About Liv

Which Is Better for Mitral Regurgitation: Annuloplasty Ring or Mechanical Valve?

Last Updated on November 27, 2025 by Bilal Hasdemir

Which Is Better for Mitral Regurgitation: Annuloplasty Ring or Mechanical Valve?
Which Is Better for Mitral Regurgitation: Annuloplasty Ring or Mechanical Valve? 2

Mitral regurgitation affects millions worldwide and can be serious if not treated. At Liv Hospital, we know how complex this condition is. We also know how important it is to pick the right treatment.

Treating mitral regurgitation needs a careful look at all options. Two main choices are annuloplasty rings and mechanical valves. We’ll help you understand the latest research and guidelines to make a smart choice.

We focus on our patients and use new methods to give you the best care. In this article, we’ll compare annuloplasty rings and mechanical valves. We’ll talk about their good points and not-so-good points.

Key Takeaways

  • Mitral regurgitation is a serious condition requiring timely treatment.
  • Annuloplasty rings and mechanical valves are two primary treatment options.
  • A thorough evaluation is key to picking the right treatment.
  • Liv Hospital’s patient-centered approach ensures world-class healthcare.
  • Stay updated with the latest research and guidelines on mitral regurgitation treatment.

Understanding Mitral Regurgitation and Its Impact

mitral regurgitation types

When the mitral valve doesn’t close right, it causes mitral regurgitation. This condition can lead to serious heart problems if not treated. Blood leaks back through the mitral valve with each heartbeat.

Definition and Pathophysiology

Mitral regurgitation is a heart disease where the mitral valve doesn’t close right. This causes blood to flow back from the left ventricle to the left atrium. If not managed, it can lead to heart failure.

Types: Degenerative vs. Functional Mitral Regurgitation

Mitral regurgitation has two main types: degenerative and functional. Degenerative is caused by problems with the mitral valve, like leaflet prolapse. Functional is due to left ventricular dysfunction, often from coronary artery disease or cardiomyopathy.

Clinical Presentation and Diagnostic Approaches

The symptoms of mitral regurgitation depend on its severity and how long it lasts. Symptoms include shortness of breath, fatigue, and palpitations. Echocardiography is used to diagnose it, showing how well the mitral valve works.

Diagnostic Tool Information Provided
Echocardiography Assesses mitral valve morphology and function
Electrocardiogram (ECG) Evaluates heart rhythm and detects possible arrhythmias
Cardiac Catheterization Shows info on coronary artery disease and ventricular function

Treatment Options for Mitral Valve Disease

mitral valve disease treatment options

Mitral valve disease can be treated in several ways. These include medical therapy and surgical repair or replacement. The right treatment depends on the disease’s severity and the patient’s health.

Medical Management Strategies

Medical management is often the first step. It includes medications to manage symptoms and slow the disease. We use diuretics, ACE inhibitors, and beta-blockers to help.

Surgical Interventions: Repair vs. Replacement

When medical treatment fails, surgery is needed. There are two main surgical options: mitral valve repair or replacement. The choice depends on the valve’s condition and the patient’s needs.

Timing of Intervention: When Surgery Becomes Necessary

The timing of surgery is very important. We consider surgery when symptoms get worse or if the left ventricle is not working well. The goal is to act before damage is permanent, improving outcomes.

Several factors influence the decision for surgery:

  • Severity of symptoms
  • Presence of left ventricular dysfunction
  • Patient’s overall health and comorbidities

Annuloplasty Ring: Structure and Function

Mitral valve repair often includes an annuloplasty ring. This device helps restore the valve’s natural shape. It’s a key part of cardiovascular medical devices for treating mitral regurgitation.

Types: Flexible, Semi-Rigid, and Rigid Rings

There are different types of annuloplasty rings. Each type has its own benefits.

  • Flexible rings mimic the mitral valve’s natural movement. This might lower the risk of complications after surgery.
  • Semi-rigid rings strike a balance. They support the valve but also allow for some natural motion.
  • Rigid rings offer the most support. They’re used when the valve is significantly enlarged.

The right ring type depends on the patient’s condition and the surgeon’s choice.

Preservation of Natural Valve Geometry

Annuloplasty rings help keep the mitral valve’s natural shape. They support the annulus, ensuring the leaflets close properly. This reduces mitral regurgitation.

