Long-term outcomes of totally endoscopic minimally invasive mitral valve repair for Barlow’s disease: A retrospective cohort study_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

ZHONG Lishan ^1,3 , HUANG Yanying ¹ , WANG Zhenzhong ^2,3 , XIAO Shuo ^2,3 , LI Yuxin ^3,4 , FANG Dou ^3,4 , WANG Qiuji ³ , ZHANG Chaolong ¹ ,  HUANG Huanlei ^1,3

1. Guangdong Cardiovascular Institute, Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, P. R. China;
2. South China University of Technology School of Medicine, Guangzhou, 510641, P. R. China;
3. Guangdong Provincial People’s Hospital, Guangdong Academy of Medical Sciences, Southern Medical University, Guangzhou, 510080, P. R. China;
4. Southern Medical University, Guangzhou, 510515, P. R. China;

Corresponding author：

HUANG Huanlei, Email: huanghuanlei@gdph.org.cn

Keywords：

Barlow’s disease; mitral regurgitation; totally endoscopic minimally invasive; median sternotomy; mitral valve plasty

DOI：

10.7507/1007-4848.202302019

Video：

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Objective To examine the safety, efficacy and durability of totally endoscopic minimally invasive (TEMI) mitral valve repair in Barlow’s disease (BD). Methods A retrospective study was performed on patients who underwent mitral valve repair for BD from January 2010 to June 2021 in the Guangdong Provincial People’s Hospital. The patients were divided into a MS group and a TEMI group according to the surgery approaches. A comparison of the clinical data between the two groups was conducted. Results A total of 196 patients were enrolled, including 133 males and 63 females aged (43.8±14.9) years. There were 103 patients in the MS group and 93 patients in the TEMI group. No hospital death was observed. There was a higher percentage of artificial chordae implantation in the TEMI group compared to the MS group (P=0.020), but there was no statistical difference between the two groups in the other repair techniques (P>0.05). Although the total operation time between the two groups was not statistically different (P=0.265), the TEMI group had longer cardiopulmonary bypass time (P<0.001) and aortic clamp time (P<0.001), and shorter mechanical ventilation time (P<0.001) and postoperative hospitalization time (P<0.001). No statistical difference between the two groups in the adverse perioperative complications (P>0.05). The follow-up rate was 94.2% (180/191) with a mean time of 0.2-12.4 (4.0±2.4) years. Two patients in the MS group died with non-cardiac reasons during the follow-up period. The 3-year, 5-year and 10-year overall survival rates of all patients were 100.0%, 99.2%, 99.2%, respectively. Compared with the MS group, there was no statistical difference in the survival rate, recurrence rate of mitral regurgitation, reoperation rate of mitral valve or adverse cardiovascular and cerebrovascular events in the TEMI group (P＞0.05). Conclusion TEMI approach is a safe, feasible and effective approach for BD with a satisfying long-term efficacy.

Citation： ZHONG Lishan, HUANG Yanying, WANG Zhenzhong, XIAO Shuo, LI Yuxin, FANG Dou, WANG Qiuji, ZHANG Chaolong, HUANG Huanlei. Long-term outcomes of totally endoscopic minimally invasive mitral valve repair for Barlow’s disease: A retrospective cohort study. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2025, 32(1): 114-120. doi: 10.7507/1007-4848.202302019 Copy

