Aortomitral Continuity Research Articles

P473Bi-directional decremental conduction of mahaim like accessory pathway located at aortomitral continuity

P473Bi-directional decremental conduction of mahaim like accessory pathway located at aortomitral continuity

Potential Simultaneous Aortic and Mitral Valve Endocarditis in A Patient With Bio-Prosthetic Porcine Aortic Valve Replacement and Pacemaker Implantation

Background Introduction: Endocarditis is an uncommon condition in developed countries. Incidence rates range from 4 to 7 cases per 100,000 individuals a year. The incidence of simultaneous double valve endocarditis is extremely low. Objectives and Aims: This is a case study detailing a 67-year-old Caucasian male who was admitted for suspicion for endocarditis of which Duke Criteria were fulfilled for multi-valve endocarditis. We wish to demonstrate the usefulness of utilizing Duke’s Criteria for management of endocarditis in patients with multivalve involvement. Materials and Methods: Medical records were obtained from Trios Health and Sacred Heart Medical Center after permission was obtained. All documentation and acquired articles were obtained and reviewed. Results: The patient presented to the emergency department complaining of shortness of breath and cough. Evaluation in the emergency department resulted in a suspicion for endocarditis. He was subsequently admitted to the medical floors for management. A transesophageal echocardiogram was conducted, which demonstrated a peri-prosthetic valvular abscess on the aortic valve along with vegetations on the mitral valve. Due to positive Duke criteria for multivalve involvement, he was transferred to a tertiary referral center where he underwent surgery for valve replacement. Surgery noted an abscess with the destruction of the aortomitral continuity but no evidence of infection of the mitral valve. Conclusion: We recommend treatment for multivalve endocardidits when Duke Criteria is satisfied. Our patient may have had a resolution of the abscess prior to surgical intervention, which can be attributed to his vigorous treatment schedule.

Efficacy of an Anatomical Approach in Radiofrequency Catheter Ablation of Idiopathic Ventricular Arrhythmias Originating From the Left Ventricular Outflow Tract.

When anatomic obstacles preclude radiofrequency catheter ablation of idiopathic ventricular arrhythmias (VAs) originating from the left ventricular outflow tract (LVOT), an alternative approach from the anatomically opposite side (endocardial versus epicardial or above versus below the aortic valve) may be considered (anatomic ablation). The purpose of this study was to investigate the efficacy of an anatomic ablation in idiopathic LVOT VAs. We studied 229 consecutive patients with idiopathic LVOT VAs. Radiofrequency ablation from the first suitable site was successful in 190 patients, and in the remaining 39 patients, it was unsuccessful or had to be abandoned because of anatomic obstacles. In 22 of these 39 patients, an anatomic ablation was successful, and the VA origins were located in the intramural LVOT in 17 patients, basal left ventricular summit in 4, and LVOT septum near the His bundle in 1. The anatomic ablation was highly successful for idiopathic VAs originating from the intramural LVOT (>75%) and lateral LVOT, whereas it was unlikely to be successful for idiopathic VAs originating from the basal left ventricular summit (25%) and sepal LVOT. When a standard catheter ablation targeting the best electrophysiological measure of idiopathic LVOT VAs was unsuccessful or had to be abandoned because of anatomic obstacles, an anatomic ablation was moderately successful. These idiopathic LVOT VAs with a successful anatomic ablation commonly arose from the intramural LVOT among the left coronary cusp, aortomitral continuity, and epicardium, occasionally the basal left ventricular summit, and rarely the LVOT septum near the His bundle.

Challenging Radiofrequency Catheter Ablation of Idiopathic Ventricular Arrhythmias Originating From the Left Ventricular Summit Near the Left Main Coronary Artery