Keeping the valve’s natural shape can lead to better outcomes. It helps the valve function naturally and lowers the risk of future problems as noted in recent research.

Surgical Implantation Techniques

Implanting an annuloplasty ring involves several steps.

  1. Assessment and Sizing: The surgeon checks the mitral valve and picks the right ring size.
  2. Implantation: The ring is placed around the mitral annulus with sutures.
  3. Adjustment and Testing: After placement, the surgeon tests the valve. They make any needed adjustments.

In some cases, using an annuloplasty ring is better than heart valve replacement. This depends on the patient’s condition and the severity of mitral regurgitation.

Mitral regurgitation is a serious condition that affects millions worldwide. It can lead to significant health problems and even death if not treated. At Liv Hospital, we offer a patient-focused approach to help you choose the best treatment.

Choosing the right treatment is key for managing mitral regurgitation. We’ll help you understand the latest research and guidelines. This will help you decide between annuloplasty ring and mechanical valve solutions. Our team is dedicated to providing top-notch healthcare and support for international patients.

Key Takeaways

  • Mitral regurgitation is a common and serious condition if left untreated.
  • Liv Hospital offers a patient-centered approach to treating mitral regurgitation.
  • The choice between annuloplasty ring and mechanical valve depends on several factors.
  • Our team guides you through the latest research and guidelines.
  • Effective treatment management is critical for patient outcomes.

Understanding Mitral Regurgitation and Its Impact

It’s important to understand mitral regurgitation to find the best treatment. This condition happens when blood leaks back through the mitral valve during heart beats.

Definition and Pathophysiology

Mitral regurgitation happens when the mitral valve doesn’t close right. This lets blood flow back into the left atrium. It can make the left atrium work harder and grow bigger over time.

The problem involves the valve leaflets, annulus, chordae tendineae, and papillary muscles working together.

Types: Degenerative vs. Functional Mitral Regurgitation

There are two main types of mitral regurgitation. Degenerative mitral regurgitation is caused by problems with the valve leaflets or chordae tendineae. Functional mitral regurgitation is caused by the left ventricle not working right.

Characteristics Degenerative Mitral Regurgitation Functional Mitral Regurgitation
Cause Abnormalities in valve leaflets or chordae tendineae Left ventricular dysfunction or remodeling
Valve Structure Often myxomatous degeneration Normal valve structure, but abnormal function
Left Ventricular Function Typically normal Impaired

Clinical Presentation and Diagnostic Approaches

Mitral regurgitation can show up in many ways, from no symptoms to severe heart failure. Symptoms include shortness of breath, feeling tired, and irregular heartbeats. Echocardiography is key for diagnosing and understanding how severe it is.

Echocardiography helps us see how the mitral valve and left ventricle are doing. This info helps decide when surgery is needed, whether it’s repair or replacement.

Treatment Options for Mitral Valve Disease

Managing mitral valve disease needs a deep understanding of treatment options. We will cover the different ways to treat this condition. This ensures patients get the right care for their needs.

Medical Management Strategies

Medical management is often the first step for mitral valve disease. It aims to manage symptoms and slow disease growth. We use drugs like diuretics, ACE inhibitors, and beta-blockers to ease symptoms like shortness of breath and fatigue.

Diuretics help reduce lung fluid buildup. ACE inhibitors and beta-blockers improve heart function and lower blood pressure. A low-sodium diet and regular exercise are also key in managing the condition.

Key medications used in medical management include:

  • Diuretics
  • ACE inhibitors
  • Beta-blockers
  • Anticoagulants

Surgical Interventions: Repair vs. Replacement

Surgery is needed when medical treatment fails or the disease gets worse. The choice between repair and replacement depends on several factors. These include the severity of mitral regurgitation, the patient’s health, and any other health issues.

Mitral valve repair is preferred when possible. It keeps the patient’s native valve tissue and avoids lifelong anticoagulation therapy. But, if the valve is severely damaged, replacement with a mechanical or bioprosthetic valve may be needed.

