Acute Mitral Valve Regurgitation Research Articles

Abstract 12522: Non-Ischemic Papillary Muscle Rupture Due to MRSA Myocarditis

Case Presentation: A 46-year-old male with diabetes, ESRD, and recurrent MRSA bacteremia, presented with septic shock and suffered cardiac arrest. Following resuscitation EKG showed inferolateral ischemia. TTE revealed acute mitral valve regurgitation resulting from posteromedial papillary muscle rupture (PMR). An intra-aortic balloon pump was implanted for cardiogenic shock. Coronary angiography revealed right dominant circulation and thrombotic occlusion of a small caliber distal left circumflex artery (LCX). Emergent mitral valve replacement surgery was performed. Pathologic analysis of the excised muscle and leaflet showed marked acute inflammation, bacterial invasion, and myocyte necrosis, confirming non-ischemic rupture due to MRSA myocarditis. Discussion: PMR predominantly occurs after MI, complicating 0.03% of STEMI cases in the reperfusion era. Non-ischemic causes are rare. Coexistence of myocarditis, infective endocarditis (IE), and MI poses a challenge in determining etiology. Establishing causation guides whether to expedite emergent valve surgery or focus on cardiomyocyte salvage by revascularization. The posteromedial papillary muscle is most commonly involved in PMR due to single blood supply from the PDA (most commonly a branch of the RCA, and less commonly the LCX). Coronary angiography, postoperative histopathology, and culture results determined the etiology of PMR was fulminant MRSA bacteremia culminating in myocarditis. Bacterial colonization and resultant inflammation induced physical and mechanical strain leading to complete rupture. The occluded LCX was incidental, and may have been the result of septic embolization, which occurs in up to 65% of left-sided IE. Albeit rare, non-ischemic etiologies must be considered when the anatomic presentation of acute PMR on TTE is incongruent with angiography. Definitive treatment relies on surgical intervention and mechanical circulatory support is often necessary.

Mitral valve chordal rupture against the background of cardiac SARS-CoV-2 infection. Cases series

In an ever-changing information flow on coronavirus disease 2019 (COVID-19) pandemic, we describe a case series of mitral valve chordal rupture (MVCR) in non-comorbid middle-aged men that occurred over a period of 3 to 5 weeks after Severe Acute Respiratory Syndrome CoronaVirus 2 (SARS-CoV-2) infection. With significant advances in the prevention of acute rheumatic fever, the treatment of bacterial endocarditis and acute coronary syndrome, acute mitral regurgitation has become a relatively rare diagnosis. During the pandemic, there has been a surge in the incidence of spontaneous MVCR, and new data on the problem are accumulating. The presented case series are united by the fact that the infection symptoms were mild, followed by signs of probable endomyocarditis, unrecognized in time, and acute mitral valve regurgitation developed against the background of physical provocation (exercise and cough). Two patients had previously been diagnosed with mitral valve prolapse (myxomatous degeneration and connective tissue disease). Two patients were successfully operated on in different clinics. The described cases emphasize that the consequences of inflammation persistence may be more severe than the primary viral damage, which determines the importance of a comprehensive examination and long-term follow-up. To date, the differential diagnosis of patients with sudden onset of dyspnea and chest pain associated with an infectious process should include MVCR.

Transcatheter Mitral Valve Repair in Acute and Critical Cardiac Conditions.

Acute mitral valve regurgitation (MR) is an emergency condition that requires an early diagnosis of the etiology and rapid management. Surgical intervention is the first-line treatment for acute severe MR. However, many patients are denied surgical intervention due to the acute risk of surgery. Transcatheter mitral valve repair (TMVr) is a less invasive technique and becoming a potential alternative to surgery in inoperable patients but is underrepresented in the literature. This review aims to discuss the published data on the use of TMVr in unstable MR patients presenting with acute or critical cardiac conditions.

Intra-aortic Balloon Pump Securement.

Intra-aortic Balloon Pump Securement.