1.	Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: Executive summary: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 2021, 143(5): e35-e71.
2.	Cohn LH, Adams DH, Couper GS, et al. Minimally invasive cardiac valve surgery improves patient satisfaction while reducing costs of cardiac valve replacement and repair. Ann Surg, 1997, 226(4): 421-426.
3.	Pojar M, Karalko M, Dergel M, et al. Minimally invasive or sternotomy approach in mitral valve surgery: A propensity-matched comparison. J Cardiothorac Surg, 2021, 16(1): 228.
4.	Cetinkaya A, Geier A, Bramlage K, et al. Long-term results after mitral valve surgery using minimally invasive versus sternotomy approach: A propensity matched comparison of a large single-center series. BMC Cardiovasc Disord, 2021, 21(1): 314.
5.	Mestres CA, Piñón MA, Quintana E. Commentary: The Barlow valve: Understanding disease and symmetry. JTCVS Tech, 2021, 10: 66-67.
6.	van Wijngaarden AL, Kruithof BPT, Vinella T, et al. Characterization of degenerative mitral valve disease: Differences between fibroelastic deficiency and Barlow's disease. J Cardiovasc Dev Dis, 2021, 8(2): 23.
7.	Barlow CW, Ali-Ghosh H, Sajiram S. Functional anatomy and surgical principles of mitral repair for the Barlow valve: Past legacy guides the future. JTCVS Tech, 2021, 10: 58-63.
8.	da Rocha E Silva JG, Spampinato R, Misfeld M, et al. Barlow's mitral valve disease: A comparison of neochordal (Loop) and edge-to-edge (Alfieri) minimally invasive repair techniques. Ann Thorac Surg, 2015, 100(6): 2127-2133.
9.	Muneretto C, Bisleri G, Bagozzi L, et al. Results of minimally invasive, video-assisted mitral valve repair in advanced Barlow's disease with bileaflet prolapse. Eur J Cardiothorac Surg, 2015, 47(1): 46-50.
10.	De Bonis M, Lapenna E, Del Forno B, et al. Minimally invasive or conventional edge-to-edge repair for severe mitral regurgitation due to bileaflet prolapse in Barlow's disease: Does the surgical approach have an impact on the long-term results? Eur J Cardiothorac Surg, 2017, 52(1): 131-136.
11.	Kamiya H, Akhyari P, Minol JP, et al. Simple technique of repair for Barlow syndrome with posterior resection and chordal transfer via minimally invasive approach: Primary experience in a consecutive series of 22 patients. Gen Thorac Cardiovasc Surg, 2017, 65(7): 374-380.
12.	Faerber G, Tkebuchava S, Diab M, et al. Minimally-invasive mitral valve repair of symmetric and asymmetric Barlow's disease. Clin Res Cardiol, 2021, 110(12): 1881-1889.
13.	Hiemstra YL, Tomsic A, Gripari P, et al. Evolution from mitral annular dysfunction to severe mitral regurgitation in Barlow's disease. Interact Cardiovasc Thorac Surg, 2021, 32(4): 506-514.
14.	Dreyfus GD, Dulguerov F. Respect or resect in Barlow disease. J Card Surg, 2022, 37(12): 4047-4052.
15.	Hussain S, Maaz M, Kumar S. Mitral valve repair with the edge-to-edge technique: A 20 years single-center experience. J Card Surg, 2022, 37(11): 4016-4017.
16.	Chemtob RA, Mick S, Gillinov M, et al. Repair of bileaflet prolapse in Barlow syndrome: The 4-chord technique. J Card Surg, 2019, 34(7): 605-609.
17.	Del Forno B, Carino D, Bisogno A, et al. Mitral repair with complete rings or posterior bands in Barlow disease: Long-term results. Ann Thorac Surg, 2023, 115(2): 421-427.
18.	Del Forno B, De Bonis M, Agricola E, et al. Mitral valve regurgitation: A disease with a wide spectrum of therapeutic options. Nat Rev Cardiol, 2020, 17(12): 807-827.
19.	Borger MA, Kaeding AF, Seeburger J, et al. Minimally invasive mitral valve repair in Barlow's disease: Early and long-term results. J Thorac Cardiovasc Surg, 2014, 148(4): 1379-1385.
20.	Speziale G, Nasso G, Esposito G, et al. Results of mitral valve repair for Barlow disease (bileaflet prolapse) via right minithoracotomy versus conventional median sternotomy: A randomized trial. J Thorac Cardiovasc Surg, 2011, 142(1): 77-83.
21.	Sakaguchi T, Totsugawa T, Hayashida A, et al. Stepwise mitral valve repair for Barlow's disease via a minimally invasive approach. J Card Surg, 2020, 35(7): 1471-1476.
22.	Morisaki A, Takahashi Y, Fujii H, et al. Outcomes of loop technique with ring annuloplasty: A >10-year experience. Gen Thorac Cardiovasc Surg, 2022, 70(9): 793-803.
23.	Varghese R, Itagaki S, Anyanwu AC, et al. Predicting systolic anterior motion after mitral valve reconstruction: Using intraoperative transoesophageal echocardiography to identify those at greatest risk. Eur J Cardiothorac Surg, 2014, 45(1): 132-137.
24.	Seeburger J, Borger MA, Falk V, et al. Minimal invasive mitral valve repair for mitral regurgitation: Results of 1339 consecutive patients. Eur J Cardiothorac Surg, 2008, 34(4): 760-765.
25.	Ram E, Moshkovitz Y, Shinfeld A, et al. Three-dimensional video assistance improves early results in minimally invasive mitral valve surgery. ASAIO J, 2021, 67(7): 769-775.
26.	Suri RM, Schaff HV, Meyer SR, et al. Thoracoscopic versus open mitral valve repair: A propensity score analysis of early outcomes. Ann Thorac Surg, 2009, 88(4): 1185-1190.
27.	Jouan J, Berrebi A, Chauvaud S, et al. Mitral valve reconstruction in Barlow disease: Long-term echographic results and implications for surgical management. J Thorac Cardiovasc Surg, 2012, 143(4 Suppl): S17-S20.
28.	Flameng W, Meuris B, Herijgers P, et al. Durability of mitral valve repair in Barlow disease versus fibroelastic deficiency. J Thorac Cardiovasc Surg, 2008, 135(2): 274-282.

1. Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA guideline for the management of patients with valvular heart disease: Executive summary: A report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation, 2021, 143(5): e35-e71.
2. Cohn LH, Adams DH, Couper GS, et al. Minimally invasive cardiac valve surgery improves patient satisfaction while reducing costs of cardiac valve replacement and repair. Ann Surg, 1997, 226(4): 421-426.
3. Pojar M, Karalko M, Dergel M, et al. Minimally invasive or sternotomy approach in mitral valve surgery: A propensity-matched comparison. J Cardiothorac Surg, 2021, 16(1): 228.
4. Cetinkaya A, Geier A, Bramlage K, et al. Long-term results after mitral valve surgery using minimally invasive versus sternotomy approach: A propensity matched comparison of a large single-center series. BMC Cardiovasc Disord, 2021, 21(1): 314.
5. Mestres CA, Piñón MA, Quintana E. Commentary: The Barlow valve: Understanding disease and symmetry. JTCVS Tech, 2021, 10: 66-67.
6. van Wijngaarden AL, Kruithof BPT, Vinella T, et al. Characterization of degenerative mitral valve disease: Differences between fibroelastic deficiency and Barlow's disease. J Cardiovasc Dev Dis, 2021, 8(2): 23.
7. Barlow CW, Ali-Ghosh H, Sajiram S. Functional anatomy and surgical principles of mitral repair for the Barlow valve: Past legacy guides the future. JTCVS Tech, 2021, 10: 58-63.
8. da Rocha E Silva JG, Spampinato R, Misfeld M, et al. Barlow's mitral valve disease: A comparison of neochordal (Loop) and edge-to-edge (Alfieri) minimally invasive repair techniques. Ann Thorac Surg, 2015, 100(6): 2127-2133.
9. Muneretto C, Bisleri G, Bagozzi L, et al. Results of minimally invasive, video-assisted mitral valve repair in advanced Barlow's disease with bileaflet prolapse. Eur J Cardiothorac Surg, 2015, 47(1): 46-50.
10. De Bonis M, Lapenna E, Del Forno B, et al. Minimally invasive or conventional edge-to-edge repair for severe mitral regurgitation due to bileaflet prolapse in Barlow's disease: Does the surgical approach have an impact on the long-term results? Eur J Cardiothorac Surg, 2017, 52(1): 131-136.
11. Kamiya H, Akhyari P, Minol JP, et al. Simple technique of repair for Barlow syndrome with posterior resection and chordal transfer via minimally invasive approach: Primary experience in a consecutive series of 22 patients. Gen Thorac Cardiovasc Surg, 2017, 65(7): 374-380.
12. Faerber G, Tkebuchava S, Diab M, et al. Minimally-invasive mitral valve repair of symmetric and asymmetric Barlow's disease. Clin Res Cardiol, 2021, 110(12): 1881-1889.
13. Hiemstra YL, Tomsic A, Gripari P, et al. Evolution from mitral annular dysfunction to severe mitral regurgitation in Barlow's disease. Interact Cardiovasc Thorac Surg, 2021, 32(4): 506-514.
14. Dreyfus GD, Dulguerov F. Respect or resect in Barlow disease. J Card Surg, 2022, 37(12): 4047-4052.
