Research

A Near 100% Repair Rate for Mitral Valve Prolapse is Achievable in a Reference Center: Implications for Future Guidelines

 

The Journal of Thoracic and Cardiovascular Surgery
Volume 144, Issue 2, August 2012, Pages 308-312

Javier G. Castillo, MD, Anelechi C. Anyanwu, MD, Valentin Fuster, MD, PhD, and David H. Adams, MD

We have demonstrated that it is possible to repair practically all prolapsing degenerative mitral valves, with a low surgical risk and absence of residual significant mitral regurgitation in a high-volume reference center. Our study is unique because we have not selected patients and have applied mitral valve repair to all comers regardless of complexity of valve disease, patient age or comorbidity, and perceived surgical risk. Most large series of contemporary mitral valve surgery for degenerative disease in reference centers have reported a valve replacement rate of up to 5% to 10%, with preferential use of valve replacement in higher-risk groups, such as elderly patients, or for more complex valve pathology, including bileaflet prolapse. Although other series have also shown repair rates nearing 100%, those series have been limited to a selected group with posterior leaflet prolapse. Although the superiority of repair relative to replacement remains controversial for certain high-risk subsets, we have shown that with a systematic approach it is possible to repair all degenerative valves with low operative risk and good immediate result.

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The Year in Cardiovascular Surgery

 

Journal of the American College of Cardiology
Volume 27, Issue 13, March 29, 2011, Pages 1425-1444

David H. Adams, Joanna Chikwe, Farzan Filsoufi and Anelechi C. Anyanwu

The 2009 literature in cardiovascular surgery was characterized by several pivotal reports that will affect patient care and future trial design for years to come. The purpose of our annual review is to highlight key contributions in the field that focus on strategies and outcomes in cardiovascular surgery that practicing cardiovascular specialists will find both informative and useful in their daily practice. Particular emphasis this year was placed on articles that compare surgical with nonsurgical alternative treatment strategies or those that emphasize potential advances in specific surgical strategies. Our goal as always is to provide readers of the Journal with a succinct summary of specific studies organized around general categories, with pointed comments to highlight special significance or methodological limitations that cardiologists should consider in their pursuit of state-of-the-art care for their patients.

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Degenerative Mitral Valve Regurgitation: Best Practice Revolution

 

European Heart Journal
Volume 31, Issue 16, August 2010, Pages 1958-1966

JDavid H. Adams, Raphael Rosenhek, and Volkmar Falk

Degenerative mitral valve disease often leads to leaflet prolapse due to chordal elongation or rupture, and resulting in mitral valve regurgitation. Guideline referral for surgical intervention centres primarily on symptoms and ventricular dysfunction. The recommended treatment for degenerative mitral valve disease is mitral valve reconstruction, as opposed to valve replacement with a bioprosthetic or mechanical valve, because valve repair is associated with improved event free survival. Recent studies have documented a significant number of patients are not referred in a timely fashion according to established guidelines, and when they are subjected to surgery, an alarming number of patients continue to undergo mitral valve replacement. The debate around appropriate timing of intervention for asymptomatic severe mitral valve regurgitation has put additional emphasis on targeted surgeon referral and the need to ensure a very high rate of mitral valve repair, particularly in the non-elderly population. Current clinical practice remains suboptimal for many patients, and this review explores the need for a 'best practice revolution' in the field of degenerative mitral valve regurgitation.

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Why Do Mitral Valve Repairs Fail?

Journal of the American Society of Echocardiography
Volume 22, Issue 11, November 2009, Pages 1265-1268

Anelechi C. Anyanwu and David H. Adams

Mitral valve repairs, regardless of underlying etiology and the surgical techniques used to effect repair, can fail for 3 reasons: a deficient surgical technique causing immediate failure, a delayed failure of surgical technique, or the progression of native disease.

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The Year in Cardiovascular Surgery

 

Journal of the American College of Cardiology
Volume 53, Issue 25, June 23, 2009, Pages 2389-2403

David H. Adams, Anelechi C. Anyanwu, Joanna Chikwe and Farzan Filsoufi

It is a great challenge to take over the responsibility of providing readers of the JACC with this annual review that highlights key contributions in the cardiovascular surgery literature. This task has been handled with remarkable and enviable efficiency by Robert H. Jones, MD, over the past 5 years. During the series, Dr. Jones altered the format from time to time, generally focusing on reports linking outcomes of patients to decisions about whether an operation should be done. Recognizing the increasing awareness of patients regarding the “how” of surgical procedures, he also sought to highlight relevant data that would help practicing cardiologists counsel patients regarding surgical strategy.