Radiofrequency catheter ablation (RFCA) of idiopathic ventricular arrhythmias (VAs) originating from the basal portion of the left ventricular (LV) summit, which is divided from the apical LV (A-LV) summit by the great cardiac vein (GCV), is challenging. This study investigated the efficacy of RFCA and electrocardiographic and electrophysiological characteristics of these VAs. Forty-five consecutive patients with symptomatic idiopathic LV summit VAs were studied. RFCA was successful within the main trunk of the GCV in 16 patients and within a branch of the GCV traversing the basal LV (B-LV) summit in 7. Transpericardial RFCA was successful on the epicardial surface in the A-LV summit in 6 patients and was abandoned in 14 with the B-LV summit VAs because of the close proximity to the coronary arteries and thick fat pads. RFCA was successful at the aortomitral continuity in 3 patients (2 with a failed transpericardial RFCA), and left coronary cusp in 1. The RFCA success rate of the A-LV summit VAs including the GCV VAs was 100% (22/22), whereas that of the B-LV summit VAs was 48% (11/23). The B-LV summit VAs could be differentiated from the A-LV summit VAs by left bundle branch block pattern, QRS duration ≤175 ms, precordial transition ≥V1, and maximum deflection index of ≥0.55. This study revealed that ≈50% of the B-LV summit VAs could be eliminated by a direct approach through a GCV branch running below the proximal left coronary arteries and a remote approach from the adjacent endocardial sites.

The Premature Ventricular Contraction-Induced Mitral Valvular Cardiomyopathy Successfully Treated by Radiofrequency Ablation: A Case Report

[Case report] A 70-year-old man referred to our hospital because he suffered from New York Heart Association (NYHA) functional class 2 heart failure symptoms. The electrocardiogram showed frequent monomorphic premature ventricular contractions (PVCs). The echocardiogram showed moderate mitral regurgitation (MR) due to anterior mitral leaflet (AML) prolapse with reduced left ventricular ejection fraction (LVEF)of 48%. Coronary angiography showed 99% stenosis in right coronary artery and 75% stenosis in left anterior descending artery. First, we conducted percutaneous coronary intervention because he refused surgical therapy. Although complete revascularization was achieved, PVCs were not disappeared and heart failure (HF) was not improved. Next, we conducted simultaneous lidocaine challenge test and left ventriculogram showing PVC disappearance and accompanying MR improvement in Sellers classification of 2 from 3. We considered that PVCs caused both HF and MR. PVCs were disappeared and improved MR to 2 from 3. The radiofrequency ablation (RFA) was conducted, and PVCs, which arose from aorto-mitral continuity, was successfully ablated at earliest activation site. PVCs have not recurred after RFA resulting continuous MR improvement and LVEF normalization. He spends free from HF symptoms for 14 months.[Conclusion] We report a rare case of mitral valvular cardiomyopathy, in which both reduced LVEF and moderate AML prolapsing MR were successfully treated by PVC ablation.

A simplified and reproducible method to size the mitral annulus: implications for transcatheter mitral valve replacement.

Transcatheter mitral valve replacement (TMVR) provides definitive valve replacement through a minimally invasive procedure. In the setting of TMVR, it remains unclear how relevant the differences between different mitral annular (MA) diameters are. We sought to define a simplified and reproducible method to describe the MA size. Using cardiac computed tomography angiography (CTA) studies of 47 patients, 3D MA perimeter (P3D) was annotated. The aorto-mitral continuity was excluded from MA contour either by manual annotation (yielding a saddle-shape model) or by simple truncation at the medial and lateral trigones (yielding a D-shape model). The method of the least squares was used to generate the projected MA area (Aproj) and perimeter (Pproj). Intercommissural (IC) and septolateral (SL) diameters, Dmean = (IC diameter + SL diameter)/2, area-derived diameter (DArea = 2 x √(A/π)) and perimeter-derived diameter (DPerimeter = P/π) were measured. MA eccentricity, height, and calcification (MAC) were assessed. Thirty studies were re-read by the same and by another observer to test intra- and inter-observer reproducibility. Patients (age, 75 ± 12 years, 66% males) had a wide range of mitral regurgitation severity (none-trace in 8%, mild in 55%, moderate-severe in 37%), MA size (area: 5-16 cm2), eccentricity (-8-52%), and height (3-11 mm). MAC was seen in 11 cases, in whom MAC arc occupied 26 ± 20% of the MA circumference. DArea (36.0 ± 4.0 mm) and DPerimeter (37.1 ± 3.8 mm) correlated strongly (R2 = 0.97) and were not significantly different (P = 0.15). The IC (39.3 ± 4.6 mm) and the SL (31.4 ± 4.5 mm) diameters were significantly different from DArea (P < 0.001) while Dmean (35.4 ± 4.0 mm) was not (P = 0.5). The correlation of DArea was stronger with Dmean (R2 = 0.96) than with IC and SL diameters (R2 = 0.69 and 0.76, respectively). The average difference between DArea and Dmean was +0.6 mm and the 95% limits of agreement were 2.1 and -0.9 mm. Similar results were found when the D-shape model was applied. All MA diameters showed good reproducibility with high intraclass correlation coefficient (0.93-0.98), small average bias (0.37-1.1 mm), and low coefficient of variation (3-7%) for intra- and inter-observer comparisons. Reproducibility of DArea was lower in patients with MAC. MA sizing by CTA is readily feasible and reproducible. Dmean is a simple index that can be used to infer the effective MA size.

