Mitral Valve Geometry and Hemodynamics After Surgical MitralValve Annuloplasty and Implications for Percutaneous Treatment

of Patients With Recurrent Mitral Regurgitation

Ibtihal Al Amri, MDa, Philippe Debonnaire, MDa, Tomasz Witkowski, MDa,b, Frank van der Kley, MDa,Meindert Palmen, MD, PhDc, Arend de Weger, MDc, Robert J. Klautz, MD, PhDc,

Jeroen J. Bax, MD, PhDa, Martin J. Schalij, MD, PhDa, Nina Ajmone Marsan, MD, PhDa,and Victoria Delgado, MD, PhDa,*

The feasibility of transcatheter mitral valve therapy (edge-to-edge or valve-in-ring technique)

aDepartment oThe Netherlands;Wroclaw, Poland;Medical Center, L22, 2013; revised

See page 718*CorrespondinE-mail address

0002-9149/13/$ -http://dx.doi.org/1

in patients with significant mitral regurgitation (MR) recurrence after surgical restrictivemitral valve annuloplasty remains unknown. The aim of the present study was to investigatethe eligibility for transcatheter mitral valve therapy of high-surgical-risk patients withsignificant MR recurrence after initial successful restrictive mitral valve annuloplasty. A totalof 47 patients (age 67 – 10 years, 47% men) with significant MR recurrence (effectiveregurgitant orifice area ‡20 mm2, regurgitant volume ‡30 ml/beat, or vena contracta ‡3 mm)after restrictive mitral valve annuloplasty were identified. The long-term outcome of patientsdichotomized according to the surgical risk was evaluated. The echocardiographic parame-ters of mitral valve geometry and hemodynamics at the moment of diagnosis of MR recur-rence were assessed to evaluate the eligibility for transcatheter valve therapy. Duringa median follow-up of 3 years, 23 patients (48.9%) died. The patients with a high-surgical risk(logistic European System for Cardiac Operative Risk Evaluation score ‡20%) had signifi-cantly worse long-term survival than those with a low-surgical risk (logistic European Systemfor Cardiac Operative Risk Evaluation score <20%; 50% and 88%, respectively; p [ 0.002).All high-surgical-risk patients showed geometric mitral valve features that would allowtranscatheter mitral valve therapy (mitral annular area 7 – 2.0 cm2, coaptation length 6 –1.6 mm, anterior and posterior mitral leaflet length 24 – 2.8 mm and 15 – 3.1 mm, respec-tively). In conclusion, patients with significant MR recurrence after initial successfulrestrictive mitral valve annuloplasty and a high risk of redo mitral valve surgery had lowerlong-term survival rates than patients who could undergo repeat surgery. � 2013 ElsevierInc. All rights reserved. (Am J Cardiol 2013;112:714e719)

Functional mitral regurgitation (MR) is an importantprognostic determinant of patients with heart failure.1e4

Optimal medical management can improve heart failuresymptoms and halt progression of left ventricular remodel-ing but does not affect survival.5 Surgical mitral valve repairis an effective therapy that provides significant improve-ments in symptoms and left ventricular function.6,7

However, despite significant advances in surgical tech-niques, the operative risks of patients with heart failure andsignificant functional MR are not negligible, and MRrecurrence rates can reach almost 20% at long-term follow-up.8e11 Reoperation of these high-risk patients has beenassociated with high mortality.8 New minimally invasive ortranscatheter-based mitral valve repair and replacementtechniques might be feasible therapeutic options for patients

f Cardiology, Leiden University Medical Center, Leiden,bDepartment of Cardiology, Fourth Military Hospital,and cDepartment of Thoracic Surgery, Leiden Universityeiden, The Netherlands. Manuscript received Februarymanuscript received and accepted April 19, 2013.for disclosure information.g author: Tel: (þ31) 71-526-2020; fax: (þ31) 71-526-6809.: v.delgado@lumc.nl (V. Delgado).

