Search Results (269)

Background/Objectives: Minimally invasive (MIS) mitral valve surgery has been proven to be a safe and effective alternative to median sternotomy (ST), with advantages in postoperative recovery and morbidity. However, its role in the setting of infective endocarditis (IE) remains uncertain. This meta-analysis aims to evaluate the outcomes of MIS in mitral valve surgery for infective endocarditis. Methods: A PRISMA-compliant search for studies including patients undergoing MIS for mitral valve IE was performed through 14 January 2026, in PubMed, Scopus and Cochrane. Time-to-event data were reconstructed from published Kaplan–Meier curves. A secondary comparative analysis focusing on MIS versus ST techniques was conducted. Results: Fourteen retrospective studies comprising 949 patients were analyzed. In the MIS cohort, early mortality was 4.2% (95%CI: 1.8%, 7.4%). Overall survival was 86.7% at 1 year, 75.2% at 5 years and 56.2% at 10 years. Freedom from IE-related reoperation remained high at 97.5%, 95.9%, and 90.7% at 1, 5, and 10 years, respectively. Mitral valve repair was performed in 52.5% of patients. In secondary comparative analyses, overall survival at 4-year follow-up was not different between MIS and ST [HR: 0.82 (95%CI: 0.43, 1.57), p = 0.55]. MIS was associated with a significantly shorter intensive care unit (ICU) stay [MD: −1.52 days (95%CI: −2.08, −0.97), p < 0.01]. Conclusions: MIS for mitral valve IE is associated with favorable early and long-term outcomes, comparable survival with sternotomy, and reduced ICU stay. These findings suggest that MIS may be considered as a feasible and potentially effective alternative for the management of mitral valve IE in carefully selected patients. Further prospective comparative studies are warranted. Full article

Mitral valve regurgitation is the second most common valvular heart disease in Europe, and an estimated 10% of individuals older than 75 years have severe mitral regurgitation. Mitral valve repair is the preferred strategy to treat mitral regurgitation and is associated with better outcomes than mitral valve replacement. Despite the proven efficacy of surgical repair, available data in functional aetiologies reported a non-negligible rate of echocardiographically detected severe mitral regurgitation within ten years of the index procedure, in some cases resulting in redo interventions. Data on the optimal management of patients with failed mitral repair remain limited. The aim of this review is to present the available approaches for treating failed mitral valve repair and to describe criteria for selecting the most appropriate strategy on the basis of the underlying mechanism of repair failure, with respect to possible surgical re-repair and novel transcatheter edge-to-edge repair techniques in the presence of favourable mitral valve anatomies. Full article

Background and Clinical Significance: Carcinoid heart disease (CHD) is an uncommon valvular manifestation of neuroendocrine tumours, usually affecting right-sided cardiac valves. Left-sided involvement is rare and is generally associated with bronchopulmonary carcinoid, right-to-left shunting, or markedly elevated circulating vasoactive substances. Therapeutic decision-making is particularly challenging in advanced disease when severe tricuspid regurgitation occurs in patients at prohibitive surgical risk. Case Presentation: We report the case of a 61-year-old male patient with progressive dyspnoea, abdominal distension, lower-limb oedema, facial flushing, and 15 kg of unintentional weight loss. Transthoracic and transoesophageal echocardiography demonstrated torrential tricuspid regurgitation caused by thickened, retracted, and immobile leaflets, with additional mitral and aortic valve involvement, raising strong suspicion of CHD. An agitated-saline contrast study demonstrated delayed right-to-left shunting without patent foramen ovale, suggesting an extracardiac, likely intrapulmonary, shunt. Somatostatin receptor PET/CT identified a pancreatic lesion with metastatic disease, and bone marrow biopsy confirmed neuroendocrine tumour infiltration. Owing to prohibitive surgical risk, as reflected by a Tricuspid Regurgitation Impact Score (TRI-SCORE) with an estimated in-hospital mortality of 65%, unfavourable tricuspid anatomy for repair, and refractory venous congestion, heterotopic bicaval valve implantation was performed (TricValve system -P&F). Discussion: This case highlights the role of echocardiography in recognising the characteristic phenotype of CHD, detecting occult right-to-left shunting, and supporting selection of a palliative transcatheter intervention. It also illustrates the value of a multimodality diagnostic strategy integrating echocardiography, functional oncological imaging, and histopathology in tumour-related cardiac disease. Conclusions: In selected inoperable patients with advanced carcinoid-related tricuspid regurgitation, heterotopic bicaval valve implantation may represent a feasible strategy for reducing venous congestion and improving functional status. Full article