98-06: Ablation of Outflow Tract Ventricular Arrhythmias in Patients with Prior Failed Ablation

Introduction: Ablation (RFA) of ventricular arrhythmias (VAs) arising from the outflow tracts (OT) is estimated to have a success rate of 80–90% in published clinical studies. However, in patients with prior failed ablation, they may be referred for redo RFA at tertiary centers or consideration for epicardial RFA. Understanding the reasons for failure of initial RFA may help improve mapping techniques at initial RFA, success rates of initial RFA, and pre-operative counseling prior to redo RFA regarding procedural expectations (ie, need for epicardial puncture, likelihood of success). Methods: Patients referred for redo RFA to a tertiary care center between 2013–2015 for redo RFA of presumed outflow tract PVCs were included. Included patients had detailed summaries of initial RFA procedure, inferiorly directed PVCs with tall, monophasic R waves in leads II, III, and aVF, and otherwise structurally normal hearts. 4 Results: 55 patients were included (67% male; age 62 + 15 years). All patients had prior failed RFA at referring centers. In detailed reports, 10% had 6/55 (11%) had only reported right ventricular OT (RVOT) mapping, 45/55 (82%) had reported comprehensive mapping of left (LV) and right OTs and coronary sinus (CS), and the remainder had LV and RVOT mapping but no reported CS mapping. 50/55 (91%) of patients had acute success after redo RFA, with 47/55 (85%) with long-time success at 3 month follow-up. No patients had epicardial puncture performed. Of 5 acute failures, 3 were due to proximity to coronary arteries with no RFA delivered, and 2 were due to proximity to the His bundle and concern for risk of heart block. In 3 recurrences, 2 had recurrence of PVCs of a different morphology but also arising from the OT (wider QRS, larger maximum deflection index [MDI], and earlier transition than initial VA), and 1 had recurrence of the same VA. Average procedural time was 45 + 29 minutes. The most common site of successful RFA was at the endocardial aspect of the LV summit (15/50, 30%), LV aspect just beneath the left/right (L/R) junction of the aortic cusps or right cusp (15/50, 30%), endocardial aorto-mitral continuity (10/50, 20%), coronary sinus (5/50, 10%), and supravalvar pulmonary artery (5/50, 10%). No acute complications occurred. All patients with prior RVOT only mapping had a V3 or earlier transition and foci in the LVOT. Conclusion: Redo RFA for OT VAs is common and success rates are high. After initial failed RFA, patients rarely require epicardial puncture and traditional endocardial mapping at less common sites (endocardial LV summit, L/R cusp junction, supravalvar pulmonary artery) may be useful.

Supraventricular Tachycardia in a Patient with an Interrupted Inferior Vena Cava

The noncoronary cusp and aortomitral continuity should be evaluated for early atrial activation when atrial tachycardias are noted to arise near the His bundle region, especially when the activation is diffuse around the His and when the P-wave morphology predicts a left atrial focus. In patients with congenital anomalies, alternate routes for catheter position need to be explored, including retrograde access for left atrial tachycardias and positioning of intracardiac echocardiography in the azygous vein for visualization of intracardiac structures. Consideration of remote magnetic navigation, if available, is another approach.

Should the Aortic Root Be the Preferred Route for Ablation of Focal Atrial Tachycardia Around the AV Node?: Support From Intracardiac Echocardiography.