This year we will continue to highlight articles describing outcomes as well as strategy in cardiovascular surgery that practicing cardiovascular specialists will find informative and relevant to patient care. We have organized original articles around general topics, and provide insight into the potential relevance or methodological flaws that readers should consider when evaluating their significance.

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State of the Art: Degenerative Mitral Valve Disease

 

Heart, Lung and Circulation
Volume 18, Issue 5, October 2009, Pages 319-329

Joanna Chikwe and David H. Adams

Mitral valve repair offers superior long-term survival, freedom from cardiac morbidity, and quality of life in patients with severe mitral regurgitation compared to medical management and mitral valve replacement; it is the treatment of choice in these patients. Mitral valve repair is the only treatment that restores normal life expectancy to otherwise healthy patients with advanced degenerative mitral valve disease. This review focuses on indications, timing and techniques for mitral valve repair in degenerative disease, emphasizing the importance of anatomy in surgical outcomes.

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Valve Disease: Asymptomatic Mitral Regurgitation: Does Surgery Save Lives?

 

Nature Reviews Cardiology
Volume 6, Issue 5, May 2009, Pages 330-332

David H. Adams and Anelechi C. Anyanwu

Management of asymptomatic patients with severe mitral valve regurgitation is controversial—conservative surveillance and early mitral valve repair have both been advocated as reasonable approaches on the basis of divergent data. A new study by Kang et al. fuels this debate. However, careful assessment of the existing literature can provide insight into the optimal care of this population of patients.

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Ischemic Mitral Regurgitation: Recent Advances

 

Current Treatment Options in Cardiovascular Medicine
Volume 10, Issue 6, December 2008, Pages 529-537

Anelechi C. Anyanwu and David H. Adams

This article reviews recent developments in the pathophysiology and management of ischemic mitral regurgitation. Recent imaging studies using three-dimensional echocardiography have added clarity to the mechanism responsible for this condition. This article also discusses recent studies on outcomes of surgical repair, including current results and potential risks of restrictive annuloplasty. Because of the limitations imposed by restrictive annuloplasty, adjunctive surgical methods focusing on the left ventricle or papillary muscles are being investigated to address this disease. In the interim, a downsized complete rigid or semirigid annuloplasty repair appears to offer good midterm outcomes.

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Seeking a Higher Standard for Degenerative Mitral Valve Repair: Begin with Etiology

 

The Journal of Thoracic and Cardiovascular Surgery;
Volume 136, Issue 3, September 2008, Pages 551-556

David H. Adams and Anelechi C. Anyanwu

Despite the widely held consensus that valve repair is the preferred surgical treatment for patients suffering from degenerative mitral valve disease, valve replacement for this condition remains all too prevalent. In the past few years interest in mitral valve repair has expanded among cardiologists and surgeons, with the recognition that asymptomatic patients with severe mitral regurgitation may be candidates for surgery provided they are likely to undergo valve repair and obtain a durable result. We address both issues in the context of a recent article published in the Journal, which explored the results of mitral valve repair in degenerative disease according to etiologic classification – Barlow’s disease or fibroelastic deficiency.

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Degenerative Mitral Valve Regurgitation: Surgical Echocardiography

 

Current Cardiology Reports;
Volume 10, Issue 3, May 2008, Pages 218-225

David H. Adams, Anelechi C. Anyanwu, Lissa Sugeng, and Roberto M. Lang

Echocardiography is an essential tool in managing patients with mitral regurgitation. It allows identification and precise summation of anatomic lesions that lead to valve dysfunction. In this article, we highlight important aspects of mitral valve anatomy and pathophysiology as they pertain to surgical repair and discuss the critical role of echocardiography in surgical planning and assessment. Better understanding of surgical anatomy of the mitral valve and systematic segmental valve analysis by echocardiographers will allow easy identification of complex valve lesions or dysfunctions that require advanced surgical skill, techniques, or expertise to affect a repair. By triggering referral of such patients to "reference" mitral valve surgeons and by providing information that enables the surgeons to adequately plan a repair preoperatively, echocardiographers will help eliminate the scenario in which mitral valve replacements are performed because the surgeons discover intraoperatively that it is beyond their skill to repair a valve.