see front matter � 2013 Elsevier Inc. All rights reserved.0.1016/j.amjcard.2013.04.044

with recurrent MR after surgical mitral valve repair.12e17

The percentage of patients who might be candidates forpercutaneous mitral valve repair or replacement techniquesafter restrictive mitral annuloplasty remains unknown.Accordingly, the present study aimed at evaluating the long-term survival of patients with significant MR recurrenceafter successful surgical restrictive mitral valve annuloplastyand to investigate whether patients with a high risk ofsurgical reoperation would be suitable for transcathetervalve therapy.

Methods

A total of 47 patients with significant recurrence of MRafter initially successful surgical mitral valve repair wereidentified from an ongoing clinical registry. Successfulsurgical restrictive mitral valve annuloplasty was defined asno residual MR and coaptation of the mitral leaflets of�8 mm at the level of the central scallops on the trans-esophageal echocardiogram performed in the operatingtheater.18 Significant MR recurrence was defined as aneffective regurgitant orifice area of �20 mm2, regurgitantvolume of �30 ml/beat, or vena contracta �3 mm.18

Patients with significant MR recurrence due to dehiscence of

www.ajconline.org

Figure 1. Echocardiographic measurements of coaptation length, coaptation depth, tenting area, and mitral leaflet lengths in parasternal long-axis view. Fromthe parasternal long-axis view of the left ventricle (LV), the (A) coaptation length, (B) tenting area and coaptation depth, and (C) length of the mitral leaflets canbe measured. AML ¼ anterior mitral leaflet length; Ao ¼ aorta; LA ¼ left atrium; PML ¼ posterior mitral leaflet length; RV ¼ right ventricle.

Valvular Heart Disease/Transcatheter Valve Therapy for MR Recurrence 715

the mitral ring were excluded. The clinical and echocar-diographic characteristics were collected at the diagnosis ofsignificant MR recurrence. The patients were divided into 2groups according to the operative risk, which was calculatedusing the logistic European System for Cardiac OperativeRisk Evaluation (EuroSCORE): patients with a high oper-ative risk were defined by a logistic EuroSCORE of �20%and those with a low operative risk were defined by alogistic EuroSCORE of <20%. The survival rates of eachgroup were retrospectively evaluated with the follow-upperiod starting with the diagnosis of MR recurrence. Inaddition, the eligibility for transcatheter valve therapy(edge-to-edge repair or valve-in-ring procedure) was eval-uated according to various hemodynamic and geometricparameters of the mitral valve measured on the transthoracicechocardiogram. The clinical and echocardiographic datawere recorded at the departmental Cardiology InformationSystem (EPD-Vision, Leiden University Medical Center,Leiden, The Netherlands) and the echocardiographic data-base and were retrospectively analyzed. The follow-up datawere recorded from a review of the medical records andretrieval of the survival status through municipal civilregistries. The end point was all-cause mortality.

Transthoracic echocardiography (System Five or Vivid 7,GE Norway, Horten, Norway) was performed in all patientsbefore hospital discharge to confirm the absence of MR andrepeated during the follow-up period at the discretion of thetreating physician. The left ventricular dimensions, geom-etry, and function were assessed according to currentrecommendations.19 The mitral valve geometry and hemo-dynamics were evaluated from the echocardiogram thatshowed significant MR recurrence. That echocardiogramwas considered the baseline echocardiogram for the presentevaluation. MR severity was quantitatively determined by

the proximal isovelocity surface area method and bymeasuring the vena contracta according to the currentguidelines.20 The geometry of the mitral valve was evalu-ated in mid-systole, as previously described.21,22 The tentingarea, coaptation depth, and coaptation length were measuredin the parasternal long-axis view. The coaptation length wasmeasured as the length of apposition of the anterior andposterior mitral leaflets at the A2-P2 level (Figure 1). Thetenting area was measured as the area enclosed between theannular line and the mitral leaflets. The coaptation depthwas defined as the distance between the coaptation point andthe annular line (Figure 1). The mobile length of the anteriorand posterior mitral leaflets was measured in mid-diastole(Figure 1). The mitral annular area was calculated accordingto the ellipsoid assumption, measuring the annular diametersat the apical 2- and 4-chamber views.23