The purpose of this study was to determine the optimal approach to focal atrial tachycardia originating from around the atrioventricular node. Focal atrial tachycardia (FAT) demonstrating earliest activation around the atrioventricular (AV) node during right atrial (RA) mapping has been eliminated by ablation at the RA para-Hisian region, from the left atrium (LA) or the noncoronary aortic cusp (NCC). However the optimal approach has not been determined. We conducted a retrospective analysis of a consecutive series of 148 patients undergoing catheter ablation for FAT between 2006 and 2014 in our institution. Earliest activation was recorded in the peri-AV nodal region during RA mapping in 34 patients (23%). Of these, 7 patients (20.5%) had successful ablation at the RA septum, using either radiofrequency (n= 4) or cryoenergy (n= 3). Seven FATs (20.5%) were ablated from the LA at the region of the aortomitral continuity, and 20 patients (59%) had successful ablation in the NCC, including 1 patient with a recurrence after a temporarily successful cryoablation from the RA. The proportion of the 3 approaches in this series showed a significant temporal evolution and overall frequency favoring ablation in the NCC (p= 0.011 for time trend and 0.013 for actual vs. expected frequencies). Intracardiac echocardiography proved superior catheter stability with the NCC approach. There were 2 cases of atrioventricular block and 1 recurrence after RA ablation versus no complications or recurrent FAT with NCC and LA approaches. Most peri-AV nodal FATs can be safely and effectively ablated from the NCC. The strategy of preferential NCC approach avoids RA para-Hisian ablation with the accompanying risk of AV block.

Echocardiographic Assessment of Mantle Radiation Mitral Stenosis

The long-term sequelae of mantle radiotherapy include lung disease and cardiac disorders. Dyspnea on exertion is a common complaint and can be due to one or more pathologies. We describe a case of mantle radiotherapy-induced mitral stenosis, characterized by aorto-mitral continuity calcification and absent commissural fusion which precludes balloon valvotomy. The latency period is long, and this patient presented 42 years after radiotherapy. Importantly, as previously described with radiation-induced valve disease, significant mitral stenosis developed 10 years after surgery for significant aortic stenosis. Two-dimensional and three-dimensional transthoracic and transesophageal echocardiography should be considered during assessment of symptomatic survivors of Hodgkin's disease where the index of suspicion for valvular stenosis increases over time. Given the natural history of mantle radiation valvular disease, a lower threshold for surgical intervention in radiation-induced mitral stenosis may need to be considered if cardiac surgery is planned for other reasons in order to avoid repeated sternotomy in patients with prior irradiation.

Demonstration of a hidden interaction between the aortomitral continuity and the conduction system in a case of idiopathic left ventricular outflow tract ventricular tachycardia

We describe a case of idiopathic left ventricular outflow ventricular tachycardia. Monomorphic ventricular arrhythmia (VA) with a right bundle branch block morphology and an inferior axis was induced through exercise or isoproterenol infusion. During VA bigeminy, a spiked presystolic potential (PP) preceding the VA with a qrS pattern in the unipolar electrogram was recorded at the aortomitral continuity (AMC). Radiofrequency catheter ablation eliminated the VA despite the persistence of sinus-PP bigeminy. Furthermore, these PP rates were dependent on the preceding sinus rhythm rates. The present case suggests a hidden interaction between the AMC and the conduction system.

A simplified D-shaped model of the mitral annulus to facilitate CT-based sizing before transcatheter mitral valve implantation

BackgroundThe nonplanar, saddle-shaped structure of the mitral annulus has been well established through decades of anatomic and echocardiographic study. Its relevance for mitral annular assessment for transcatheter mitral valve implantation is uncertain. ObjectiveOur objectives are to define the methodology for CT-based simplified “D-shaped” mitral annular assessment for transcatheter mitral valve implantation and compare these measurements to traditional “saddle-shaped” mitral annular assessment. MethodsThe annular contour was manually segmented, and fibrous trigones were identified using electrocardiogram-gated diastolic CT data sets of 28 patients with severe functional mitral regurgitation, yielding annular perimeter, projected area, trigone-to-trigone (TT) distance, and septal-lateral distance. In contrast to the traditional saddle-shaped annulus, the D-shaped annulus was defined as being limited anteriorly by the TT distance, excluding the aortomitral continuity. Hypothetical left ventricular outflow tract (LVOT) clearance was assessed. ResultsProjected area, perimeter, and septal-lateral distance were found to be significantly smaller for the D-shaped annulus (11.2 ± 2.7 vs 13.0 ± 3.0 cm2; 124.1 ± 15.1 vs 136.0 ± 15.5 mm; and 32.1 ± 4.0 vs 40.1 ± 4.9 mm, respectively; P < .001). TT distances were identical (32.7 ± 4.1 mm). Hypothetical LVOT clearance was significantly lower for the saddle-shaped annulus than for the D-shaped annulus (10.7 ± 2.2 vs 17.5 ± 3.0 mm; P < .001). ConclusionBy truncating the anterior horn of the saddle-shaped annular contour at the TT distance, the resulting more planar and smaller D-shaped annulus projects less onto the LVOT, yielding a significantly larger hypothetical LVOT clearance than the saddle-shaped approach. CT-based mitral annular assessment may aid preprocedural sizing, ensuring appropriate patient and device selection.