Transcatheter edge-to-edge repair (TEER) is a recent minimally invasive method of managing mitral regurgitation (MR) in dogs with myxomatous mitral valve disease (MMVD). As the goal of intervention is to minimize MR severity, this study aimed to determine the association between reduced MR and changes in myocardial work indices after TEER in dogs. Ten client-owned dogs with moderate-to-severe MR were enrolled in the study, and all underwent TEER with multimodal imaging guidance. Myocardial work was analyzed before and after the procedure, and the MR severity, transmitral pressure gradients, left atrial and ventricular measurements, and index of myocardial work (GWI: the total myocardial work during systole; GCW: work contributing to LV ejection; GWW: ineffective work that contributes to no forward displacement; and GWE: ratio of constructive work to total work) were calculated. TEER significantly reduced MR severity in the majority of dogs, and this MR decrease was associated with a greater efficiency of myocardial work, more constructive work, and less wasted energy. No significant negative associations of moderate post-procedure gradients with short-term clinical outcomes emerged. TEER-mediated reduction in MR improves myocardial function in dogs. However, long-term studies are also needed to examine the effects of residual MR and transmitral gradients on cardiac function and clinical outcome. Full article

Hypertrophic cardiomyopathy (HCM), with or without obstructive phenomena, remains underdiagnosed and undertreated. This condition often involves pathological changes in the mitral valve leaflets and apparatus, which can lead to relevant mitral regurgitation (MR). The mechanism of MR is mostly related to the systolic anterior motion (SAM) of the anterior mitral leaflet. The treatment of patients with hypertrophic obstructive cardiomyopathy (HOCM) with persistent symptoms despite optimal pharmacological therapy includes septal myectomy or transcoronary ablation of septal hypertrophy (TASH). Percutaneous edge-to-edge repair of the mitral valve represents an innovative alternative therapy with promising results regarding clinical symptoms and echocardiographic findings. In this article, we provide a concise, critical overview of the current evidence on this technique in HOCM and delineate future perspectives and unresolved issues. Full article

Background: Mitral regurgitation due to Barlow’s disease remains surgically demanding. Despite widespread experience, consensus is lacking on whether the Alfieri repair can serve as a deliberate and durable rather than a rescue strategy in this complex pathology. Methods: We retrospectively analyzed patients undergoing mitral valve repair due to severe mitral regurgitation resulting from Barlow’s disease using either the Alfieri or Neochordae repair techniques. Patients received a uniform semi–rigid annuloplasty ring, while leaflet resection and concomitant coronary or aortic procedures were excluded. Results: Baseline demographics and echocardiography were broadly comparable. Perioperative mortality was 0% in both cohorts, with similarly low rates of major complications. Aortic cross–clamp time was significantly shorter with Alfieri repair (p < 0.001). No relevant postoperative transmitral gradient or systolic anterior motion occurred. At a mean follow–up of 4.2 years, more–than–moderate MR was observed in one patient per group (Alfieri 2.4% vs. Neochordae 1.2%). At 10 years, the cumulative incidence of more–than–moderate mitral regurgitation and redo mitral surgery was similarly low between techniques (p = 0.810 and p = 0.460). Most patients were NYHA class I–II at last follow–up, demonstrating improved functional status. Echocardiography showed left ventricular reverse remodeling without intergroup differences. Conclusions: These data indicate that the Alfieri approach provides durable competence and hemodynamic safety comparable to the Neochordae technique while reducing cross–clamp time, supporting its use as a deliberate strategy rather than a bailout in anatomically suitable valves. Full article

Background: Annuloplasty is a key component of mitral valve repair, yet the impact of ring design on early outcomes remains unclear. Methods: This retrospective study included 153 consecutive patients undergoing mitral valve repair with annuloplasty. Ring designs were grouped into semi-rigid rings, semi-rigid bands, rigid rings, and other designs. The primary outcome was new-onset postoperative atrial fibrillation (AF). Secondary outcomes included early complications and repair durability based on follow-up echocardiography. Results: Postoperative AF occurred in 14.4% of patients and did not differ across ring design groups (p = 0.791). No independent predictors of AF were identified, although a longer aortic cross-clamp time showed a borderline association. Early outcomes were favorable, with 2.0% mortality and 5.9% rethoracotomy. Follow-up echocardiography was available in 79.7% of patients, with good or moderate repair observed in 95.9%. Echocardiographic repair failure occurred in 2.5% of patients. No clear association was observed between ring design and repair durability. Conclusions: In this real-world cohort, no significant association was detected between annuloplasty ring design and early postoperative AF or short-term outcomes. These findings should be interpreted cautiously, given the low event rate and small subgroup sizes. Full article