Of several percutaneous mitral valve repair techniques,the edge-to-edge procedure using the MitraClip device(Abbott Vascular, Abbott Park, Illinois) has the largestexperience.24 The valve-in-ring implantation has beensuccessfully performed for failed surgical mitral ringannuloplasty using the Edwards SAPIEN valve (EdwardsLifesciences, Irvine, California).12,14,25,26 According tocurrently used clinical criteria in the assessment of theeligibility of a patient for transcatheter valve therapy,24,27,28

patients with recurrence of significant MR were consideredamenable for transcatheter mitral valve therapy if they wereat high surgical risk (logistic EuroSCORE �20%) for redomitral valve repair and did not need any other cardiacsurgery. Furthermore, they should not have a history ofrheumatic valve disease or endocarditis and should have noevidence of acute myocardial infarction in the 12 weeksbefore the intended treatment. Moreover, transesophagealechocardiography and transseptal catheterization had to be

Table 2Surgical history of patients with recurrent mitral regurgitation after mitral valve annuloplasty

Variable All Patients (n ¼ 47) Low-Risk Patients (n ¼ 16) High-Risk Patients (n ¼ 31) p Value

Previous CABG (%) 51 50 52 0.9Previous CorCap cardiac support device (%) 17 13 19 0.6Previous tricuspid valvuloplasty (%) 36 27 40 0.4Complete, semirigid annuloplasty ring (%) 100 100 100 1.0Mitral valve annuloplasty ring size (mm) 27 � 2.2 28 � 2.4 26 � 2.0 0.07

CABG ¼ coronary artery bypass grafting.

Table 1Baseline characteristics of patients with recurrent mitral regurgitation after mitral valve annuloplasty

Variable All Patients (n ¼ 47) Low-Risk Patients(n ¼ 16)

High-Risk Patients(n ¼ 31)

p Value

Age (yrs) 68 � 11 60 � 11 72 � 8 0.001Male gender (%) 47 69 36 <0.05Body surface area (m2) 2 � 0.2 2 � 0.2 2 � 0.2 0.2Ischemic cardiomyopathy (%) 33 47 26 0.2Atrial fibrillation (%) 26 6 36 <0.05Hypertension (%) 50 46 52 0.7Hyperlipidemia (%) 53 46 56 0.6Positive family history for cardiovascular disease (%) 45 54 40 0.4Diabetes mellitus (%) 20 8 26 0.2Smoking (%) 11 14 9 0.6Exsmoker (%) 41 43 39 0.8Chronic obstructive pulmonary disease (%) 17 14 19 0.7Previous stroke (%) 13 21 8 0.2Peripheral vascular disease (%) 13 0 20 0.07New York Heart Association functional class (%) 0.6III 42 36 46IV 21 18 23

Creatinine (mmol/L) 149 � 107 156 � 152 145 � 76 0.8Glomerular filtration rate (ml/min) 57 � 31 68 � 42 50 � 21 0.2Cardiac resynchronization therapy (%) 43 42 44 0.9Medications (%)b Blocker 62 75 56 0.3Angiotensin-converting enzyme or angiotensin receptor blocker 51 42 56 0.4Diuretics 87 75 92 0.2Anticoagulants 51 58 48 0.6Aspirin 95 92 96 0.6Statins 62 67 60 0.7Digoxin 35 42 32 0.6

Figure 2. Cumulative survival of patients dichotomized according tosurgical risk.