Unusual response to entrainment of ventricular tachycardia: In or out?

FEATURED ARRHYTHMIA Unusual response to entrainment of ventricular tachycardia: In or out? Roderick Tung, MD, FHRS, Kalyanam Shivkumar, MD, PhD, FHRS From the UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, Los Angeles, California. Case presentation A 70-year-old man with history of inferior myocardial infarction with an ejection fraction of 25% was urgently transferred for ablation of incessant slow ventricular tachycardia (VT). Electroanatomic mapping revealed extensive inferolateral scar extending to the inferior septum. Entrainment mapping demonstrated an entrance in periannular inferolateral scar with an exit anterior to the aortomitral continuity. Entrain- ment mapping was performed in the scar at a site in between these 2 regions. Is this response in or out of the circuit? (Figure 1) Commentary Entrainment mapping, or continuous resetting of VT, is the gold standard technique for characterizing the components within a reentrant circuit. Demonstration of an isthmus requires the presence of (1) concealed fusion, (2) postpacing interval within 30 ms of the tachycardia cycle length, and (3) stimulus-QRS (S-QRS) interval equal to electrogram-QRS (EGM-QRS) interval. 1 The presence of these responses is highly predictive of termination with ablation. 2,3 In this case, overdrive pacing of the slow VT (680 ms) is performed at 620 ms (10 mA @ 2 ms). Two distinct diastolic potentials are seen during VT, and it is important to distinguish the near-field EGM captured from far-field components in order to accurately measure the postpacing interval. 4 Disappearance of a local EGM during pacing represents either direct capture or saturation of the channel from pacing. Two features confirm that the early diastolic EGM is not captured during entrainment: (1) the S-QRS interval would be longer as the EGM-QRS occurs in early diastole and (2) analysis of the onset of pacing reveals KEYWORDS Ventricular tachycardia; Entrainment ABBREVIATIONS EGM-QRS ¼ electrogram-QRS; MES ¼ multiple exit site; S-QRS ¼ stimulus-QRS; VT ¼ ventricular tachycardia (Heart Rhythm Address reprint requests and correspondence: Dr Roderick Tung, UCLA Cardiac Arrhythmia Center, David Geffen School of Medicine at UCLA, 100 Medical Plaza, Suite 660, Los Angeles, CA 90095. E-mail address: rtung@mednet.ucla.edu. 1547-5271/$-see front matter B 2014 Heart Rhythm Society. All rights reserved. saturation (Figure 2, dashed circle) from the pacing current in the absence of local and QRS capture. The last entrained beat demonstrates overt or manifest fusion. The postpacing interval measured to the peak component of the return sensed EGM is within 30 ms of the tachycardia cycle length (680 ms). The S-QRS interval appears to match the EGM-QRS interval when measuring the peak deflection of the late diastolic EGM. These responses suggest entrainment from an outer loop site on the periphery of the reentrant circuit with antidromic fusion outside the circuit. However, careful analysis of the first 2 paced beats on the tracing demonstrates a QRS morphology with an exact 12-lead match for the VT. The possibility of transient loss of capture during these 2 complexes is ruled out by acceleration of the VT to the pacing cycle length (620 ms). These 2 beats represent concealed fusion with a perfect match for the VT, and the S-QRS interval (145 ms) matches the EGM-QRS interval when the EGM is timed to the onset of the return diastolic potential rather than the peak. Analysis of the diastolic EGM before pacing is useful because the EGM is not yet saturated by the pacing channel, which allows more detailed analysis of multicomponent local EGMs (Figure 2). Closer analysis of this EGM confirms a fractionated compo- nent of the late diastolic potential 35 ms before the peak deflection (EGM-QRS interval 145 ms). Note that the first entrained beat after the onset of pacing has the same morphology as the last entrained beat. Interpretation of this entrainment response using the first 2 complexes in Figure 1 suggests a critical isthmus site. Ablation at this site resulted in the abrupt termination of VT within 4 seconds (Figure 3). We have previously reported the observation of multiple exit site (MES) morphologies when pace mapping within scar during sinus rhythm. 5 These sites are likely specific for reentrant isthmuses and importantly can be identified as surrogates for critical sites in sinus rhythm. However, pacing during sinus rhythm from a point-like source is likely to have a radial spread of activation in contrast to a broad reentrant wave front with a preferential exit during VT. Therefore, activation through MESs out of scar is more likely to be seen during pace mapping. The entrainment response in this case likely represents an alternate exit site from a common http://dx.doi.org/10.1016/j.hrthm.2013.09.006