Acute mitral valve regurgitation secondary to papillary muscle rupture due to infective endocarditis

BackgroundPapillary muscle rupture due to infective endocarditis is a rare event and proper management of this condition has not been described in the literature. Our case aims to shed light on treatment strategies for these patients using the current guidelines.Case presentationThis case presents a 58-year-old male with acute heart failure secondary to papillary muscle rupture. He underwent an en bloc resection of his mitral valve with a bioprosthetic valve replacement. Specimen pathology later showed necrotic papillary muscle due to infective endocarditis. The patient was further treated with antibiotic therapy. He recovered well post-operatively and continued to do well after discharge.ConclusionIn patients who present with papillary muscle rupture secondary to infective endocarditis, clinical symptoms should drive the treatment strategy. Despite the etiology, early mitral valve surgery remains treatment of choice for patients who have papillary muscle rupture leading to acute heart failure. Culture-guided prolonged antibiotic treatment is vital in this category of patients, especially those who have a prosthetic valve implanted.

Mitral valve repair in papillary muscle rupture.

Papillary muscle rupture (PMR) is a significant mechanical complication following myocardial infarction (MI), a condition associated with a high mortality. It results in severe mitral valve regurgitation (MR), often accompanied by cardiogenic shock and pulmonary edema, requiring both emergent medical treatment and surgical intervention. Surgical treatment includes either chordal sparing mitral valve replacement or mitral valve repair, which is associated with a high mortality. Mitral valve repair is believed to be superior to mitral valve replacement with respect to improving left ventricular function, albeit with risk of repair failure and resulting in increased cross clamp times. Concomitant coronary revascularization may improve both short- and long-term outcomes after surgery. With advances in medical innovations in the field of transcatheter devices, these devices may serve as a bridge to recovery or treatment in the setting of acute MR due to PMR. However, long-term data will be required to establish the non-inferiority of one treatment modality over the other. Management of these patients should be guided by a dedicated mitral heart team.

RIGHT UPPER LOBE PULMONARY EDEMA: AN UNDERRECOGNIZED PRESENTATION OF ACUTE ISCHEMIC MITRAL VALVE REGURGITATION

SESSION TITLE: Monday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Unilateral pulmonary edema due to acute mitral valve insufficiency can create a diagnostic challenge for clinicians. While this presentation is uncommon, many case reports have demonstrated this radiologic finding, suggesting this may be an underrecognized phenomenon1. CASE PRESENTATION: An 80-year-old male with a history of hypertension and coronary artery disease status post three-vessel bypass in 2010 was admitted and treated for an inferior wall myocardial infarction with a bare metal stent to the left circumflex artery. One week later he presented to the emergency department with new onset shortness of breath and cough that began the day after his recent discharge. Physical examination was notable for a healthy appearing male in mild respiratory distress on 3 liters of oxygen, a 3/6 holosystolic murmur, no JVD, no peripheral edema and diminished lung sounds in the right lung fields with bibasilar crackles. Laboratory evaluation was notable for a WBC of 10.8, a procalcitonin of <0.10, and a troponin of 5.81. Chest radiograph revealed diffuse airspace disease with predominate right upper lobe infiltrate. A transesophageal echocardiogram revealed a non-dilated left ventricle with an ejection fraction of 35-40%, pulmonary arterial systolic pressure of 63mmHg, a severely enlarged left atrium, severe mitral regurgitation in the setting of a posterior mitral valve leaflet that appears tethered; consistent with ischemic mitral regurgitation with systolic reversal of flow in the right upper and lower pulmonary veins. The troponin level down trended throughout the admission, and the new mitral valve regurgitation was deemed ischemic in etiology given the patient’s recent inferior wall infarct less than 7 days prior. The right upper lobe infiltrate and shortness of breath markedly improved with diuresis and afterload reduction. The patient was discharged in improved condition with plans for outpatient evaluation for a mitral clip procedure. DISCUSSION: Classically cardiogenic pulmonary edema is symmetrically distributed in both lung fields with central predominance. In our patient, the pulmonary edema was primarily found in the right upper lobe, which has been established in the literature as a radiologic finding seen in up to 9% of acute mitral valve regurgitation cases2. This report emphasizes this classic radiologic finding as it is often misdiagnosed as pneumonia. The absence of fever and leukocytosis and the presence of a holosystolic murmur should raise clinical suspicion for a pulmonary infiltrate of non-infectious etiology. CONCLUSIONS: Unilateral pulmonary edema due to acute mitral valve insufficiency can create a diagnostic challenge for clinicians. This report highlights the unique clinical presentation to facilitate a broadened differential when faced with this clinical dilemma. Reference #1: 1. Gamsu G, Peters DR, Hess D, Lehman DH, Amend WJ. Isolated right upper lobe pulmonary edema. West J Med. 1981;135(2):151-4. Reference #2: 2. Morris PD, Warriner DR, Channer KS. Focal pulmonary edema: an unusual presentation of acute mitral regurgitation Thorax 2013; 68:498. DISCLOSURES: No relevant relationships by Kenneth Brownell, source=Web Response No relevant relationships by Arjun Kalaria, source=Web Response No relevant relationships by Parth Shah, source=Web Response