716 The American Journal of Cardiology (www.ajconline.org)

feasible. For the transapical valve-in-ring procedure, acomplete annuloplasty ring should have been implantedduring the mitral valve repair and the left ventricle had to betransapically accessible (i.e., no previous cardiac supportdevice). For the transcatheter edge-to-edge procedure, thefollowing echocardiographic parameters are of importance:mitral valve orifice area �2.0 cm2, coaptation length of themitral leaflets >2.0 mm, and sufficient mitral leaflet tissuefor mechanical coaptation, defined as a mitral leaflet lengthof �10 mm.24,27

Continuous variables are presented as the mean � SD andcategorical variables as percentages. Comparisons of thebaseline characteristics between the high-risk and low-risksurgical patients were performed using the Student t test forcontinuous variables and Pearson’s chi-square test for cate-gorical variables. Unadjusted survival rates after significantMR recurrence were calculated using the Kaplan-Meier

method, and log-rank tests were applied to evaluate thedifferences between the survival rates of patients at high andlow operative risk. Patients who were lost to follow-up were

Table 4Echocardiographic mitral valve characteristics of patients with recurrent mitral regurgitation (MR) after mitral valve annuloplasty

Variable All Patients (n ¼ 47) Low-Risk Patients (n ¼ 16) High-Risk Patients (n ¼ 31) p Value

Mitral regurgitant volume (ml) 29 � 10 29 � 11 29 � 11 0.9Effective mitral regurgitant orifice area (mm2) 20 � 10 20 � 10 20 � 10 0.8Vena contracta (mm) 5 � 1 5 � 2 5 � 1 0.8Mitral regurgitation grade 2 � 0.6 2 � 0.5 3 � 0.6 0.6Mitral valve annulus area by ellipsoid assumption (cm2) 7 � 2 7 � 2 6 � 2 0.6Mitral valve ring size (mm) 27 � 2.2 28 � 2.4 26 � 2.0 0.07Mean mitral valve gradient (mm Hg) 4 � 2 4 � 2 4 � 2 0.9Central jet (%) 87 100 81 0.06Coaptation depth (mm) 10 � 3 11 � 3 10 � 4 0.5Coaptation length (mm) 6 � 2 6 � 1 6 � 2 0.7Tenting area (cm2) 1 � 0.8 1 � 0.7 1 � 0.8 0.8Length of the anterior mitral leaflet (mm) 24 � 3 24 � 2 23 � 3 0.2Length of the posterior mitral leaflet (mm) 15 � 3 16 � 3 14 � 3 0.01

Table 3Echocardiographic characteristics of patients with recurrent mitral regurgitation (MR) after mitral valve annuloplasty

Variable All Patients (n ¼ 47) Low-Risk Patients (n ¼ 16) High-Risk Patients (n ¼ 31) p Value

Left ventricular end-diastolic volume (ml) 187 � 72 191 � 93 182 � 60 0.7Left ventricular end-systolic volume (ml) 138 � 65 141 � 85 134 � 53 0.8Left ventricular end-diastolic diameter (mm) 62 � 9 61 � 10 62 � 8 0.7Left ventricular end-systolic diameter 54 � 10 52 � 12 55 � 10 0.5Intraventricular septum thickness (mm) 10 � 3 10 � 2 10 � 3 0.4Posterior wall thickness (mm) 10 � 3 9 � 2 10 � 3 0.9Left ventricular ejection fraction (%) 28 � 10 29 � 11 27 � 10 0.6Pulmonary artery pressure (mm Hg) 39 � 9 38 � 7 40 � 11 0.6

Valvular Heart Disease/Transcatheter Valve Therapy for MR Recurrence 717

considered at risk until the date of last contact, at which pointthey were censored. All statistical tests were 2-tailed, andp <0.05 was considered statistically significant. Statisticalanalysis was performed using the Statistical Package forSocial Sciences, version 17.0.2, for Windows (SPSS,Chicago, Illinois).

