Oct;8(10):1223-7.
157 158 159
6. Nifong LW, Chitwood WR, Pappas PS, Smith CR, Argenziano M, Starnes VA, et al.
AC C
156
EP
153
Robotic mitral valve surgery: a United States multicenter trial. J Thorac Cardiovasc Surg. 2005 Jun;129(6):1395-404.
7. Cheng W, Fontana GP, De Robertis MA, Mirocha J, Czer LS, Kass RM, et al. Is robotic
160
mitral valve repair a reproducible approach? J Thorac Cardiovasc Surg. 2010
161
Mar;139(3):628-33.
7
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8. Nifong LW, Rodriguez E, Chitwood WR Jr. 540 consecutive robotic mitral valve repairs
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including concomitant atrial fibrillation cryoablation. Ann Thorac Surg. 2012
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Jul;94(1):38-42; discussion 43. 9. Yoo JS, Kim JB1, Jung SH. Mitral durability after robotic mitral valve repair: analysis of
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200 consecutive mitral regurgitation repairs. J Thorac Cardiovasc Surg. 2014
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Dec;148(6):2773-9.
10. Zhou YX, Leobon B, Berthoumieu P, Roux D, Glock Y, Mei YQ, et al. Long-term
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outcomes following repair or replacement in degenerative mitral valve disease. Thorac
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Cardiovasc Surg. 2010; 58:415–21.
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11. Gillinov AM, Faber C, Houghtaling PL, Blackstone EH, Lam BK, Diaz R, et al. Repair
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versus replacement for degenerative mitral valve disease with coexisting ischemic heart
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disease. J Thorac Cardiovasc Surg. 2003; 125:1350–62.
12. Suri RM, Schaff HV, Dearani JA, Sundt TM 3rd, Daly RC, Mullany CJ, et al. Survival
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advantage and improved durability of mitral repair for leaflet prolapse subsets in the
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current era. Ann Thorac Surg. 2006; 82:819–26. 13. Mohty D, Orszulak TA, Schaff HV, Avierinos JF, Tajik JA, Enriquez-Sarano M. Very
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long-term survival and durability of mitral valve repair for mitral valve
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prolapse. Circulation. 2001;104(12) Suppl 1 :11–7.
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14. Gillinov AM, Blackstone EH, Nowicki ER, Slisatkorn W, Al-Dossari G, Johnston DR, et
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al. Valve repair versus valve replacement for degenerative mitral valve disease. J Thorac
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Cardiovasc Surg. 2008; 135:885–93.
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15. Rodriguez E, Nifong LW, Chu MW, Wood W, Vos PW, Chitwood WR. Robotic mitral
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valve repair for anterior leaflet and bileaflet prolapse. Ann Thorac Surg. 2008
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Feb;85(2):438-44; discussion 444. 16. Suri RM, Clavel MA, Schaff HV, Michelena HI, Huebner M, Nishimura RA, et al. Effect
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of Recurrent Mitral Regurgitation Following Degenerative Mitral Valve Repair: Long-
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Term Analysis of Competing Outcomes. J Am Coll Cardiol. 2016 Feb 9;67(5):488-98.
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Tables:
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Table. Patient characteristics: Robotic MVr patients requiring a reoperation. Reoperation for Recurrent MR Age/
1st operation
Original pathology
Symptoms/ Degree of MR
Reoperation – time from 1st surgery
Reason for Reoperation (technical failure/new pathology/mixed)
Reintervention approach
Procedure performed
New PML chord elongation + ABD (Mixed)
Median Sternotomy
Re-repaired with neochords to PML, new annuloplasty band and ALC
New AML chord rupture. Neochords were intact (New pathology)
Median Sternotomy
Bioprosthetic MVR
Sex
SC
#
RI PT
1
65M
Triangular P2 resection + PAB
Simple
Asymptomatic, severe MR
1835 days
2
76M
Neochordae to AML + ALC + PAB
Complex
Symptomatic, severe MR
55 days
3
48M
Neochordae to AML + ALC + PMC + PAB
Complex
Symptomatic, moderate MR
2 days
Neochord + native chord rupture (Mixed)
Robotically Assisted
Re-repaired with additional neochords
4
44M
PAB / Severe myxomatous disease
Complex
Symptomatic, severe MR
63 days
New AML chord rupture + ABD (Mixed)
Median Sternotomy
Mechanical MVR
5
53M
Neochordae to AML + PMC + PAB
Complex
Symptomatic, severe MR
624 days
Neochord to AML rupture (Technical failure)
Median Sternotomy
Re-repaired with PMC and cleft closure in PML
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EP
TE D
M AN U
1
Reoperation for reasons other than Recurrent MR
1
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Triangular PML resection + PMC + PAB
Complex
-
182 days
Infective Endocarditis
7
46M
Triangular PML resection + PAB
Simple
-
410 days
Left Atrial Mass/Thrombus
RI PT
64M
Median Sternotomy
Bioprosthetic MVR
Median Sternotomy
Mass Removal
EP
TE D
M AN U
SC
MR=Mitral regurgitation; AML=Anterior mitral leaflet; PML=Posterior mitral leaflet; ABD=Annuloplasty band dehiscence; MVR=Mitral Valve Replacement; AAB=Anterior Annuloplasty Band; PAB=Posterior Annuloplasty Band; ALC=Anterolateral Commisuroplasty; PMC=Posteromedial Commisuroplasty
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3 4 5
6
2
AC C
EP
TE D
M AN U
SC
RI PT
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AC C
EP
TE D
M AN U
SC
RI PT
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