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Tricuspid Valve Repair for Treatment and Prevention of Secondary Tricuspid Regurgitation in Patients Undergoing Mitral Valve Surgery

 

Current Cardiology Reports;
Volume 10, Issue 2, March 2008, Pages 110-117

Ani C. Anyanwu, Joanna Chikwe, and David H. Adams

Secondary or functional tricuspid regurgitation occurring late after mitral valve surgery is associated with high morbidity and mortality. In this article, we review the pathophysiology of secondary tricuspid regurgitation and the evidence supporting the use of tricuspid valve annuloplasty for preventing and treating secondary tricuspid regurgitation. Liberal application of tricuspid valve annuloplasty is recommended to prevent progression of secondary regurgitation, as contrary to widely held opinion, fixing the left-sided valve dysfunction often does not resolve secondary tricuspid valve dysfunction. Based on existing literature, assessing the tricuspid valve annular dimensions can be recommended as part of all mitral valve operations, and annuloplasty strongly considered in patients with tricuspid annular dilatation or moderate to severe tricuspid regurgitation.

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Guidelines for Reporting Mortality and Morbidity After Cardiac Valve Interventions

 

The Journal of Thoracic and Cardiovascular Surgery;Volume 135, Issue 4, April 2008, Pages 732-738
The Annals of Thoracic Surgery; Volume 85, Issue 4, April 2008, Pages 1490-1495
European Journal of Cardio-Thoracic Surgery; Volume 33, Issue 4, April 2008, Pages 523-528

Cary W. Akins MD Craig Miller MD, Marko I. Turina MD, Nicholas T. Kouchoukos MD, Eugene H. Blackstone MD, Gary L. Grunkemeier PhD, Johanna J.M. Takkenberg MD, PhD, Tirone E. David MD, Eric G. Butchart MD, David H. Adams MD, David M. Shahian MD, Siegfried Hagl MD, John E. Mayer MD and Bruce W. Lytle MD.

The Councils of The American Association for Thoracic Surgery, The Society of Thoracic Surgeons, and The European Association for Cardio-Thoracic Surgery have directed an Ad Hoc Liaison Committee for Standardizing Definitions of Prosthetic Heart Valve Morbidity to review current clinical practice to update and clarify these reporting guidelines. The guidelines are intended to cover treatment of all four cardiac valves in both adult and pediatric patients. Further, these guidelines apply uniformly, irrespective of whether the therapy was carried out as a conventional open operation, as a minimally invasive (video-assisted or robotic) surgical procedure, or with percutaneous interventional catheter techniques.

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The Cardiologist’s Role in Increasing the Rate of Mitral Valve Repair in Degenerative Disease

 

Current Opinion in Cardiology;
Volume 23, Issue 2, March 2008, Pages 105-110

David H. Adams and Ani C. Anyanwu

In the hands of reference mitral valve-repair surgeons, 95-100% of degenerative valves are repairable, regardless of etiology; however, in the general cardiac surgical community, the repair rates are around 50%. In contrast to fibroelastic deficiency, Barlow's valves have more complex pathology and require advanced techniques to effect a repair. We present a simple algorithm that enables the cardiologist to stratify degenerative mitral valves into those that are repairable by any experienced cardiac surgeon and those that require reference-center referral to deliver a high probability of repair. Such targeted referral strategy should result in near 100% repair rate for degenerative disease.

Essentially, all degenerative mitral valves are repairable. By matching echocardiographic findings to the appropriate surgical skill level required to consistently deliver a repair, valve replacement for degenerative mitral valve disease should be infrequent.

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Seminars in Thoracic and Cardiovascular Surgery

Volume 19, Issue 2, Pages 89-190 (Summer 2007)

Degenerative Mitral Valve Disease

David H. Adams, MD, Guest Editor

 

Degenerative Mitral Valve Disease: Introduction

David H. Adams

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Etiologic Classification of Degenerative Mitral Valve Disease: Barlow's Disease and Fibroelastic Deficiency

 

Ani C. Anyanwu, David H. Adams

Barlow’s disease and fibroelastic deficiency are the two dominant forms of degenerative mitral valve disease and have unique differentiating characteristics on clinical and echocardiographic assessment. Preoperative differentiation of patients by both cardiologists and surgeons is important because the techniques, surgical skill, and expertise required to achieve a repair vary among these etiological subsets. Barlow’s patients often have multiple complex lesions, thus high rates of repair are only likely to be achieved by a reference mitral valve repair surgeon. In contrast, many forms of fibroelastic disease should be repaired at a high rate by experienced general cardiac surgeons. In this article, we highlight the differentiation of Barlow’s disease and fibroelastic deficiency.