Results

The baseline demographic and clinical characteristics ofthe patients are listed in Table 1. The surgical patient historyis listed in Table 2. Of the 47 patients, 31 were considered tohave a high risk of redo mitral valve repair or replacement(logistic EuroSCORE �20%), and 16 to have low operativerisk. The baseline characteristics were similar in bothgroups. However, the high-surgical-risk patients weremostly women, were older, and were more likely to haveatrial fibrillation than the low-surgical-risk patients. Duringa median follow-up of 3.1 years (interquartile range 1.4 to6.4), 23 patients (48.9%) died. Patients with a high risk ofreoperation had significantly worse long-term survival thanthose with a low risk. The cumulative survival curves arepresented in Figure 2. After 3 years of follow-up, thecumulative survival rate of the low-surgical-risk patientswas 88% compared with 50% in the group of patients athigh risk of reoperation at the diagnosis of MR recurrence(p ¼ 0.002).

The baseline echocardiographic characteristics of thepatients are listed in Table 3. The geometric and hemody-namic characteristics of the mitral valve are listed inTable 4. According to their mitral valve characteristics andthe clinical and technical criteria, all high-surgical-riskpatients with MR recurrence would be amenable for trans-catheter valve therapy with the MitraClip device (AbbottVascular). None of the patients had rheumatic valvemorphology or active endocarditis. Previous implantation ofa cardiac support device (e.g., CorCap cardiac supportdevice, Acorn Cardiovascular, St. Paul, Minnesota) might,however, have contraindicated a transapical approach for thevalve-in-ring procedure in 6 patients (19%). However, anantegrade transseptal approach would be still feasible inthese patients.

Discussion

The findings of the present study demonstrated higherlong-term mortality rates at 3 years of follow-up amongpatients with recurrent MR and a high risk of surgical redomitral valve repair or replacement comparedwith patientswhowould potentially qualify for surgical reoperation. However,according to the clinical, technical, and echocardiographiccriteria of the mitral valve anatomy, all high-surgical-riskpatients would qualify for less-invasive transcatheter-basedvalve therapy that eventually might lead to better outcomes.

718 The American Journal of Cardiology (www.ajconline.org)

Functional MR has a recurrence rate of almost 20% aftersurgical mitral valve repair, with mortality risks of �30%with repeat surgery.6e8,10,11 Although reoperative mitralvalve surgery can be performed using a lateral mini-thoracotomy and avoiding repeat sternotomy, most of theseapproaches have been performed on-pump.29 In contrast,transcatheter valve therapy approaches aim at furtherreducing the risks of redo mitral valve repair in selectedhigh-risk patients by also avoiding cardioplegic arrest andcardiopulmonary bypass. Several transcatheter mitral valverepair technologies have been developed in the past decade.In patients with an annuloplasty ring in the mitral position,implantation of a transcatheter-delivered valved stent hasbeen demonstrated to be feasible. This concept, known asthe valve-in-ring procedure, has been described in experi-mental models and a few case reports in which EdwardsSAPIEN devices (Edwards Lifesciences) or Melody valves(Medtronic Heart Valves, Santa Ana, California) weredeployed into previously placed mitral annuloplasty ringsusing a retrograde transapical or antegrade transatrialapproach.12,15e17,25,26 Several technical aspects of thisprocedure should be remembered. First, proper size match-ing of the surgical ring and prosthesis is highly important toprovide optimal prosthetic function and avoid complica-tions. The noncircular shape of the surgical rings challengesthe sizing of the prosthesis. In vitro testing has shown thattranscatheter implantation of the Edwards SAPIEN valvewithin a Carpentier-Edwards Physio annuloplasty ring(Edwards Lifesciences) will lead to a more circular shape ofthe ring, adapting to the shape of the deployed transcathetervalve.17 This has not been described with the Melody valve,which adapted to the D-shape of the annuloplasty ring. Thereported results were promising, with no perivalvularleakage and only trivial to mild central MR.15,16 Anotherconcern is that incomplete rings might not provide thenecessary support for implantation of the Edwards SAPIENvalve prosthesis (Edwards Lifesciences).14 In the presentanalysis, all patients had had a previously surgically placedcomplete semirigid Carpentier-Edwards Physio annulo-plasty ring (Edwards Lifesciences). Another technical aspectis that the transcatheter valve should be positioned at thecenter of the mitral valve with equal proportions within theleft ventricle and the left atrium, to reduce the risk of leafletflaring and ventricular outflow obstruction. Furthermore, inpatients with a history of CorCap cardiac support deviceplacement, a transapical approach for the valve-in-ringprocedure might not be feasible. A transvenous transseptalapproach would, however, be possible in this group ofpatients.