Surgical Option Advantages Disadvantages
Mitral Valve Repair Preserves native valve tissue, lower risk of complications May not be suitable for severely damaged valves
Mechanical Valve Replacement Durable, long-lasting Requires lifelong anticoagulation, risk of mechanical failure
Bioprosthetic Valve Replacement No need for lifelong anticoagulation, lower risk of complications May require replacement in the future due to degeneration

Timing of Intervention: When Surgery Becomes Necessary

The timing of surgery is critical and depends on several factors. These include the severity of symptoms, left ventricular function, and any complications. Surgery is considered when symptoms worsen or when there are signs of left ventricular dysfunction, even if the patient is not showing symptoms.

“The decision to proceed with surgery should be made on a case-by-case basis, taking into account the individual patient’s risk factors and possible benefits.” –

Cardiovascular Surgery Guidelines

Regular check-ups with a cardiologist are vital. They help monitor disease progression and decide the best time for surgery.

Annuloplasty Ring: Structure and Function

Annuloplasty rings help support the mitral valve annulus. They ensure the leaflets close properly and reduce leakage. These rings are key in treating mitral regurgitation, providing a strong and effective fix.

Types of Annuloplasty Rings

There are different types of annuloplasty rings, like flexible, semi-rigid, and rigid ones. Each type is chosen based on the patient’s needs and the surgeon’s preference.

  • Flexible Rings: These rings let the mitral valve move naturally, preserving its function.
  • Semi-Rigid Rings: They offer a mix of flexibility and support, allowing for some natural motion.
  • Rigid Rings: These rings provide the most stability and are used when the valve is very dilated.

Preservation of Natural Valve Geometry

Annuloplasty rings are great because they keep the mitral valve’s natural shape. They support the annulus and help the leaflets close right, keeping the valve working well.

Surgical Implantation Techniques

Putting in an annuloplasty ring needs careful technique to get the right fit. The ring’s size is very important. It must match the patient’s annular size for the best results.

Ring Type Characteristics Clinical Use
Flexible Preserves natural annular dynamics Ideal for patients with relatively normal annular motion
Semi-Rigid Balances flexibility and stability Suitable for most mitral regurgitation cases
Rigid Provides maximum stability Used in cases with significant annular dilatation

Understanding annuloplasty rings helps us see their importance in treating mitral regurgitation. The right ring type and precise implantation are key to a successful mitral valve repair.

Mechanical Mitral Valves: Design and Function

Cardiac health technologies have improved a lot. Now, we have advanced mechanical mitral valves. These are key in treating mitral regurgitation, giving patients a strong and effective option.

Mechanical mitral valves have changed a lot. They’ve moved from simple designs to complex prosthetics. The evolution of mechanical valve technology has seen better materials, designs, and functions.

Evolution of Mechanical Valve Technology

Heart valves have a long history. Early ones had problems like clotting and breaking. But, new materials and engineering have made valves better and more reliable.

  • Old valves often caused clots and needed a lot of blood thinners.
  • New valves use materials like pyrolytic carbon to cut down on clotting.
  • Today’s manufacturing makes valves more precise and consistent.

Contemporary Mechanical Valve Options

Now, there are many mechanical mitral valves. Each has its own benefits and features. Contemporary designs aim to improve blood flow, lower risks, and better patient results.

Modern mechanical mitral valves have:

  1. Better bileaflet designs for smoother blood flow.
  2. Materials that lower the risk of clots and other issues.
  3. Options tailored to each patient’s needs.

Complete Elimination of Regurgitation Benefit

Mechanical mitral valves stop regurgitation completely. They replace the old valve with a new one. This improves heart function and quality of life for patients.

Compared to annuloplasty rings, mechanical valves fix mitral regurgitation for good. This is great for those with severe regurgitation or can’t have repair.

Annuloplasty Ring vs Mechanical Valve: A Comparative Look

Choosing between an annuloplasty ring and a mechanical valve is a big decision in mitral regurgitation surgery. We’ll look at the main differences between these two options. We’ll cover their structure, function, how they work, and their impact on the heart.

Structural and Functional Differences

Annuloplasty rings and mechanical valves both aim to fix mitral regurgitation. But they do it in different ways. An annuloplasty ring is used in mitral valve repair. It keeps the patient’s own valve but fixes the annular dilation that causes regurgitation.

A mechanical valve, on the other hand, is used in mitral valve replacement. It replaces the diseased valve with a prosthetic one. Mechanical valves are long-lasting but need lifelong anticoagulation to prevent blood clots.