Annulus upsizing for mitral valve re-replacement in children

Mitral valve replacement remains the last resort for treatment of congenital mitral valve disease. Enlarging the mitral annulus at the time of mitral valve replacement may allow implantation of a larger prosthesis in children. All mitral valve replacement procedures from 1990 to 2012 were included, and mitral annulus enlargement techniques were analyzed. A control group of patients undergoing replacement of a previously implanted mechanical mitral valve prosthesis was compared with the cohort of patients who underwent annular enlarging procedures. Primary end points were increases in annulus size and Z score, and freedom from paced rhythm. Among 205 mitral valve replacement procedures, 16 (8%) included techniques to upsize the mitral annulus in 15 patients, all but 1 of whom had undergone prior mitral valve replacement. These patients were compared with a control cohort of 53 patients undergoing mitral valve re-replacement without annulus enlargement. The annulus was upsized by 18% ± 11% (compared with 16% ± 20% in controls, P = .5) using open balloon dilation in 4 patients, radial annular incisions in 5 patients, and patch augmentation of the aorto-mitral continuity in 7 patients. The mean valvar diameter Z score increased from -0.2 ± 1.3 to +1.1 ± 1.4 (P < .001), compared with an increase from -0.3 ± 1.2 to 0.9 ± 1.1 in controls (P < .001). During a mean follow-up of 6.5 ± 6.4 years, 4 of 12 patients required permanent pacing in the upsizing group (predominantly with patch augmentation), versus 5 of 53 patients in the control group. In children undergoing mitral valve replacement, various techniques can be used to upsize the mitral annulus and allow implantation of a larger prosthesis. There is a nontrivial risk of heart block with annulus upsizing, which deserves further study.

Anesthetic and hemodynamic management of a rare case of Brucella multivalvular endocarditis in cardiogenic shock undergoing emergency aortic valve replacement and mitral valve repair

We describe a very rare case of human brucella multivalvular endocarditis. Patient presented in a state of cardiogenic shock with low urine output and a history of breathlessness. Patient was diagnosed to have brucellosis 2 months back by blood cultures and agglutination tests and was receiving doxycycline and rifampicin therapy. Echocardiography showed severe aortic regurgitation, moderate mitral regurgitation, severe left ventricular dysfunction and a mobile vegetation attached to the aortic valve. Patient was scheduled for emergency surgery; while preparing for surgery hemodynamic monitoring, non-invasive ventilation and inotropic supports were started. During surgery, the aortic valve was found perforated and the aortomitral continuity was disrupted. Aortic valve replacement and mitral valve repair were performed. Hemofiltration was used during cardiopulmonary bypass. Weaning from bypass was achieved with the help of inodilators, dual chamber pacing and intra-aortic balloon pump.

Prosthetic Valve Endocarditis after Double Valve Replacement with the Manouguian Procedure

Prosthetic valve endocarditis is a rare but severe complication after double mitral and aortic valve replacement. It is debated whether or not all prostheses should be replaced simultaneously, because of high operative mortality with redo double valve replacement. We report a case of prosthetic valve endocarditis after double mitral and aortic valve replacement with the Manouguian procedure. A 56-year-old man had undergone double valve replacement 12 years prior and presented with high fever 2 months after dental treatment. Enterococcus faecalis was isolated from blood cultures twice. Transthoracic echocardiography showed perivalvular mitral regurgitation, but no vegetations or abscess. Transesophageal echocardiography revealed an abscess on the aortomitral continuity of the Manouguian patch. We removed all previous prostheses and performed redo aortic and mitral valve replacements with a repeat Manouguian procedure. The postoperative course was satisfactory. Precise preoperative evaluation by transesophageal echocardiography and radical removal of the infected prostheses resulted in successful treatment.

