Bioprosthetic Mitral Valve Research Articles

Late thrombosis of a mitral bioprosthetic valve with associated massive left atrial thrombus

Late thrombosis of a mitral bioprosthetic valve with associated massive left atrial thrombus

Bioprosthetic Mitral Valve Leaflet Thrombosis, Novel Oral Anticoagulants a Potential Solution for a Sticky Problem

A 52-year-old female presented with NYHA class III dyspnoea on a background of a previous bioprosthetic mitral valve replacement. This was inserted five years previously for severe mitral regurgitation secondary to anthracycline cardiomyopathy. The patient had declined a mechanical valve prosthesis. Transoesophageal echocardiography demonstrated restricted leaflet motion, and confirmed severe stenosis of the bioprosthetic mitral valve with a mean gradient of 12 mmHg across the valve. Coronary angiogram did not reveal significant coronary disease and after heart team discussion the patient was referred for a re-do mechanical mitral valve replacement. Whilst awaiting surgery apixaban was prescribed for a deep vein thrombosis and co-existent paroxysmal atrial fibrillation. A repeat transoesophageal echocardiogram performed on table pre-sternotomy two months later revealed normal bioprosthetic valve function with appropriate leaflet excursion and a mean gradient of 3 mmHg across the valve. The patient's symptoms had improved during the anticoagulation period. Bioprosthetic valve leaflet thrombosis (BVLT) has been reported post transcatheter and surgical bioprosthetic aortic valve replacements. This clinical vignette highlights the importance of recognising BVLT in the months and years post implantation. The case also demonstrates a potential role for novel oral anticoagulants in treating this condition. Future studies are required to determine risk factors for BVLT and optimal treatment methods.

Transcatheter heart valve in valve implantation with Edwards SAPIEN bioprosthetic valve for different degenerated bioprosthetic valve positions (First Iranian ViV report with mid-term follow up).

Introduction: After early successful experience with transcatheter aortic valve replacement (TAVR), concept of transcatheter implantation of a new valve within a failing bioprosthetic valve emerged. Valve-in-valve (ViV) implantation seems to be a simpler option for high risk surgical patients. Methods: We performed five ViV procedures in different valve positions. We included patients with failing bioprosthetic valves with high surgical risk due to concomitant comorbidities. We performed 2 transapical ViV procedures for failing mitral bioprosthetic valves, 1 transfemoral procedure for failing pulmonary valve and 2 transfemoral ViV implantation for failing tricuspid bioprosthetic valves. Results: The procedures were successfully completed in all 5 cases with initial excellent fluoroscopic and echocardiographic verification. There was no valve embolization or paravalvular leakage in any of the cases. Transcatheter valve function was appropriate with echocardiography. Post procedural clinical adverse events like pleural effusion and transient ischemic attack were managed successfully. In midterm follow up all cases remained in appropriate functional class except from the transcatheter pulmonary valve which became moderately stenotic and regurgitant. Conclusion: As the first Iranian all-comers case series with midterm follow up for ViV implantation, we had no mortality. Interestingly none of our patients had neurologic sequelae after the procedure. Midterm follow up for our patients was acceptable with good functional class and appropriate echocardiographic findings. Due to high surgical risk of the redo procedure after failing of a bioprosthetic valve especially in elderly patients with comorbidities, ViV implantation would be a good alternative to surgery for this high risk group.

Direct oral anticoagulant use in nonvalvular atrial fibrillation with valvular heart disease: a systematic review.

Direct oral anticoagulants (DOACs) are indicated for stroke prevention in patients with nonvalvular atrial fibrillation (NVAF), which, according to the American College of Cardiology/American Heart Association/Heart Rhythm Society atrial fibrillation (AF) guidelines, excludes patients with rheumatic mitral stenosis, a mechanical or bioprosthetic heart valve, or mitral valve repair. However, the data regarding use of DOACs in AF patients with other types of valvular heart disease (VHD) are unclear. We aimed to summarize and evaluate the literature regarding the safety and efficacy of DOAC use in NVAF patients with other types of VHD. After an extensive literature search, a total of 1 prospective controlled trial, 4 subanalyses, and 1 abstract were identified. Efficacy of the DOAC agents in NVAF patients with VHD mirrored the overall trial results. Bleeding risk was significantly increased in VHD patients treated with rivaroxaban, but not for dabigatran or apixaban. Of the bioprosthetic valve patients enrolled in the Apixaban for Reduction in Stroke and Other Thromboembolic Events in Atrial Fibrillation (ARISTOTLE) trial, no safety or efficacy concerns were identified. In conclusion, subanalyses of DOAC landmark AF trials revealed that dabigatran, rivaroxaban, and apixaban may be safely used in AF patients with certain types of VHD: aortic stenosis, aortic regurgitation, and mitral regurgitation. More evidence is needed before routinely recommending these agents for patients with bioprosthetic valves or mild mitral stenosis. Patients with moderate to severe mitral stenosis or mechanical valves should continue to receive warfarin, as these patients were excluded from all landmark AF trials.