Percutaneous Mitral Valve Interventions (Repair): Current Indications and Future Perspectives.

Mitral valve regurgitation (MR) is the commonest valvular abnormality encountered among adult patients with cardiac valvular disease and conveys significant morbidity and mortality. The mitral valve is a complex anatomical structure and etiology for regurgitation is classified as either primary or secondary MR. Identification of the etiology in severe MR is critical in determining the appropriate treatment strategy. Transcatheter mitral valve repair (TMVR) is a minimally invasive technique for treatment of selected patients with symptomatic chronic moderate-severe or severe (3 to 4+) MR. While surgery remains the mainstay for treatment in primary MR, several technological advances within the last decade have made transcatheter mitral valve intervention increasingly feasible and safe in clinical practice. Use of TMVR in patients with severe MR has successfully reduced patient symptoms, disease morbidity, improved quality of life, and facilitated reverse remodeling with potential for a survival advantage among certain patients with secondary MR. Recent randomized controlled trials on MitraClip use in secondary MR have reinvigorated interest in this disease and refocused our attention on optimizing patient selection and timing of intervention to maximize benefit from using such percutaneous devices. In our review, we discuss etiologies and pathophysiology in both acute MR and development of chronic severe MR. We discuss management strategies for MR among patients based on etiology, particularly percutaneous mitral valve interventional therapies. We perform an extensive review comparing and contrasting existing data on safety, efficacy, durability, and appropriate patient selection related to MitraClip implantation in both primary and secondary MR. Lastly, we explore percutaneous MV therapies beyond the MitraClip as we await larger scale trials on these devices prior to them making way into day-to-day practice.

Left ventricular free-wall rupture, a potentially lethal mechanical complication of acute myocardial infarction: an unusual and illustrative case report

BackgroundThere are three major mechanical complications after acute myocardial infarction: left ventricular free-wall rupture, ventricular septum rupture and acute mitral valve regurgitation. The left ventricular free-wall rupture is a serious and often lethal complication following an ST elevation myocardial infarction. However, very rarely this rupture can be contained by the pericardium, forming a pseudoaneurysm.Case presentationWe report a case of a 66-year-old man with multiple cardiovascular risk factors and previous ST elevation myocardial infarction, complaining of atypical chest pain. His electrocardiogram was in normal sinus rhythm, with the presence of Q wave in inferior leads and T-wave inversion in lateral leads. A transthoracic echocardiogram showed a left ventricular pseudoaneurysm. In the coronary angiography, multi-vessel disease was found. On-pump CABG was performed and a posterolateral left ventricular giant pseudoaneurysm were observed. Due its “petrous” consistency it was impossible to perform an aneurysmectomy.ConclusionsThe diagnosis of left ventricular pseudoaneurysm can be difficult, as patients often present either asymptomatic or with non-specific symptoms attributed to other causes. A multimodality imaging diagnostic approach can be necessary. Immediate surgery is considered the treatment of choice because untreated pseudoaneurysms have a high risk of rupture leading to cardiac tamponade, shock and death.