15. Hussain S, Maaz M, Kumar S. Mitral valve repair with the edge-to-edge technique: A 20 years single-center experience. J Card Surg, 2022, 37(11): 4016-4017.
16. Chemtob RA, Mick S, Gillinov M, et al. Repair of bileaflet prolapse in Barlow syndrome: The 4-chord technique. J Card Surg, 2019, 34(7): 605-609.
17. Del Forno B, Carino D, Bisogno A, et al. Mitral repair with complete rings or posterior bands in Barlow disease: Long-term results. Ann Thorac Surg, 2023, 115(2): 421-427.
18. Del Forno B, De Bonis M, Agricola E, et al. Mitral valve regurgitation: A disease with a wide spectrum of therapeutic options. Nat Rev Cardiol, 2020, 17(12): 807-827.
19. Borger MA, Kaeding AF, Seeburger J, et al. Minimally invasive mitral valve repair in Barlow's disease: Early and long-term results. J Thorac Cardiovasc Surg, 2014, 148(4): 1379-1385.
20. Speziale G, Nasso G, Esposito G, et al. Results of mitral valve repair for Barlow disease (bileaflet prolapse) via right minithoracotomy versus conventional median sternotomy: A randomized trial. J Thorac Cardiovasc Surg, 2011, 142(1): 77-83.
21. Sakaguchi T, Totsugawa T, Hayashida A, et al. Stepwise mitral valve repair for Barlow's disease via a minimally invasive approach. J Card Surg, 2020, 35(7): 1471-1476.
22. Morisaki A, Takahashi Y, Fujii H, et al. Outcomes of loop technique with ring annuloplasty: A >10-year experience. Gen Thorac Cardiovasc Surg, 2022, 70(9): 793-803.
23. Varghese R, Itagaki S, Anyanwu AC, et al. Predicting systolic anterior motion after mitral valve reconstruction: Using intraoperative transoesophageal echocardiography to identify those at greatest risk. Eur J Cardiothorac Surg, 2014, 45(1): 132-137.
24. Seeburger J, Borger MA, Falk V, et al. Minimal invasive mitral valve repair for mitral regurgitation: Results of 1339 consecutive patients. Eur J Cardiothorac Surg, 2008, 34(4): 760-765.
25. Ram E, Moshkovitz Y, Shinfeld A, et al. Three-dimensional video assistance improves early results in minimally invasive mitral valve surgery. ASAIO J, 2021, 67(7): 769-775.
26. Suri RM, Schaff HV, Meyer SR, et al. Thoracoscopic versus open mitral valve repair: A propensity score analysis of early outcomes. Ann Thorac Surg, 2009, 88(4): 1185-1190.
27. Jouan J, Berrebi A, Chauvaud S, et al. Mitral valve reconstruction in Barlow disease: Long-term echographic results and implications for surgical management. J Thorac Cardiovasc Surg, 2012, 143(4 Suppl): S17-S20.
28. Flameng W, Meuris B, Herijgers P, et al. Durability of mitral valve repair in Barlow disease versus fibroelastic deficiency. J Thorac Cardiovasc Surg, 2008, 135(2): 274-282.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Long-term outcomes of totally endoscopic minimally invasive mitral valve repair for Barlow’s disease: A retrospective cohort study

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