Reconstruction of aorto-mitral continuity with a handmade aorto-mitral bioprosthetic valve for extensive bivalvular endocarditis†

Surgical treatment is effective to exclude all infected tissue in patients with infective endocarditis. Although various techniques have been reported, it has remained a great challenge for patients with extensive infected regions. A patient with extensive bivalvular endocarditis including the aortic and mitral valve and aorto-mitral continuity is described. A handmade aorto-mitral bioprosthetic valve was created to reconstruct the defect after extensive debridement. The patient was discharged on the 30th postoperative day without inflammatory signs.

A Rare Case of Permanent Junctional Reciprocating Tachycardia Ablated on the Roof of the Left Atrium

Left-sided anteroseptal accessory pathways that course through the aortomitral fibrous continuity are some of the rarest types of accessory pathways. At this region the atrium and ventricle are separated by their greatest distance because of the intervening aortic valve. These pathways often have a long circuitous course that may involve the root and cusps of the aortic valve. Prior reports have demonstrated the feasibility of ablating these pathways along the anteroseptal mitral annulus, the left ventricular outflow tract, or in the left or noncoronary cusps of the aortic valve. We describe a case of a concealed decremental anteroseptal accessory pathway that was ablated on the roof of the left atrium remote from the mitral or aortic valve annuli. This report indicates that when an appropriate site for ablation of a left-sided anteroseptal accessory pathway is not found close to a valve annulus, these pathways may be amenable to ablation by targeting their atrial insertion site.

Austrian syndrome in the context of a fulminant pneumococcal native valve endocarditis

This is the case of a young male suffering from Austrian syndrome, which is the triad of endocarditis, meningitis, and pneumonia due to invasive S. pneumoniae infection. He reported recurrent fever for six months without any antibiotic treatment, which may have determined the further course of the syndrome. Echocardiography revealed massive native valve endocarditis, and the patient was considered for ultima-ratio cardiac surgery. Intraoperative aspect presented extensive affection of the aortic root with full destruction of aortic valve, mitral valve, and aortomitral continuity. The myocardium showed a phlegmon-like infiltration. Microbiologic testing of intraoperatively collected specimens identified penicillin-sensitive Streptococcus pneumoniae. S. pneumoniae is a very uncommon cause for infective infiltrative endocarditis and is associated with severe clinical courses. Austrian syndrome is even more rare, with only a few reported cases worldwide. In those patients, only early diagnosis, immediate antibiotic treatment, and emergent cardiac surgery can save lives.

Long-Term Results After Operations for Active Infective Endocarditis in Native and Prosthetic Valves

The objective of this study was to evaluate the midterm results of patients who underwent operations for active infective endocarditis. Within a 10-year period, 141 patients with active infective endocarditis received surgical therapy. We assessed outcome, freedom from reinfection, and freedom from reintervention. Prosthetic valve endocarditis was included in this series. Surgical strategies included valve replacement with a tissue valve in 62% of patients and valve repair in 29% of patients. In 29% of patients, reconstruction of the aortomitral continuity, left ventricular outflow tract, or sinus of Valsalva was preferably performed with 1 or more bovine pericardial patches. In-hospital mortality was 11% and postoperative stroke rate was 7%. Multivariate logistic regression revealed multivalve involvement (p=0.052; odds ratio [OR], 5.84; 95% confidence interval [CI], 0.98-34.57), preoperative neurologic impairment (p=0.006; OR, 9.71; 95% CI, 1.92-49.09), and European system for cardiac operative risk evaluation (EuroSCORE) in quartiles (p=0.023; OR, 2.88; 95% CI, 1.15-7.17) to be independent predictors for in-hospital death. One-year and 5-year actuarial survival was 77% and 69%, respectively. One-year and 5-year actuarial freedom from reinfection was 100% and 90%, respectively. Freedom from reoperation at 5 years was 100%. Five-year survival was 74% for single-valve endocarditis and 46% for multivalve endocarditis (p<0.001). One-year freedom from reinfection was 100% for both single-valve and multivalve endocarditis; 5-year freedom from reinfection was 95% for single-valve endocarditis versus 67% for multivalve endocarditis (p=0.049). Despite a high early mortality during the first year, surgical intervention for active infective endocarditis provided excellent results with regard to freedom from reinfection and reoperation. A strategy of extensive debridement, reconstruction of destroyed cardiac structures using xenopericardium, followed by valve replacement or repair is highly effective and shows favorable long-term outcomes.