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Principles of Reconstructive Surgery in Degenerative Mitral Valve Disease

 

Farzan Filsoufi, Alain Carpentier

Degenerative mitral valve disease is the most common cause of mitral regurgitation (MR) in developed countries. The most common etiologies of valvular regurgitation are Barlow’s disease and fibroelastic deficiency. ... In patients with degenerative mitral valve disease and severe MR, reconstructive surgery should be performed before the occurrence of clinical symptoms, atrial fibrillation, pulmonary hypertension, and left ventricular dysfunction or enlargement. The goals of reconstructive surgery are preservation or restoration of normal leaflet motion, creation of a large surface of coaptation, and stabilization of the entire annulus with a remodeling annuloplasty. Today, reconstructive techniques are standardized, reliable, and reproducible, and therefore should be applied systematically to all patients with degenerative valvular disease.
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The Intraoperative “Ink Test”: A Novel Assessment Tool in Mitral Valve Repair

 

The Journal of Thoracic and Cardiovascular Surgery;
Volume 133, Issue 6, June 2007, Pages 1635-1636

Ani C. Anyanwu and David H. Adams

Mitral valve repair is the established therapy of choice for most patients with mitral regurgitation. Assessment of repair quality traditionally relies on visual inspection, saline testing, and transesophageal echocardiography (TEE). Although invaluable in assessing valve competency, the saline test is limited because it does not provide confirmation of the surface of coaptation; a valve that is competent on saline testing might actually have a minimal surface of coaptation or excess anterior leaflet tissue below the closure line. Although TEE might demonstrate such imperfections (specifically inadequate zone of coaptation or a tendency for systolic anterior motion), there is an understandable reluctance to reinstitute cardiopulmonary bypass to address such TEE findings if the valve is otherwise competent. Such a strategy, however, leaves some patients with an inadequate surface of coaptation and might be one explanation for recurrent mitral regurgitation.1 There is a need for a technique that allows the surgeon to confirm the amount of leaflet tissue below the valve closure line before weaning from cardiopulmonary bypass. We describe a simple “ink test,” which allows an accurate assessment (and optimization) of the surface of coaptation during mitral valve reconstruction.

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Large Annuloplasty Rings Facilitate Mitral Valve Repair in Barlow’s Disease

 

Presented at the Forty-second Annual Meeting of The Society of Thoracic Surgeons, Chicago, IL, Jan 30–Feb 1, 2006.
The Annals of Thoracic Surgery;
Volume 82, Issue 6, December 2006, Pages 2096-2101

David H. Adams, Ani C. Anyanwu, Parwis B. Rahmanian, Vivian Abascal, Sacha P. Salzberg, Farzan Filsoufi

Mitral valve repair can be predictably performed in Barlow’s disease with excellent early outcomes. Large annuloplasty rings help minimize the risk of systolic anterior motion and are an important adjunct to established repair techniques in this patient cohort with large annular size and excess leaflet tissue.
... as we acheived a 100% success rate (no significant residual MR), with minimal morbidity and no mortality, we believe such complicated mitral valve repairs are worthwhile and are preferable to valve replacement.

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Physiologic Basis for the Surgical Treatment of Ischemic Mitral Regurgitation

 

The American Heart Hospital Journal;
Volume 4, Issue 4, Fall 2006, Pages 261-268

Farzan Filsoufi, Parwis B. Rahmanian, Ani Anyanwu, David H. Adams

Ischemic mitral regurgitation (MR) can complicate severe coronary artery disease and myocardial infarction. Ischemic MR results from left ventricular remodeling after myocardial infarction and can also accompany acute myocardial ischemia. The most common mechanism of ischemic MR is Carpentier's type IIIb dysfunction due to an apical and lateral displacement of papillary muscles leading to a tethering of the mitral leaflets. This apical tenting of the leaflets prevents the free margin from reaching the plane of the annulus, significantly reduces the surface of coaptation, and causes MR. Recent advances in imaging studies have led to a better understanding of the pathophysiology of this condition as well as to the development of innovative surgical approaches to treat this disease. Current research efforts have mainly focused on 2 directions: (1) percutaneous approaches to correct MR, and (2) surgical therapy to address the ventricular component of the disease. In this article, the authors define ischemic MR and review its pathophysiology, current management strategies, and future directions.