Background: Reintervention after mitral valve repair represents a relevant clinical challenge, yet the mechanisms and timing of repair failure remain incompletely defined. Understanding how the interval between index repair and reoperation affects failure mechanisms and the feasibility of repeat repair may help refine surgical strategies. Methods: We retrospectively analyzed 194 patients undergoing repeat mitral valve surgery between 2010 and 2025 after prior repair. Median age was 70 years and 61.3% were male. Patients were stratified by time to reoperation: 0–5 years (n = 91), 6–10 years (n = 42), and >10 years (n = 61). Median left ventricular ejection fraction was 58%, atrial fibrillation prevalence 32.5%, minimally invasive approach 21.6%, and EuroSCORE II 4.8%. Results: Baseline characteristics and operative risk were comparable across groups. However, mechanisms of repair failure differed significantly. Early failures were more commonly due to recurrent leaflet prolapse (47.8%), whereas late failures showed a higher incidence of mitral stenosis (63.9%). The rate of repeat mitral repair decreased over time, being higher in early failures compared with intermediate and late failures (17.6% vs. 14.3% vs. 8.2%). Conclusions: Timing of mitral repair failure is associated with distinct mechanisms and influences surgical management. Early failures are more frequently related to prolapse recurrence and are more amenable to re-repair, whereas late failures are characterized by structural degeneration and more often require valve replacement. Full article

Minimal access cardiac surgery (MACS) can mitigate the increasing risk profile of cardiac surgery patients and is associated with improved postoperative outcomes. One of the ways to manage the steep learning curve of MACS is the use of surgical simulation training. We conducted a narrative review to identify the relevant literature discussing MACS simulation training. We identified 20 studies using our search strategy. Various platforms were represented: high-fidelity (n = 8), low-fidelity (n = 6), and animal studies (n = 6). Virtual reality (VR) appeared in two wet-lab studies as an adjunct. The surgical approach was video-assisted thoracoscopic surgery (VATS) in 11 and robotic-assisted thoracoscopic surgery (RATS) in nine. The most simulated procedure was minimal access mitral valve (MV) repair (n = 16). Most studies (n = 16) evaluated the impact of simulation training on the surgical skill of participants with varying baseline MACS experience. A small proportion of included studies (n = 4) carried out only fidelity testing. While some standardised assessment tools were used, there was considerable variation in how surgical skill and fidelity were assessed. There are an increasing number of publications on MACS simulation training, with equal focus on bench and animal models. MV procedures were the most simulated, suggesting a drive towards increasing the scope of minimal access MV training. Full article

Mitral transcatheter edge-to-edge repair (M-TEER) has emerged as a cornerstone in the management of severe mitral regurgitation, serving as a robust, low-risk alternative to conventional mitral valve surgery. Although thromboembolic risk remains a critical clinical challenge, that varies significantly across the clinical continuum, from pre-procedural substrates to post-procedural management. This review highlights the role of atrial cardiomyopathy in creating a prothrombotic milieu even prior to intervention, while during the procedure, device time emerges as a potentially dominant independent predictor of embolic burden, marking the periprocedural window as the period of peak hazard. Furthermore, this article addresses the notable disparity between the near-universal presence of subclinical ischemic lesions on magnetic resonance imaging and the infrequent incidence of overt neurological deficits. As the post-procedural phase is considered, we discuss the shift from standardized antithrombotic protocols to individualized strategies and the potential role of concomitant left atrial appendage occlusion. Ultimately, integrating these stage-specific clinical and procedural determinants with emerging technologies—like digital twins and artificial intelligence—represents a promising frontier for mitigating embolic risks, optimizing procedural planning and patient safety in the evolving landscape of mitral valve interventions. Full article

Transcatheter structural heart interventions, including aortic, mitral and tricuspid valve replacement or repair, and patent foramen ovale, atrial septal defect, and left atrial appendage closure, have dramatically expanded over the past two decades, providing substantial improvements in both clinical outcomes and quality of life. These interventions are performed in a high-risk patient population, which is at risk for both thrombotic and bleeding complications. The introduction of prosthetic devices into the arterial or venous circulation under heterogeneous hemodynamic conditions inevitably increases the risk for thrombotic events and thromboembolic complications. Consequently, the selection of antithrombotic therapy (AT) regimen and its duration is complex and should be tailored to each patient’s risk profile, balancing the expected risk and benefits. This state-of-the-art review critically examines the thrombotic risks inherent to transcatheter structural heart interventions, synthesizes available evidence and current guidelines recommendations on antithrombotic management, and defines persisting gaps in knowledge while discussing the most relevant ongoing clinical trials. Full article