Invited Commentary

Invited Commentary

Transvalvular pressure gradients for different methods of mitral valve repair: only neochordoplasty achieves native valve gradients.

Many surgical and interventional methods are available to restore patency for patients with degenerative severe mitral valve regurgitation. Leaflet resection and neochordoplasty, which both include ring annuloplasty, are the most frequently performed techniques for the repair of posterior mitral leaflet flail. It is unclear which technique results in the best haemodynamics. In this study, we investigated the effect of different mitral valve reconstruction techniques on mitral valve haemodynamics and diastolic transvalvular pressure gradient in an ex vivo porcine model. Eight porcine mitral valves were tested under pulsatile flow conditions in an in vitro pulsatile flow loop for haemodynamic quantification. Severe acute posterior mitral leaflet flail was created by resecting the posterior marginal chorda. The acute mitral valve regurgitation was corrected using 4 different repair techniques, in each valve, in a strictly successive order: (i) neochordoplasty with polytetrafluoroethylene sutures alone and (ii) with ring annuloplasty, (iii) edge-to-edge repair and (iv) triangular leaflet resection, both with ring annuloplasty. Valve haemodynamics were measured and quantified for all valve configurations (native, rupture and each surgical reconstruction). The results were analysed using a validated statistical linear mixed model, and the P-values were calculated using a 2-sided Wald test. All surgical reconstruction techniques were able to sufficiently correct the acute mitral valve regurgitation. Neochordoplasty without ring annuloplasty was the only reconstruction technique that resulted in haemodynamic properties similar to the native mitral valve (P-values from 0.071 to 0.901). The diastolic transvalvular gradient remained within the physiological range for all reconstructions but was significantly higher than in the native valve for neochordoplasty with ring annuloplasty (P < 0.000), edge-to-edge repair (P < 0.000) and leaflet resection (P < 0.000). Neochordoplasty without ring annuloplasty resulted in a significantly better pressure gradient than neochordoplasty with a ring annuloplasty (P < 0.000). Additionally, neochordoplasty with a ring annuloplasty resulted in significantly lower transvalvular pressure gradients than edge-to-edge repair (P < 0.000) and leaflet resection (P < 0.000). Neochordoplasty with or without ring annuloplasty was the reconstruction technique that almost achieved native physiological haemodynamics after repair of posterior mitral leaflet flail after acute isolated chordal rupture in our ex vivo porcine model.

Without Chords You Flood the Accordian: An Atypical Cause of Sudden Dyspnea in a Healthy Adult

