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Endoscopic Papillary Muscle Repositioning For Secondary Mitral Regurgitation In Patients With Severe Left Ventricular Dysfunction
Jonas Pausch, Oliver Bhadra, Hermann Reichenspurner, Lenard Conradi.
University Heart & Vascular Center Hamburg, Hamburg, Germany.

Background Subannular mitral valve (MV) repair techniques have been developed to address increased rates of MR recurrence after MV repair in patients with secondary mitral regurgitation (SMR) type IIIb. Additional papillary muscles repositioning (PMR) is feasible in a minimally-invasive MV surgery setting, nevertheless the periprocedural outcome of patients with severely depressed left ventricular ejection fraction (LVEF) remains unknown. Methods A total of 98 consecutive patients with SMR type IIIb underwent PMR between 2016 and 2021 at our institution. Mainly due to concomitant CABG procedures, 62 patients underwent full-sternotomy and were excluded from the current analysis, whereas 36 patients were treated by a minimally-invasive technique using 3D-endoscopy. Of these, 18 patients suffered from severely depressed LVEF (LVEF≤35%) (study group) and were compared to the remaining 18 patients with LVEF >35% (control group). Periprocedural outcome was retrospectively analyzed. Results Despite more severe impairment of LVEF (study vs. control group LVEF: 30% (29-34) vs. 40% (40-45), p<0.001) and tricuspid annular plane systolic excursion (TAPSE) (17mm (16-19) vs. 22mm (19-25), p=0.002), the severity of SMR (e.g., study vs. control group EROA: 0.27cm² (0.23-0.31) vs. 0.35cm² (0.29-0.38cm²) and the degree of MV leaflet tethering (e.g., study vs. control group tenting height: 13mm (11-14) vs. 11mm (11-12), p=0.57; tenting area: 328mm² (293-350) vs. 291mm² (273-327), p=0.57) were similar. Also, frequencies of concomitant tricuspid valve repair, atrial ablation and occlusion of the left atrial appendage were similar between groups. Duration of surgery, cardiopulmonary bypass and aortic cross clamp times were similar. Perioperative extracorporeal life support (ECLS) was not necessary. Periprocedural rates of low-cardiac-output syndrome (3 (16.7%) study group vs. 1 (5.6%) control group, p=0.29) were similar between groups. Furthermore, postoperative ventilation time (5.7h (4.2-8.7) study group vs. 6.0h (4.6-9.8) control group, p=0.45) and duration of ICU stay (2d (1-3) study group vs. 2d (1-3) control group, p=0.23) were similar. 30-day survival was 100%. Conclusion Standardized PMR via endoscopic MV surgery resulted in favorable periprocedural outcome in patients with severe LV dysfunction. Compared to patients with less severe LV dysfunction, acute results were similar suggesting minimally-invasive surgery can safely be extended to this patient population.

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