Hemodynamic Performance Comparison

Annuloplasty rings and mechanical valves work differently in terms of blood flow. Annuloplasty rings keep the mitral valve’s natural shape, which might lead to better blood flow. Research shows that successful repairs with these rings can make blood flow almost normal again.

Mechanical valves, while they stop regurgitation, can cause unnatural blood flow. But, newer mechanical valves are made to reduce these issues. They are very good at stopping regurgitation.

Impact on Left Ventricular Remodeling

How these options affect the left ventricle is also important. Mitral valve repair with an annuloplasty ring can help the left ventricle stay healthy. This is because the repair keeps the valve’s natural function and the subvalvular apparatus intact.

On the other hand, replacing the valve with a mechanical one can also help the left ventricle. But, losing the native valve and its attachments might affect the outcome. The right choice depends on the patient’s specific situation, the surgeon’s skill, and the risks and benefits of each option.

In summary, both annuloplasty rings and mechanical valves have their roles in treating mitral regurgitation. The decision between them depends on many factors, including the patient’s condition, the surgeon’s expertise, and the risks and benefits of each procedure.

Latest Research: Five-Year Outcomes with Annuloplasty Rings

Recent studies have given us new insights into annuloplasty rings for treating mitral regurgitation. These cardiovascular medical devices are evolving. It’s key to know their long-term effects to better care for patients.

Annuloplasty rings are changing how we treat mitral regurgitation. Their durability, whether flexible or rigid, is key to their success.

Comparing Flexible vs. Rigid Ring Durability

Flexible and rigid annuloplasty rings both have their benefits. Flexible rings aim to keep the mitral valve’s natural shape. This might help the left ventricle work better after surgery. Rigid rings, on the other hand, offer a more stable fix, which suits some patients better.

A study compared these rings and found both have low complication rates. Flexible rings might see a bit more mitral regurgitation return over five years. Yet, the difference isn’t big enough to be significant. This means both rings could work well, depending on the patient.

Recurrence Rates of Mitral Regurgitation

How often mitral regurgitation comes back after using annuloplasty rings is important. Studies show the rates vary. This depends on the ring type, why the mitral regurgitation happened, and the patient’s health.

  • Degenerative mitral regurgitation tends to have lower recurrence rates compared to functional mitral regurgitation.
  • The use of a rigid ring may reduce recurrence in certain patient populations.
  • Long-term follow-up is essential to monitor for signs of recurrence and manage it appropriately.

Left Ventricular Function and Remodeling Results

Annuloplasty rings’ effect on the left ventricle is also key. They help keep the mitral valve’s natural shape. This can help the left ventricle function better.

Research shows successful use of these rings can improve the left ventricle’s pumping ability. It also helps reduce the ventricle’s size, showing positive changes.

As we keep tracking patients with annuloplasty rings, we learn more about their long-term effects. This knowledge helps us improve treatment plans and outcomes for patients.

Clinical Outcomes with Mechanical Valves

Mechanical valves are a key choice for treating mitral regurgitation in cardiac surgery. We look at how well mechanical valves work, focusing on immediate results, long-term performance, and the risk of blood clots.

Immediate Post-operative Results

Mechanical valves are very good at stopping regurgitation right after surgery. Studies show that patients with these valves see big improvements in heart function. For example, a study in the Journal of Cardiac Surgery found that mechanical valves help reduce symptoms and improve life quality.

The first few days after surgery are very important. Patients need to be watched closely for problems like bleeding or irregular heartbeats. Good care during this time is key to a good recovery.

Long-term Valve Performance

Mechanical valves last a long time and work well for many years. But, patients with these valves must take blood thinners for life. This is a big part of managing their care.

Valve Type Durability Anticoagulation Requirement
Mechanical Valve High Lifelong
Bioprosthetic Valve Moderate Short-term or None

The table shows that mechanical valves are very durable but need blood thinners forever. This is something to think about when caring for patients.

Thromboembolic Complications and Management

One big risk with mechanical valves is blood clots. These can be very serious and need quick action. We stress the importance of blood thinners to prevent clots.

To manage this risk, we check blood thinner levels often and teach patients about the therapy. By being proactive, we can lower the chance of blood clots and improve patient results.

Anticoagulation Requirements and Lifestyle Implications

Patients with mechanical mitral valves must take lifelong anticoagulation therapy. This is because mechanical valves increase the risk of blood clots. We will look at how this affects their daily lives and overall health.

