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Mitral Valve Surgery: Current Status and Future Challenges
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Mitral Valve Surgery: Current Status and Future Challenges

A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Cardiology".

Deadline for manuscript submissions: 5 October 2025 | Viewed by 6098

Special Issue Editors

Dr. Antonio Lio

E-Mail Website
Guest Editor
Department of Cardiac Surgery and Heart Transplantation, Azienda Ospedaliera San Camillo Forlanini, 00151 Rome, Italy
Interests: cardiac surgery; aortic diseases; heart valve diseases; coronary artery bypass surgery; cardiothoracic surgery; cardiovascular; valvular heart disease
Dr. Marco Russo

E-Mail Website
Guest Editor
Department of Cardiac Surgery and Heart Transplantation, Azienda Ospedaliera San Camillo Forlanini, 00151 Rome, Italy
Interests: cardiac surgery; heart valve diseases; coronary artery bypass surgery; cardiovascular

Special Issue Information

Dear Colleagues,

The treatment of mitral valve disease remains dynamic. The literature has previously shown the great advantage of mitral valve repair over replacement, especially in degenerative mitral valve disease. Since the introduction of the “French Correction” by Carpentier, which remarks the importance of leaflets’ resection, new concepts in leaflet repair techniques have emerged; these modifications have the final goal of the minimization of leaflet resection, focusing on techniques for leaflet remodeling and neochordae implantation.

Moreover, the surgical approach has changed over years and several different approaches have been proposed to minimize the invasiveness of the standard sternotomy approach, such as ministernotomy and minithoracotomy. The latest innovation, the endoscopic approach (including robotic surgery), has gained support in recent years.

To date, no particular technique has definitively demonstrated superiority relative to another, and the benefits of minimally invasive and robotic mitral valve surgery are still a point of debate.

In this scenario, recently, there has been a rapid adoption and implementation of transcatheter alternatives for mitral valve disease, including transcatheter edge-to-edge repair, transapical neochordal implantation and percutaneous annuloplasty (directly, or indirectly through coronary sinus remodeling). Finally, transcatheter alternatives for mitral valve replacement are emerging.

The aim of the present Research Topic is to give the latest evidence or new findings regarding the different approaches in cases of mitral valve repair (resectional vs non-resectional techniques, sternotomy vs minimally invasive/robotic surgery) or replacement (focusing on different surgical prostheses available); manuscripts within this area of research will be accepted.

Moreover, an analysis of transcatheter alternatives and comparison between the results of surgical or transcatheter techniques is encouraged for submission.

Dr. Antonio Lio
Dr. Marco Russo
Guest Editors

Manuscript Submission Information

Manuscripts should be submitted online at www.mdpi.com by registering and logging in to this website. Once you are registered, click here to go to the submission form. Manuscripts can be submitted until the deadline. All submissions that pass pre-check are peer-reviewed. Accepted papers will be published continuously in the journal (as soon as accepted) and will be listed together on the special issue website. Research articles, review articles as well as short communications are invited. For planned papers, a title and short abstract (about 100 words) can be sent to the Editorial Office for announcement on this website.

Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Journal of Clinical Medicine is an international peer-reviewed open access semimonthly journal published by MDPI.

Please visit the Instructions for Authors page before submitting a manuscript. The Article Processing Charge (APC) for publication in this open access journal is 2600 CHF (Swiss Francs). Submitted papers should be well formatted and use good English. Authors may use MDPI's English editing service prior to publication or during author revisions.

Keywords

  • mitral valve
  • mitral valve repair
  • mitral valve replacement
  • minimally invasive surgery
  • robotic surgery

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Published Papers (6 papers)