The MitraClip (Abbott Vascular) procedure is becomingan important option among the currently available therapiesfor MR. The main limiting factors seem to be the undesireddevelopment of mitral stenosis and the ability to grasp bothmitral leaflets to deliver the MitraClip (Abbott Vascular).Using the European criteria of mitral valve anatomy, allhigh-surgical-risk patients with recurrent MR in the presentanalysis would have qualified for the transcatheter edge-to-edge procedure. The feasibility of MitraClip (AbbottVascular) implantation in patients with recurrent MR aftersurgical mitral valve annuloplasty was demonstrated by Limet al.13 The use of standard transesophageal imaging was

difficult in these patients because of an echocardiographicshadow caused by the previously placed surgical mitralannuloplasty ring, which limited guidance of MitraClipdevice (Abbott Vascular) placement and assessment ofleaflet grasping and insertion. Because this technique isinherently dependent on echocardiographic imaging duringthe procedure, additional imaging approaches such astransthoracic echocardiography could be necessary.Furthermore, insertion of a MitraClip device (AbbottVascular) after restrictive mitral valve annuloplasty couldpotentially lead to mitral stenosis. Assessment of the mitraltransvalvular gradient is therefore required before theprocedure, realizing that flow accelerations around the ringcould lead to an overestimation of the diastolic gradientswhen assessed by echocardiography.

Some limitations should be acknowledged. First, thepatient population was rather small and precluded us fromperforming multivariate analysis to investigate the indepen-dent determinants of the long-term prognosis of these patients.In addition, the evaluation was retrospective. Despite the earlystage of experience with the transcatheter valve-in-ring andedge-to-edge procedure in patients with recurrent MR aftersurgical mitral valve annuloplasty, these options seem feasiblein high-risk patients. Additional studies are required forclarification of approval indications and long-term efficacy.

Disclosures

Dr. Victoria Delgado received consulting fees from St.Jude Medical and Medtronic. The remaining authors haveno conflicts of interest to disclose.

1. Bursi F, Enriquez-Sarano M, Nkomo VT, Jacobsen SJ, Weston SA,Meverden RA, Roger VL. Heart failure and death after myocardialinfarction in the community: the emerging role of mitral regurgitation.Circulation 2005;111:295e301.

2. Trichon BH, Felker GM, Shaw LK, Cabell CH, O’Connor CM.Relation of frequency and severity of mitral regurgitation to survivalamong patients with left ventricular systolic dysfunction and heartfailure. Am J Cardiol 2003;91:538e543.

3. Bursi F, Barbieri A, Grigioni F, Reggianini L, Zanasi V, Leuzzi C,Ricci C, Piovaccari G, Branzi A, Modena MG. Prognostic implicationsof functional mitral regurgitation according to the severity of theunderlying chronic heart failure: a long-term outcome study. Eur JHeart Fail 2010;12:382e388.

4. RossiA,Dini FL, Faggiano P,Agricola E,CicoiraM, Frattini S, SimioniucA, Gullace M, Ghio S, Enriquez-Sarano M, Temporelli PL. Independentprognostic value of functional mitral regurgitation in patients with heartfailure: a quantitative analysis of 1256 patients with ischaemic and non-ischaemic dilated cardiomyopathy. Heart 2011;97:1675e1680.