Lifelong Anticoagulation with Mechanical Valves

Mechanical mitral valve replacement means a lifetime of anticoagulation therapy. Anticoagulation therapy usually involves warfarin or other vitamin K antagonists. It’s important to regularly check INR levels to make sure the therapy works well and to avoid bleeding.

This lifelong therapy has big implications for patient care. It requires sticking to medication and regular INR checks. We stress the need for patients to understand the risks and benefits of anticoagulation therapy.

Bleeding Risk Assessment and Management

Anticoagulation is key to preventing blood clots but raises the risk of bleeding. Patients on anticoagulation therapy need to know the signs of bleeding and when to get medical help. Managing this risk involves regular INR checks and adjusting doses as needed.

Tools to assess bleeding risk can help identify those at higher risk. To reduce bleeding risk, we manage anticoagulation therapy carefully, avoid certain medications, and educate patients on safety measures.

Impact on Daily Activities and Quality of Life

Lifelong anticoagulation can affect many areas of a patient’s life. It may change daily activities, travel plans, and even hobbies or sports. Patients must be aware of their anticoagulation status and take steps to prevent bleeding.

Despite these challenges, many patients with mechanical mitral valves live active and meaningful lives. With the right management and support, individuals can adjust to the lifestyle changes brought by anticoagulation therapy. We help patients create personalized care plans that meet their unique needs.

Post-Operative Care and Recovery Comparison

Recovering from mitral regurgitation surgery is as important as the surgery itself. The paths to recovery for annuloplasty rings and mechanical valves are different. Knowing these differences helps patients recover well.

Hospital Stay and Early Recovery Differences

The time spent in the hospital after surgery can vary. Patients with annuloplasty rings usually stay less than those with mechanical valves. This is because annuloplasty is simpler and some patients are healthier.

“While some patients may be discharged within a week, others may require longer hospitalization due to possible complications.”

At home, recovery is different too. Patients with annuloplasty rings often get back to normal faster. But, those with mechanical valves must take lifelong medication to prevent blood clots.

Rehabilitation Protocols for Each Procedure

Rehab plans after surgery depend on the type of procedure. Patients with annuloplasty rings focus on getting more active slowly. Those with mechanical valves must manage their blood-thinning medicine closely. Following these plans is key to a safe recovery.

Long-term Follow-up Requirements

Regular check-ups are vital for both types of patients. Cardiologists monitor how the valve is working and adjust treatment as needed. For mechanical valve patients, this includes keeping an eye on their blood-thinning medicine. “Long-term care is not just about managing the valve; it’s about keeping the heart healthy,” a cardiology expert says.

In summary, both annuloplasty rings and mechanical valves help with mitral regurgitation. But, their recovery paths are different. Understanding these differences helps patients recover better and make informed choices about their care.

Quality of Life Outcomes and Life Expectancy

Mitral regurgitation treatment, whether through annuloplasty ring or mechanical valve, has a big impact on patients’ lives. It affects their daily life, long-term survival, and how happy they are with their treatment.

Return to Normal Activities After Each Procedure

Patients who get an annuloplasty ring usually recover faster than those with mechanical valves. This is because the surgery for an annuloplasty ring is less invasive. They can get back to normal activities in 6-12 weeks.

On the other hand, recovery from a mechanical valve implant takes longer. It can take 8-16 weeks or more. This is because of the need for anticoagulation therapy and the more invasive nature of the procedure.

Long-term Survival Rates

Both annuloplasty rings and mechanical valves improve long-term survival for patients with mitral regurgitation. Studies show that five-year survival rates for patients with annuloplasty rings are 80% to 90%. Those with mechanical valves have slightly lower survival rates due to the risks of lifelong anticoagulation therapy.

Patient-Reported Satisfaction and Outcomes

Patient-reported outcomes are key to measuring the success of mitral regurgitation treatment. Patients with annuloplasty rings often report higher satisfaction. This is because their natural valve is preserved, and they need less anticoagulation medication.

On the other hand, patients with mechanical valves must take lifelong anticoagulation therapy. This can affect their quality of life. Yet, both groups see big improvements in symptoms and how well they can function.

The choice between an annuloplasty ring and a mechanical valve depends on the patient. It should consider the patient’s specific needs, lifestyle, and preferences. By understanding the effects of each treatment, patients and healthcare providers can make better choices.