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Research

10 pages, 944 KiB  
Article
Morphometric Measurements Prior to Totally Endoscopic Mitral Valve Repair: Technical and Educational Aspects
by Marie-Elisabeth Stelzmueller, Daniel Zimpfer and Wilfried Wisser
J. Clin. Med. 2025, 14(8), 2581; https://doi.org/10.3390/jcm14082581 - 9 Apr 2025
Viewed by 381
Abstract
Objective: The totally endoscopic approach is on the rise to become the new standard in mitral valve surgery. The aim of this study was to develop a morphometric measurement tool for educational purposes to predict operability with low conversion and high repair [...] Read more.
Objective: The totally endoscopic approach is on the rise to become the new standard in mitral valve surgery. The aim of this study was to develop a morphometric measurement tool for educational purposes to predict operability with low conversion and high repair rates. Methods: From January 2020 to March 2023, 64 patients underwent totally endoscopic mitral valve repair (TE-MVR). Of these, 15 patients were deemed to be unsuitable for TE-MVR due to narrow space and/or anticipated complex repair techniques and underwent repair through sternotomy (MVR-open). Angio-CT scanning was performed for preoperative planning and measurements of the following: the distance between the sternum and the spine (DSS), the distance between the skin incision and the anterior anulus of the mitral valve (DNM) and the intercostal space at the level of the skin incision (ICS). Results: The repair rate for all patients was 98.7%. In the TE-MVR group, the conversion rate to sternotomy was 3.1%. The 30-day survival was 100%. The DSS was 130.4 ± 18.8 mm and 108.1 ± 17.3 mm, and the DSM 70.7 ± 12.1 mm and 58.5 ± 13.6 mm in the TE-MVR and MVR-open, respectively (p < 0.001). Twenty-one TE-MVR patients were found to be technically demanding due to friction and less freedom to move the instruments. The composite morphometric parameter DSS plus 4xICS minus DNM was 53.3, 39.8 and 25.6 for TE-TMReasy, TE-TMRdemanding and MVR-open, respectively (p < 0.05 and p < 0.01). Conclusions: Surgical skills and a long history of expertise are mandatory to achieve excellent results with a low conversion and high repair rate. The composite morphometric parameter may be an easy tool for educational demands to predict the ease and feasibility of TE-MVR. Full article
(This article belongs to the Special Issue Mitral Valve Surgery: Current Status and Future Challenges)
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10 pages, 568 KiB  
Article
Surgical or Transcatheter Mitral Valve Replacement After Prior Bioprosthesis or Ring Implantation: A Landmark Analysis of Early and Long-Term Outcomes
by Francesco Pollari, Huan Liang, Ferdinand Vogt, Miroslaw Ledwon, Lucia Weber, Joachim Sirch, Erik Bagaev, Matthias Fittkau and Theodor Fischlein
J. Clin. Med. 2024, 13(23), 7097; https://doi.org/10.3390/jcm13237097 - 24 Nov 2024
Viewed by 777
Abstract
Background: In recent years, the use of transcatheter valve-in-valve implantation in the mitral position (TMVI) for the treatment of mitral valve pathology following ring or bioprosthetic implantation has emerged as a less invasive option in comparison to repeated mitral valve surgery (RMVS). We [...] Read more.
Background: In recent years, the use of transcatheter valve-in-valve implantation in the mitral position (TMVI) for the treatment of mitral valve pathology following ring or bioprosthetic implantation has emerged as a less invasive option in comparison to repeated mitral valve surgery (RMVS). We aimed to compare the early and mid-term results of these two strategies. Method: We retrospectively analyzed all patients who underwent a mitral intervention in our institution between 2005 and 2022. Applying the exclusion criteria, 41 subjects were analyzed: 23 underwent RMVS, while 18 underwent a TMVI. The time-dependency treatment effect was approached using a landmark analysis, applying the Kaplan–Meier analysis at different time points. Results: The two study groups were comparable in terms of age (p = 0.18), gender (p = 0.78), body surface area (p = 0.33), and EuroSCORE II (p = 0.06). No patients died perioperatively or had a stroke. Two patients in each group died within the first 30 days following the procedure (RMVS 8.3% vs. TMVI 11.1%; p = 0.75). Eighteen patients had died at follow-up; two underwent re-intervention on their mitral valve (one in each group). The mean survival was not statistically different between groups (RMVS 8 ± 1.1 years, 95% CI 5.8–10.2, vs. TMVI 4.79 ± 0.82 years, 95% CI 3.1–6.4; log-rank = 0.087). A landmark analysis of survival after four years showed significantly worse survival for patients in the TMVI group in comparison with those treated surgically (log-rank = 0.047). Conclusions: TMVI and RMVS are both effective strategies with similar short-term outcomes. However, patients in the TMVI group showed a significantly lower survival rate after four years. Full article
(This article belongs to the Special Issue Mitral Valve Surgery: Current Status and Future Challenges)