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The Pathophysiology of Ischemic Mitral Regurgitation: Implications for Surgical and Percutaneous Intervention

 

Presented at the 2006 ACC i2 Summit in Atlanta, Georgia.
Journal of Interventional Cardiology;
Volume 19, Issue s1, October 2006, Pages S78–S86

Ani Anyanwu, Parwis B. Rahmanian, Farzan Filsoufi, David H. Adams

Mitral regurgitation (MR) resulting from prior myocardial infarction is now recognized as an important clinical sequel that directly impacts the long-term outcome of patients. The pathophysiology of this disease process is now well established, and much clinical interest is currently directed toward defining the optimal management strategy of patients with ischemic MR. This review will focus on current concepts relating to the pathophysiology and therapy of ischemic MR.

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Current Concepts in Mitral Valve Repair for Degenerative Disease

 

Heart Failure Reviews; Special Issue: Mitral Valve Repair,
Volume 11, Number 3, September 2006, Pages 241-257

David H. Adams, Ani Anyanwu, Parwis B. Rahmanian, Farzan Filsoufi

Mitral valve repair remains an underutilized technique for patients with degenerative mitral valve disease. A clear understanding of pathological anatomy and dysfunction helps the referring cardiologist and surgeon define the likelihood of repair for a given patient with mitral valve disease. With currently available surgical techniques, the majority of degenerative mitral valve patients should enjoy the benefits of a valve repair if referred appropriately. Patients referred in a timely fashion that receive a mitral valve repair can expect to enjoy a normal survival in line with the general population.

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Mitral Valve Repair with Carpentier-McCarthy-Adams IMR ETlogix Annuloplasty Ring for Ischemic Mitral Regurgitation: Early Echocardiographic Results From A Multi-Center Study

 

Circulation;
Volume 114, Issue 1 Supplement, July 2006, Pages I588-593

Masao Daimon, Shota Fukuda, David H. Adams, Patrick M. McCarthy, A. Marc Gillinov, Alain Carpentier, Farzan Filsoufi, Vivian M. Abascal, Vera H. Rigolin, Sacha Salzberg, Anna Huskin, Michelle Langenfeld and Takahiro Shiota

Surgical repair of IMR with the novel asymmetric CMA IMR ETlogix annuloplasty ring provided excellent early results with effective reduction of MR, MAD, and leaflet tethering. This novel etiology-specific strategy may result in improved outcomes in IMR patients.

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Another Chapter In an Enlarging Book: Repair Degenerative Mitral Valves

 

Journal of Thoracic and Cardiovascular Surgery;
Volume 125, Issue 6, June 2003, Pages 1197-1199

David H. Adams, Farzan Filsoufi

The superiority of mitral valve repair over replacement in patients with degenerative mitral valve disease is now widely held to be true. It would be surprising to see a single hand raised in a medical audience today if you asked, “Who would prefer to have his or her own valve replaced instead of repaired?” Intuitively it is attractive to keep the parts you were born with. Other potential advantages including better preservation of left ventricular function, avoidance of long-term anticoagulation (mechanical valves) or reoperation (bioprosthetic valves), and improved survival all favor mitral valve repair as the gold standard.

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Pitfalls and Limitations In Measuring and Interpreting the Outcomes of Mitral Valve Repair

 

David H. Adams, Ani Anyanwu

The Journal of Thoracic and Cardiovascular Surgery; Volume 131, Issue 3, March 2006, Pages 523-529
We outline specific challenges in measuring and reporting outcomes of mitral valve repair. Although we illustrate these using the study of Serri and colleagues, the pitfalls are not unique to their study and apply to varying degrees in all studies of mitral valve repair. Knowledge of these pitfalls is necessary to improve the quality of outcomes-based research on mitral valve repair, to allow accurate interpretation of these studies, and also to permit useful extrapolation of results.