SESSION TITLE: Cardiothoracic Surgery SESSION TYPE: Affiliate Case Report Poster PRESENTED ON: Tuesday, October 31, 2017 at 01:30 PM - 02:30 PM INTRODUCTION: Acute mitral valve regurgitation (AMR) occurs when there is structural compromise in components of the mitral valve. Clinical presentations may be confounded by more common cardiopulmonary processes1. This may delay diagnosis and management, thus increasing patient morbidity and mortality2. CASE PRESENTATION: An 84 YOF presents with a 6 day history of myalgias, palpitations, cough + SOB. PMH includes HTN, esophageal spasm, and DVT. Admission exam reveals tachycardia, irregularly irregular rhythm, and grade IV holosystolic murmur along the left sternal border. Bilateral (bl) rales heard in her lower lung fields. ECG confirms A-fib with RVR.WBC is 17,700, lactic acid 1.4 mmol/L, BNP 8,838 pg/mL, procalcitonin 0.46 ng/mL.Urine Streptococcal pneumoniae Ag is positive.Blood, sputum cultures + rapid influenza testing are negative. CXR shows mild cardiomegaly with bl pulmonary edema (Fig 1).Non-contrast chest CT shows bl upper lobe (UL) groundglass densities, moderate bl pleural effusions, bibasilar atelectasis, and focal areas of bl UL nodularity(Fig 2).Despite rate control + broad spectrum antibiotics, her hypoxia worsened.TTE showed EF 70%, normal ventricular sizes, PASP 50 mmHg, moderately dilated LA, myxomatous mitral thickening with a flail posterior leaflet, ruptured chordae tendinae, severe mitral regurgitation and an eccentric anterior jet penetrating the pulmonary veins.Pt is mechanically ventilated due to acute hypoxic respiratory failure + undergoes mitral valve repair.One week post-op, she is in no respiratory distress and saturating well on room air, suggesting complete reversal of her acute cardiopulmonary disease (Fig 3). DISCUSSION: Chord rupture is the most common etiology of AMR, typically affecting the thinner posterior mitral leaflets3. It is most often seen as a spontaneous event in elderly pts with no known heart disease presenting with sudden SOB and hypotension3. LA pressure rapidly increases causing pulmonary congestion + edema3. CXR findings of RUL pulmonary edema has high specificity but bl edema and effusions are more common1-3. Bl pulmonary edema is often interpreted as a manifestation of CHF or underlying infection and can delay tx of the valvular defect.CT findings in AMR include intralobar septal thickening, parabronchial cuffing and diffuse groundglass opacities1,3. CONCLUSIONS: SOB is commonly encountered in medicine.Despite evidence of infection or another common cardiopulmonary process, clinical correlation of sudden dyspnea and new murmur should prompt suspicion of AMR.CXR, CT and echo should all be utilized to evaluate AMR severity and initiate urgent surgical intervention.This case demonstrates the potential to reverse clinical symptoms and drastically improve pt outcomes. Reference #1: Brander L et al. Right-sided pulmonary oedema.Lancet 1999;354:1440. Reference #2: Morris P et al. Focal pulmonary oedema: an unusual presentation of acute mitral regurgitation.Thorax 2013;68:498. Reference #3: Lucenti M et al. Acute shortness of breath. J Emerg Med 2003;24(3):319. DISCLOSURE: The following authors have nothing to disclose: Patrick Twohig, Jaclyn Rivington, Rex Yung No Product/Research Disclosure Information

Complete Neurologic Recovery From Extreme Hypoglycemia Secondary to Cardiogenic Liver Failure: A Case Report.

Cardiogenic shock from acute severe mitral valve regurgitation can cause acute liver failure due to hypoperfusion. Impaired liver glycogenesis can then lead to profound hypoglycemia. The time frame for restoring normoglycemia without neurologic sequelae is not clearly established in humans. Thus, the clinical decision to provide further resuscitation in the setting of extreme hypoglycemia mainly depends on the patient's overall clinical condition, provider opinion, and/or institutional practice. Here, we report a case where the patient made complete neurologic recovery from extreme hypoglycemia (<5 mg/dL by central laboratory testing) secondary to acute cardiogenic shock and liver failure.

A case of acute severe mitral valve regurgitation caused by Abiotrophia defectiva endocarditis

<b>A case of acute severe mitral valve regurgitation caused by Abiotrophia </b><b>defectiva endocarditis </b>

Anterolateral Papillary Muscle Rupture Caused by Brucella Endocarditis

Introduction: Brucellosis is a common zoonosis in Iran, transmitted to humans by direct contact with infected animal materials like fleece, animal excrement, leather, butchery or by the consumption of contaminated animal products (e.g. fresh cheese, unpasteurized milk or dairy products, and raw meat and raw liver that is consumed semi-roasted by kebab sellers in Iran. Case Presentation: A 21-year-old woman presented with respiratory failure due to pulmonary edema from severe acute mitral valve regurgitation in the setting of acute Brucella endocarditis. She was found to have a ruptured anterolateral papillary muscle from necrosis caused by corroding large vegetations on the anterior mitral valve leaflet. Conclusions: This occurrence is an exceptionally rare phenomenon, in Brucella mitral endocarditis. Urgent transesophageal echocardiography (TEE) revealed large mobile vegetation on the anterior papillary muscle with severe mitral valve regurgitation. The patient underwent mitral valve replacement. During valve replacement surgery, anterior mitral valve vegetation and rupture of the AL-PM were confirmed. We also considered that prolonged post-operative antibiotic treatment was indicated in our patient to protect the newly implanted prosthetic valves.