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9 pages, 5882 KiB  
Article
Simplifying Mitral Valve Repair with Novel Premeasured Chordal Loops
by Daniel Shell, Natcha Bunwatcharaphan, Michael Seitz, Michael Rowland, Manoras Chengalath and Cheng-Hon Yap
J. Clin. Med. 2024, 13(23), 7029; https://doi.org/10.3390/jcm13237029 - 21 Nov 2024
Viewed by 661
Abstract
Background: The ”respect” approach to surgical mitral valve repair, which involves implanting artificial neochordae, is gaining increased adoption. Surgeons are possibly prone to error in the manual construction of neochordae, which can lead to prolonged cross-clamp times. Novel systems such as Chord-X Pre-Measured [...] Read more.
Background: The ”respect” approach to surgical mitral valve repair, which involves implanting artificial neochordae, is gaining increased adoption. Surgeons are possibly prone to error in the manual construction of neochordae, which can lead to prolonged cross-clamp times. Novel systems such as Chord-X Pre-Measured Loops (On-X Life Technologies, Inc., Austin, TX, USA) eliminate the need for manual neochordae construction, potentially simplifying the mitral repair procedure. However, clinical data on its use are currently limited to a small publication. Methods: We conducted a retrospective cohort study to evaluate the use of Chord-X loops in 40 consecutive patients who underwent surgery in Geelong, Victoria, Australia, between May 2020 and February 2024. Three surgeons participated in this study. Results: All patients were referred for severe mitral valve regurgitation secondary to myxomatous degeneration, with P2 prolapse being the most common pathology. Chord-X Pre-Measured Loops effectively corrected a variety of leaflet pathologies, including bi-leaflet disease, with a single set of loops sufficing in most patients. Intraoperative and follow-up echocardiographic assessments revealed no greater than mild mitral regurgitation in any patient, with 75% exhibiting no or trace mitral regurgitation. Conclusions: The Chord-X Pre-Measured Loops system demonstrated safety, efficacy, and reproducibility across all patients. Surgeons were able to easily adopt this technology without requiring additional training. We believe this technology offers a safe option for surgeons performing low-volume mitral repair surgeries. Full article
(This article belongs to the Special Issue Mitral Valve Surgery: Current Status and Future Challenges)
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11 pages, 1946 KiB  
Article
Contemporary Outcomes of Degenerative Mitral Valve Surgery in a Regional Tertiary Care Center
by Paolo Berretta, Michele Galeazzi, Francesca Spagnolo, Martina Giusti, Simone D’Alessio, Olimpia Bifulco, Emanuele Di Campli, Francesca Mazzocca, Pietro Giorgio Malvindi, Carlo Zingaro, Alessandro D’Alfonso and Marco Di Eusanio
J. Clin. Med. 2024, 13(22), 6751; https://doi.org/10.3390/jcm13226751 - 9 Nov 2024
Viewed by 935
Abstract
Objective: As percutaneous mitral valve techniques become more prevalent, it is important to evaluate the contemporary outcomes of surgical mitral valve interventions. This study assessed the current results and procedural trends of mitral valve surgery for degenerative mitral regurgitation (DMR) at a [...] Read more.
Objective: As percutaneous mitral valve techniques become more prevalent, it is important to evaluate the contemporary outcomes of surgical mitral valve interventions. This study assessed the current results and procedural trends of mitral valve surgery for degenerative mitral regurgitation (DMR) at a regional tertiary care center. Methods: Data were analyzed from 693 consecutive DMR patients who underwent isolated mitral valve operations, with or without tricuspid valve repair and atrial fibrillation ablation between 2017 and 2024. The outcomes were defined according to MVARC criteria. The study endpoints included successful mitral valve repair, in-hospital results, and operative and long-term mortality. Logistic regression was applied to assess the impact of valve lesions and patient risk factors on the probability of valve repair. Survival was analyzed using Kaplan–Meier methodology. The follow up was 100% complete. Results: Mitral valve repair was performed in 90.9% of cases, with only 0.9% requiring the conversion to replacement due to unsuccessful repair. Posterior leaflet lesions had the highest success rate (93.4%), while anterior leaflet lesions had a lower rate (86.2%), with anterior pathology being a negative predictor of repair (OR 2.57, p = 0.02). The type of lesion (prolapse vs. flail), the commissural involvement, and the increased risk for SAM had no statistically significant impact on valve repair outcome. Less invasive transaxillary access was used in 63.2% of patients, and its adoption increased significantly (from 50.9% to 67.4% p = 0.03) over time, resulting in more frequent fast-track extubation and home discharges. The rate of in-hospital mortality was 0.6%, while the rate of 5-year survival was 95.5%. Conclusions: Contemporary surgical techniques for DMR lead to high repair rates and excellent recovery outcomes. Despite the rise in transcatheter options, our findings confirm that surgery remains the gold standard for most DMR patients. Full article