Background/Objectives: Totally endoscopic mitral valve repair reduces surgical trauma and accelerates recovery but can be technically challenging, particularly for precise annuloplasty suturing. The VirtuoSEW^® (LSI Solutions, Victor, NY 14564m, USA) automated annular suturing system was developed to standardize and simplify suture placement. This study was an early evaluation of this technology’s safety, efficacy, and feasibility in totally endoscopic microInvasive mitral valve repair (µMVr). Methods: We conducted a retrospective observational study of 20 patients with severe mitral valve disease of various etiologies. All patients underwent mitral valve repair using the VirtuoSEW^® system for automated placement of annuloplasty sutures, combined with leaflet resection or chordal management as appropriate. Postoperative outcomes were assessed at one month using echocardiography and clinical evaluation. Perioperative and postoperative complications and early mortality were systematically recorded. Results: VirtuoSEW^®-assisted mitral valve repair was safe and effective, achieving complete elimination of severe mitral regurgitation in all patients (N = 20, 100%). Annuloplasty rings included Physio-ring (N = 12, 60%), Memo 3D (N = 4, 20%), and Memo 4D (N = 4, 20%), combined with leaflet repair techniques: leaflet plication (N = 5, 25%), neochordae implantation (N = 7, 35%), sliding plasty (N = 2, 10%), commissural repair (N = 1, 5%), and hemibutterfly repair (N = 1, 5%). Concomitant procedures included: tricuspid valve repair (N = 1, 5%) and atrial septal defect closure (N = 1, 5%). Mitral annulus diameter decreased from 42.0 ± 5.3 mm to 34.2 ± 2.2 mm (p = 0.001). Mean total surgery, cardiopulmonary bypass, and aortic cross-clamp times were 170.3 ± 21.3, 143.4 ± 21.5, and 80.4 ± 7.9 min, respectively. ICU stay was 1.0 ± 0.2 days, with a hospital stay of 8.0 ± 1.9 days. No perioperative complications—including bleeding (N = 0, 0%), stroke (N = 0, 0%), infections (N = 0, 0%), or 30-day mortality (N = 0, 0%)—occurred. Conclusions: µMVR invasive mitral valve repair using the VirtuoSEW^® system is safe, effective, and reproducible, as well as compatible with almost all repair techniques, providing complete restoration of valve competence with no early device-related complications. To our knowledge, this is the first clinical study reporting outcomes with this device, supporting its potential to streamline mitral repair and improve procedural efficiency. Full article

Background: Annuloplasty ring sizing is critical for durable outcomes in surgical mitral valve repair (MVr). However, there is no clear consensus on optimal sizing strategies. Artificial intelligence (AI)-based imaging tools may help to reduce uncertainty in preoperative decision-making by providing objective, reproducible and reliable measurements. This study evaluated the predictive capability of a fully automated, computed tomography (CT)-based AI-driven tool for annuloplasty ring sizing in patients undergoing minimally invasive MVr (MI-MVr). Methods: A total of 71 consecutive patients undergoing MI-MVr for Carpentier type II mitral valve insufficiency during the study period were included. Preoperative CT scans were analyzed using a cloud-based, fully automated AI tool to quantify mitral valve geometric parameters. Correlations between AI-derived measurements and implanted ring sizes were assessed using the Pearson correlation test. Univariable and multivariable linear regression analyses were performed to identify independent predictors of ring size selection. Results: Several AI-derived parameters correlated significantly with implanted ring size, with the strongest correlations observed for commissural width (R = 0.693, p < 0.001) and mitral annular area (R = 0.693, p < 0.001). In multivariable regression analysis, these parameters were the strongest predictors of annuloplasty ring size (R² = 0.504, p < 0.001). Using this model, accurate annuloplasty ring sizing could be predicted in 78.8% of patients. There were no in-hospital mortality and residual mitral regurgitation at discharge. Conclusions: A fully automated, CT-based AI-driven tool demonstrated good accuracy for preoperative annuloplasty ring size prediction in MI-MVr and may have the potential to support surgical decision-making, reduce operator dependence, and improve reproducibility. Full article