Patient Selection: Individualizing Treatment Decisions

Treating mitral regurgitation needs a personal touch. We look at several key factors for each patient. The choice between an annuloplasty ring or a mechanical valve depends on these factors.

Age and Life Expectancy Considerations

Age and life expectancy are key in choosing treatment. Younger patients might get a mechanical valve for its long life. Older patients might get an annuloplasty ring to avoid lifelong blood thinners.

We think about life expectancy when picking a treatment. For example, a patient with a long life might need a more lasting solution. A patient with a shorter life might choose to avoid blood thinners.

Anatomical Feasibility for Repair

How well the mitral valve can be repaired is also important. We decide to repair or replace based on the valve’s damage and the heart’s shape.

An annuloplasty ring is often chosen when the valve can be fixed. This is when the valve’s size is the main issue. But, a mechanical valve might be needed for more serious damage.

Comorbidities and Contraindications

Other health issues and things that might make treatment risky also matter. Some conditions make one valve option riskier than the other.

Comorbidity Consideration for Annuloplasty Ring Consideration for Mechanical Valve
Atrial Fibrillation May require anticoagulation regardless Requires lifelong anticoagulation
Bleeding Disorders May be preferable to avoid anticoagulation May be contraindicated due to anticoagulation needs
Renal Disease Less impact from anticoagulation Careful monitoring required due to anticoagulation

By looking at these factors, we can make treatment plans that fit each patient best. This helps improve outcomes for mitral regurgitation treatment.

Conclusion: Evidence-Based Approach to Mitral Regurgitation Treatment

We’ve looked into mitral regurgitation and its treatments, like annuloplasty rings and mechanical valves. The right choice depends on the patient and the treatment’s success.

Choosing between heart valve replacement or repair is key. Annuloplasty rings keep the natural valve, while mechanical valves last longer.

In mitral valve regurgitation treatment, each patient is different. We must think about their age, health, and other conditions to pick the best treatment.

Using evidence-based methods helps us get the best results for patients with mitral regurgitation. We need to keep up with new research and guidelines. And we must consider each patient’s unique situation.

FAQ

 

 

What is mitral regurgitation, and how is it diagnosed?

Mitral regurgitation happens when the mitral valve doesn’t close right. This lets blood flow back into the heart. Doctors use echocardiography to see how bad it is and decide what to do next.

What are the main differences between annuloplasty rings and mechanical valves?

Annuloplasty rings fix the mitral valve, keeping it natural. Mechanical valves replace the valve and need lifelong blood thinners. Doctors pick one based on the patient’s condition.

What are the benefits and drawbacks of mitral valve repair versus replacement?

Repairing the valve with annuloplasty rings avoids blood thinners. But, it might not work for everyone. Replacing it with a mechanical valve stops leaks but means taking blood thinners forever.

How do annuloplasty rings preserve the natural geometry of the mitral valve?

Annuloplasty rings support the valve’s ring, making it work better. This helps the valve close right and reduces leaks. It keeps the valve’s natural shape and function.

What are the anticoagulation requirements for mechanical mitral valves?

People with mechanical valves need to take blood thinners forever. They also need regular checks to make sure the dose is right.

How do the post-operative care and recovery differ between annuloplasty rings and mechanical valves?

After surgery, care and recovery vary. Patients with mechanical valves need closer monitoring and blood thinner management. Hospital stays and rehab plans also differ.

What are the quality of life outcomes and life expectancy for patients undergoing annuloplasty ring or mechanical valve implantation?

Both options can improve life and life span for those with mitral regurgitation. The best choice depends on the patient’s health and situation.

How are treatment decisions individualized for patients with mitral regurgitation?

Doctors tailor treatment based on age, health, and other factors. They choose the best option to help each patient the most.

What are the latest research findings on the durability and effectiveness of annuloplasty rings and mechanical valves?

New studies compare annuloplasty rings and mechanical valves. They show the importance of choosing the right treatment for each patient. Research keeps improving, giving better insights into treatment options.

What are the key considerations for patients with mitral regurgitation when choosing between annuloplasty rings and mechanical valves?

Patients should think about their condition, lifestyle, and need for blood thinners. Talking to a doctor is key to making a good choice.

References

Subscribe to Liv E-newsletter