5. Carabello BA. The current therapy for mitral regurgitation. J Am CollCardiol 2008;52:319e326.

6. Bax JJ, Braun J, Somer ST, Klautz R, Holman ER, Versteegh MI,Boersma E, Schalij MJ, van der Wall EE, Dion RA. Restrictiveannuloplasty and coronary revascularization in ischemic mitral regur-gitation results in reverse left ventricular remodeling. Circulation2004;110:II103eII108.

7. Westenberg JJ, van der Geest RJ, Lamb HJ, Versteegh MI, Braun J,Doornbos J, de RA, van der Wall EE, Dion RA, Reiber JH, Bax JJ.MRI to evaluate left atrial and ventricular reverse remodeling afterrestrictive mitral annuloplasty in dilated cardiomyopathy. Circulation2005;112:I437eI442.

8. Crabtree TD, Bailey MS, Moon MR, Munfakh N, Pasque MK, LawtonJS, Moazami N, Aubuchon KA, Al-Dadah AS, Damiano RJ Jr.Recurrent mitral regurgitation and risk factors for early and latemortality after mitral valve repair for functional ischemic mitralregurgitation. Ann Thorac Surg 2008;85:1537e1542.

Valvular Heart Disease/Transcatheter Valve Therapy for MR Recurrence 719

9. Magne J, Senechal M, Dumesnil JG, Pibarot P. Ischemic mitralregurgitation: a complex multifaceted disease. Cardiology 2009;112:244e259.

10. Tahta SA, Oury JH, Maxwell JM, Hiro SP, Duran CM. Outcome aftermitral valve repair for functional ischemic mitral regurgitation. J HeartValve Dis 2002;11:11e18.

11. McGee EC, Gillinov AM, Blackstone EH, Rajeswaran J, Cohen G,Najam F, Shiota T, Sabik JF, Lytle BW, McCarthy PM, Cosgrove DM.Recurrent mitral regurgitation after annuloplasty for functionalischemic mitral regurgitation. J Thorac Cardiovasc Surg 2004;128:916e924.

12. de Weger A, Ewe SH, Delgado V, Bax JJ. First-in-man implantation ofa trans-catheter aortic valve in a mitral annuloplasty ring: novel treat-ment modality for failed mitral valve repair. Eur J Cardiothorac Surg2011;39:1054e1056.

13. Lim DS, Kunjummen BJ, Smalling R. Mitral valve repair with theMitraClip device after prior surgical mitral annuloplasty. CatheterCardiovasc Interv 2010;76:455e459.

14. Himbert D, Descoutures F, Brochet E, Iung B, Detaint D, Messika-Zeitoun D, Alkhoder S, Mimoun L, Sordi M, Depoix JP, Ducrocq G,Nataf P, Vahanian A. Transvenous mitral valve replacement afterfailure of surgical ring annuloplasty. J Am Coll Cardiol 2012;60:1205e1206.

15. Kondo N, Shuto T, McGarvey JR, Koomalsingh KJ, Takebe M,Gorman RC, Gorman JH III, Gillespie MJ. Melody valve-in-ringprocedure for mitral valve replacement: feasibility in four annuloplastytypes. Ann Thorac Surg 2012;93:783e788.

16. Shuto T, Kondo N, Dori Y, Koomalsingh KJ, Glatz AC, Rome JJ,Gorman JH III, Gorman RC, Gillespie MJ. Percutaneous transvenousMelody valve-in-ring procedure for mitral valve replacement. J AmColl Cardiol 2011;58:2475e2480.

17. Kempfert J, Blumenstein J, Chu MW, Pritzwald-Stegmann P, KobilkeT, Falk V, Mohr FW, Walther T. Minimally invasive off-pump valve-in-a-ring implantation: the atrial transcatheter approach for re-operativemitral valve replacement after failed repair. Eur J Cardiothorac Surg2009;35:965e969.