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The Clinical Development of Percutaneous Heart Valve Technology: A Position Statement of the Society of Thoracic Surgeons (STS), the American Association for Thoracic Surgery (AATS), and the Society for Cardiovascular Angiography and Interventions (SCAI)

 

Endorsed by the American College of Cardiology Foundation (ACCF) and the American Heart Association (AHA)
Journal of Thoracic and Cardiovascular Surgery; Volume 129, Issue 5, May 2005, Pages 970-976
Journal of the American College of Cardiology; Volume 45, Issue 9, 3 May 2005, Pages 1554-1560
The Annals of Thoracic Surgery; Volume 79, Issue 5, May 2005, Pages 1812-1818
Catheterization and Cardiovascular Interventions; Volume 65, Issue 1, May 2005, Pages 73-79

Thomas A. Vassiliades, Jr, Peter C. Block, Lawrence H. Cohn, David H. Adams, Jeffrey S. Borer, Ted Feldman, David R. Holmes, Warren K. Laskey, Bruce W. Lytle, Michael J. Mack and David O. Williams

This joint position statement represents the combined efforts of four professional societies (Society of Thoracic Surgeons [STS], American Association for Thoracic Surgery [AATS], American College of Cardiology [ACC], and Society for Cardiovascular Angiography and Interventions [SCAI]), two government agencies (the U.S. Food and Drug Administration [FDA] and the Centers for Medicare and Medicaid Services [CMS]), and numerous industry representatives to assess the foreseeable directions of a class of emerging technologies being developed to enable the percutaneous treatment of cardiac valve dysfunction.

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Current Management of Ischemic Mitral Regurgitation

 

The Mount Sinai Journal of Medicine;
Volume 72 Number 2, March 2005, Pages 105-115

Farzan Filsoufi, Sacha P. Salzberg, David H. Adams

A better understanding of the pathophysiology of IMR and increased awareness of its negative impact on long-term survival explain the recent rise in the number of patients referred for surgical correction of IMR at the time of coronary revascularization. The most common mechanism of IMR is Carpentier's type IIIb dysfunction, for which an undersized remodeling annuloplasty is the treatment of choice. In this article we define ischemic mitral regurgitation and review its pathophysiology, clinical presentations, diagnosis, indication for surgery, and management.

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High-Risk Mitral Valve Surgery: Perioperative Hemodynamic Optimization with Nesiritide (BNP)

 

The Annals of Thoracic Surgery;
Volume 80, Issue 2, August 2005, Pages 502-506

Sacha P. Salzberg, Farzan Filsoufi, Anelechi Anyanwu, Kai von Harbou, Alan Gass, Sean P. Pinney, Alain Carpentier and David H. Adams

Nesiritide is a recombinant brain-type natriuretic peptide (BNP), which decreases pulmonary arterial (PA) pressures and myocardial oxygen consumption while increasing coronary flow and urine output. Mitral valve (MV) surgery in patients with severe mitral regurgitation (MR), impaired left ventricular function, and pulmonary hypertension is associated with a high operative mortality. We hypothesized that the perioperative use of Nesiritide is safe, and may improve surgical outcomes.

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Current Results of Combined Coronary Artery Bypass Grafting and Mitral Annuloplasty in Patients with Moderate Ischemic Mitral Regurgitation

 

The Journal of Heart Valve Disease;
Volume 13, Number 5, September 2004, Pages 747-753

Farzan Filsoufi, Lishan Aklog, John G. Byrne, Lawrence H. Cohn, David H. Adams

Recent decreased operative mortality in combined CABG and mitral annuloplasty for moderate ischemic MR suggests that a more liberal application of this approach may be warranted.

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Surgical Treatment of the Ischemic Mitral Valve

 

The Journal of Heart Valve Disease;
Volume 11, Supplement 1, January 2002, Pages S21-S25

David H. Adams, Farzan Filsoufi, Lishan Aklog

It is now understood that Carpentier type IIIb dysfunction is the basis for ischemic MR, and that a reduction remodeling annuloplasty can improve leaflet coaptation in this setting.

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Mitral Valve Repair in Redo Cardiac Surgery

 

Journal of Cardiac Surgery;
Volume 17, Issue 1, January 2002, Pages 40-45

David H. Adams, Farzan Filsoufi, John G. Byrne, Alexandros Karavas, Lishan Aklog

An increasing number of patients are being referred for mitral valve repair in the redo cardiac surgery setting. The most common clinical scenarios involve prior coronary bypass surgery or aortic valve replacement, each presenting special challenges in terms of gaining valve exposure to enable repair while limiting dissection as much as possible.

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