(This article belongs to the Special Issue Mitral Valve Surgery: Current Status and Future Challenges)
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10 pages, 1077 KiB  
Article
Robotic Mitral Valve Repair: Impact of Experience on Results and Complex Mitral Disease Treatment
by Antonio Lio, Marco Russo, Beatrice Sangiorgi, Francesca Nicolò, Ilaria Chirichilli, Francesco Irace, Federico Ranocchi and Francesco Musumeci
J. Clin. Med. 2024, 13(13), 3744; https://doi.org/10.3390/jcm13133744 - 26 Jun 2024
Viewed by 1228
Abstract
Background/Objectives: Robotically assisted mitral valve (MV) surgery is the least invasive surgical approach to the MV. The aim of the present study is to report our experience with robotically assisted MV repair, trying to define how experience could impact on postoperative results. [...] Read more.
Background/Objectives: Robotically assisted mitral valve (MV) surgery is the least invasive surgical approach to the MV. The aim of the present study is to report our experience with robotically assisted MV repair, trying to define how experience could impact on postoperative results. Methods: This is a retrospective study on 144 patients who underwent robotic MV repair from November 2011 to March 2023. Patients were divided in two groups: Group 1, including 39 patients (November 2011–January 2013) operated using the Da Vinci Si system, and Group 2, including 105 patients operated (February 2020–March 2023) using the new Da Vinci Xi system. Results: Mean age was 58 ± 10 years. Increased use of external aortic clamp was observed in Group 2. A significant reduction of surgical times was observed: cardiopulmonary bypass time was 155 ± 44 min in Group 1 and 121 ± 36 min in Group 2 (p = 0.002), whereas cross-clamp time was 112 ± 25 min in Group 1 and 68 ± 39 min in Group 2 (p < 0.001). In-hospital mortality was 0.7%, and 10-year survival was 96 ± 2%. Freedom from reoperation was 100%. A higher percentage of complex and most complex MV repairs were performed in Group 2 (36% in Group 1 vs. 52% in Group 2, p = 0.001). Conclusions: Robotic-assisted MV repair is associated with excellent results. Experience is a key element to overcome the limitations of this technology. Finally, the robotic platform could improve results in difficult MV repair. Full article
(This article belongs to the Special Issue Mitral Valve Surgery: Current Status and Future Challenges)
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11 pages, 4921 KiB  
Article
First-in-Man Study of a Novel, Balloon-Adjustable Mitral Annuloplasty Ring
by Paul Werner, Tandis Aref, Keziban Uyanik-Uenal, Alfred Kocher, Piergiorgio Tozzi, Guenther Laufer and Martin Andreas
J. Clin. Med. 2024, 13(11), 3214; https://doi.org/10.3390/jcm13113214 - 30 May 2024
Cited by 1 | Viewed by 1418
Abstract
Objectives: Mitral valve repair is the current standard approach for mitral valve regurgitation. However, patients suffering from functional mitral regurgitation have a significant risk of recurrent regurgitation. Adjustable mitral rings may provide a solution for this adverse event. Methods: A single-center, [...] Read more.
Objectives: Mitral valve repair is the current standard approach for mitral valve regurgitation. However, patients suffering from functional mitral regurgitation have a significant risk of recurrent regurgitation. Adjustable mitral rings may provide a solution for this adverse event. Methods: A single-center, first-in-man clinical study was performed on patients suffering from mitral valve regurgitation. Patients were implanted with the study ring and followed for six months. A balloon catheter can be inserted into the study ring frame at any time after implantation and inflated independently in the areas P1, P2, or P3, which reduces the anterior-posterior diameter. Results: Five patients (75.4 ± 6.1 years; EuroSCORE II 2.1 ± 0.9%; three female) were successfully implanted. Mechanisms of mitral regurgitation were prolapse of the P2-segment in three patients and annular dilation in two patients. Surgical implantation according to the protocol was feasible and is described herein. Median cardiopulmonary bypass time and cross clamp time were 105 (118; 195) and 94 (90; 151) min, respectively. The median intensive care unit stay was 2 (2; 3) days. No perioperative, 30-day, or 6-month mortality was observed, and the repair was stable without residual or recurrent regurgitation ≥ grade 2. All patients reached the primary endpoint without device-related morbidity. Conclusions: Successful implantation was completed in five patients without device-related adverse events. Ring implantation was safe and feasible for all patients. The opportunity of post-implant adjustment to improve leaflet coaptation is a promising new therapeutic strategy that is assessed in a phase II study. Full article
(This article belongs to the Special Issue Mitral Valve Surgery: Current Status and Future Challenges)
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