18. Ciarka A, Braun J, Delgado V, Versteegh M, Boersma E, Klautz R,Dion R, Bax JJ, Van de Veire N. Predictors of mitral regurgitationrecurrence in patients with heart failure undergoing mitral valveannuloplasty. Am J Cardiol 2010;106:395e401.

19. Lang RM, Bierig M, Devereux RB, Flachskampf FA, Foster E,Pellikka PA, Picard MH, Roman MJ, Seward J, Shanewise JS,Solomon SD, Spencer KT, Sutton MS, Stewart WJ. Recommendationsfor chamber quantification: a report from the American Society of

Echocardiography’s Guidelines and Standards Committee and theChamber Quantification Writing Group, developed in conjunction withthe European Association of Echocardiography, a branch of theEuropean Society of Cardiology. J Am Soc Echocardiogr 2005;18:1440e1463.

20. Zoghbi WA, Enriquez-Sarano M, Foster E, Grayburn PA, Kraft CD,Levine RA, Nihoyannopoulos P, Otto CM, Quinones MA, RakowskiH, Stewart WJ, Waggoner A, Weissman NJ. Recommendations forevaluation of the severity of native valvular regurgitation with two-dimensional and Doppler echocardiography. J Am Soc Echocardiogr2003;16:777e802.

21. Lee AP, Acker M, Kubo SH, Bolling SF, Park SW, Bruce CJ, Oh JK.Mechanisms of recurrent functional mitral regurgitation after mitralvalve repair in nonischemic dilated cardiomyopathy: importance ofdistal anterior leaflet tethering. Circulation 2009;119:2606e2614.

22. Magne J, Pibarot P, Dagenais F, Hachicha Z, Dumesnil JG, Senechal M.Preoperative posterior leaflet angle accurately predicts outcome afterrestrictive mitral valve annuloplasty for ischemic mitral regurgitation.Circulation 2007;115:782e791.

23. Vijayaraghavan G, Boltwood CM, Tei C, Wong M, Shah PM.Simplified echocardiographic measurement of the mitral anulus. AmHeart J 1986;112:985e991.

24. Feldman T, Kar S, Rinaldi M, Fail P, Hermiller J, Smalling R, WhitlowPL, Gray W, Low R, Herrmann HC, Lim S, Foster E, Glower D.Percutaneous mitral repair with the MitraClip system: safety andmidterm durability in the initial EVEREST (Endovascular Valve Edge-to-Edge REpair Study) cohort. J Am Coll Cardiol 2009;54:686e694.

25. Petronio A, Giannini C, De CM, Guarracino F. Antegrade percuta-neous valve implantation for mitral ring dysfunction, a challengingcase. Catheter Cardiovasc Interv 2012;80:700e703.

26. Casselman F, Martens S, De BB, Degrieck I. Reducing operativemortality in valvular reoperations: the “valve in ring” procedure.J Thorac Cardiovasc Surg 2011;141:1317e1318.

27. Delgado V, Kapadia S, Marsan NA, Schalij MJ, Tuzcu EM, Bax JJ.Multimodality imaging before, during, and after percutaneous mitralvalve repair. Heart 2011;97:1704e1714.

28. Gurvitch R, Cheung A, Ye J, Wood DA, Willson AB, Toggweiler S,Binder R, Webb JG. Transcatheter valve-in-valve implantation forfailed surgical bioprosthetic valves. J Am Coll Cardiol 2011;58:2196e2209.

29. Casselman FP, La MM, Jeanmart H, Mazzarro E, Coddens J, Van PF,Wellens F, Vermeulen Y, Vanermen H. Endoscopic mitral andtricuspid valve surgery after previous cardiac surgery. Circulation2007;116:I270eI275.