Anterolateral Papillary Muscle Rupture Caused by Brucella Endocarditis

Introduction:: Brucellosis is a common zoonosis in Iran, transmitted to humans by direct contact with infected animal materials like fleece, animal excrement, leather, butchery or by the consumption of contaminated animal products (e.g. fresh cheese, unpasteurized milk or dairy products, and raw meat and raw liver that is consumed semi-roasted by kebab sellers in Iran. Case Presentation:: A 21-year-old woman presented with respiratory failure due to pulmonary edema from severe acute mitral valve regurgitation in the setting of acute Brucella endocarditis. She was found to have a ruptured anterolateral papillary muscle from necrosis caused by corroding large vegetations on the anterior mitral valve leaflet. Conclusions:: This occurrence is an exceptionally rare phenomenon, in Brucella mitral endocarditis. Urgent transesophageal echocardiography (TEE) revealed large mobile vegetation on the anterior papillary muscle with severe mitral valve regurgitation. The patient underwent mitral valve replacement. During valve replacement surgery, anterior mitral valve vegetation and rupture of the AL-PM were confirmed. We also considered that prolonged post-operative antibiotic treatment was indicated in our patient to protect the newly implanted prosthetic valves.

DIFFUSE ALVEOLAR HEMORRHAGE DUE TO SEVERE MITRAL VALVE REGURGITATION

Chronic mitral valve regurgitation has been reported as an etiological factor for diffuse alveolar hemorrhage (DAH), but there have been only a few cases that have reported acute mitral valve regurgitation to cause DAH. A 29-year-old Caucasian female with history of primary antiphospholipid

HEART's Original [症例] 腱索断裂により急性僧帽弁閉鎖不全症を伴った弾性線維性仮性黄色腫の1例

HEART's Original [症例] 腱索断裂により急性僧帽弁閉鎖不全症を伴った弾性線維性仮性黄色腫の1例

Diffuse Alveolar Hemorrhage due to Acute Mitral Valve Regurgitation

Diffuse alveolar hemorrhage (DAH) can be caused by several etiologies including vasculitis, drug exposure, anticoagulants, infections, mitral valve stenosis, and regurgitation. Chronic mitral valve regurgitation (MR) has been well documented as an etiological factor for DAH, but there have been only a few cases which have reported acute mitral valve regurgitation as an etiology of DAH. Acute mitral valve regurgitation can be a life-threatening condition and often requires urgent intervention. In rare cases, acute mitral regurgitation may result in a regurgitant jet which is directed towards the right upper pulmonary vein and may specifically cause right-sided pulmonary edema and right-sided DAH. Surgical repair of the mitral valve results in rapid resolution of DAH. Acute MR should be considered as a possible etiology in patients presenting with unilateral pulmonary edema, hemoptysis, and DAH.

Preoperative Management of Deteriorating Mitral Regurgitation and Heart Failure with Continuous Positive Airway Pressure

A 75-year-old Japanese woman with acute mitral valve prolapse and regurgitation, that developed one month previously, suffered from intractably progressive congestive heart failure (CHF). However, the emergent surgery was declined, and pharmacological treatment was discontinued due to hypotension and malignant arrhythmia. She was treated with 5-8 cmH2O of continuous positive airway pressure (CPAP) to manage CHF and Cheyne-Stokes respiration during the preoperative period of five weeks, after which plastic surgery of the mitral valve was successfully performed. CPAP can be an effective non-pharmacological treatment for CHF, unloading the left ventricle hydrostatically in order to reduce mitral regurgitation and improve oxygenation.