Background and Objectives: Atrial secondary mitral regurgitation (A-SMR), also referred to as atrial functional mitral regurgitation, has emerged as a distinct clinical phenotype characterized by left atrial enlargement, mitral annular dilatation, and preserved left ventricular geometry and systolic function. Frequently associated with long-standing atrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF), A-SMR challenges the traditional ventricular-centered classification of functional mitral regurgitation (MR) and is increasingly recognized as a clinically relevant condition. Materials and Methods: This narrative review provides an updated and critical overview of current evidence on A-SMR. We summarize available data on pathophysiology, diagnostic imaging, natural history, and therapeutic strategies, with particular emphasis on implications for cardiac surgery and clinical decision-making. Evidence was derived from observational studies, registry analyses, interventional reports, and contemporary guideline documents. Results: A-SMR is primarily driven by atrial remodeling and annular dilatation, with minimal contribution from ventricular distortion or leaflet tethering. Echocardiography and Magnetic Resonance Imaging (MRI) play a central role in diagnosis and phenotypic characterization, allowing differentiation from ventricular functional MR and identification of distinct A-SMR subtypes with potential therapeutic implications. A-SMR is a progressive condition associated with worsening symptoms and adverse clinical outcomes. Rhythm control strategies may reduce MR severity in selected patients by promoting atrial reverse remodeling. Transcatheter edge-to-edge repair (TEER) represents a treatment option for selected high-risk patients, although concerns regarding long-term durability remain in this predominantly annular disease. From a pathophysiological standpoint, surgical mitral valve repair based on annuloplasty directly targets the dominant mechanism of A-SMR and has been associated with favorable outcomes in appropriately selected patients. Conclusions: A-SMR is a distinct and increasingly recognized form of functional MR requiring a mechanism-oriented diagnostic and therapeutic approach. The 2025 ESC/EACTS Guidelines for the management of valvular heart disease have acknowledged A-SMR as a specific clinical phenotype, although dedicated phenotype-specific management recommendations remain limited. Surgical mitral valve repair, particularly when combined with AF ablation, represents a rational treatment strategy in selected patients and may improve long-term outcomes. Full article

Background: Transcatheter edge-to-edge repair (TEER) has emerged as an established treatment option for patients with severe mitral (MR) and tricuspid regurgitation (TR) who are at high surgical risk. Patients referred for TEER frequently present with advanced comorbidities, including cirrhosis or chronic liver disease (CLD). Hepatic dysfunction, driven by chronic venous congestion and impaired cardiac output, represents a key yet underrecognized determinant of prognosis in this population. The impact of TEER on hepatic function and outcomes in patients with advanced liver disease remains incompletely defined. Methods: This systematic review was conducted in accordance with PRISMA 2020 guidelines and registered in PROSPERO. A comprehensive literature search of PubMed, Scopus, Web of Science, and the Cochrane Library was performed up to 16 January 2026, without language restrictions. Studies evaluating mitral or tricuspid TEER in adult patients with cirrhosis, chronic or advanced liver disease, congestive hepatopathy, or cardiohepatic syndrome were included. Hepatic function was assessed using biochemical markers, clinical diagnoses, or composite scores such as Model for End-Stage Liver Disease (MELD) score and Model for End-Stage Liver Disease Excluding INR (MELD-XI). A qualitative synthesis was performed due to heterogeneity in study design and outcome reporting. Results: Twelve studies were included, comprising prospective and retrospective cohorts, registry-based analyses, mechanistic studies, and one illustrative case report. Six studies evaluated mitral TEER (M-TEER) and six tricuspid (T-TEER). Across both valve interventions, impaired baseline hepatic function was consistently associated with increased mortality and adverse clinical outcomes. MELD and MELD-XI scores emerged as robust prognostic markers following both M-TEER and T-TEER. Successful reduction in valvular regurgitation was associated with stabilization or improvement of hepatic parameters in selected patients, particularly after T-TEER. However, advanced cardiohepatic syndrome and limited hepatic reserve were linked to poor outcomes despite procedural success. Conclusions: Hepatic dysfunction is a powerful determinant of prognosis in patients undergoing M-TEER and T-TEER. While TEER may improve hepatic congestion and liver-related parameters in selected patients, outcomes are highly dependent on baseline hepatic reserve and global hemodynamic status. A personalized approach integrating hepatic assessment into patient selection and risk stratification is essential to optimize outcomes in this complex and growing population. Full article