Unusually Large Mitral Valve Vegetation Causing Mitral Valve Prolapse and Respiratory Failure

SESSION TITLE: Student/Resident Case Report Poster - Cardiovascular Disease I SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Vegetations are characteristic lesions of Infective endocarditis. The size of the vegetation has great clinical significance as it has been shown to determine the probability of complications including embolization, rupture, regurgitation, and heart failure. They contain bacteria and inflammatory cells interspersed in network of platelets and fibrin.In general, lesions greater than 15 mm are considered large vegetations and have higher risk of complications especially if they are mobile CASE PRESENTATION: A 70 year old woman with hyperlipidemia was brought to the hospital with severe respiratory distress. She had intermittent shortness of breath for the last three months which acutely worsened in the week prior to admission. At the time of presentation, she was found to be hypotensive, tachycardic and tachypneic. She had bilateral generalized wheezing. Chest X-ray showed florid pulmonary edema. Troponins were negative and Electrocardiography did not show any ischemic changes. Echocardiography showed an ejection fraction of 75% and severe mitral regurgitation with a 4.5 cm large vegetation in the posterior mitral leaflet that prolapsed into left atrium and left ventricle(Fig-1). Over the past one year, she had frequent dental procedures; last one a week ago. She was intubated for respiratory support and an Intra-Aortic Balloon Pump was placed. Emergency coronary angiography was performed which showed normal coronary arteries. Ceftriaxone, Vancomycin and Gentamicin were started for presumed infective Endocarditis. Blood culture and tissue culture later grew Group B beta hemolytic streptococcus. Subsequently, the mitral valve and vegetation were removed(Fig-2) and she received a bio prosthetic mitral valve implant. Ceftriaxone was continued for a total of 6 weeks with which her condition subsequently improved. DISCUSSION: Vegetations larger than 15 mm are considered large vegetation and they require immediate surgical intervention. Compared to the ones reported in literature, our patient had an enormous vegetation which measured 4.5 cm. It was attached to the posterior mitral leaflet and prolapsed into the left atrium as well as the ventricle along with the blood flow. And, the blood culture grew beta hemolytic Streptococcus. It is unusual given the general understanding that large vegetations tend to be fungal and involve tricuspid valve more than the others. CONCLUSIONS: Size is one of the most important features of infective endocarditis vegetation as it determines the potential risk of complications like embolization, valvular regurgitation and acute heart failure Reference #1: Sanfilippo AJ, Picard MH, Newell JB, et al: Echocardiographic assessment of patients with infectious endocarditis: prediction of risk for complications. J Am Coll Cardiol 1991;18:1191-9 Reference #2: Tischler MD, Vaitkus PT. The ability of vegetation size on echocardiography to predict clinical complications: a meta-analysis. J Am Soc Echocardiogr. 1997 Jun;10(5):562-8 DISCLOSURE: The following authors have nothing to disclose: Karan Wats, Syeda Batul, Suvash Shreshtha, Sunil Abrol, Vijay Shetty No Product/Research Disclosure Information

A Genomics-Based Model for Prediction of Severe Bioprosthetic Mitral Valve Calcification.

Severe bioprosthetic mitral valve calcification is a significant problem in cardiovascular surgery. Unfortunately, clinical markers did not demonstrate efficacy in prediction of severe bioprosthetic mitral valve calcification. Here, we examined whether a genomics-based approach is efficient in predicting the risk of severe bioprosthetic mitral valve calcification. A total of 124 consecutive Russian patients who underwent mitral valve replacement surgery were recruited. We investigated the associations of the inherited variation in innate immunity, lipid metabolism and calcium metabolism genes with severe bioprosthetic mitral valve calcification. Genotyping was conducted utilizing the TaqMan assay. Eight gene polymorphisms were significantly associated with severe bioprosthetic mitral valve calcification and were therefore included into stepwise logistic regression which identified male gender, the T/T genotype of the rs3775073 polymorphism within the TLR6 gene, the C/T genotype of the rs2229238 polymorphism within the IL6R gene, and the A/A genotype of the rs10455872 polymorphism within the LPA gene as independent predictors of severe bioprosthetic mitral valve calcification. The developed genomics-based model had fair predictive value with area under the receiver operating characteristic (ROC) curve of 0.73. In conclusion, our genomics-based approach is efficient for the prediction of severe bioprosthetic mitral valve calcification.

346 - Patients with Prosthetic Valves and Need for Left Ventricular Assist Device

Introduction: The use of left ventricular assist device (LVAD) in patients with prosthetic valves has been a subject of debate. The risk of thromboembolic (TE) events remains a concern especially if anticoagulation had to be interrupted in case bleeding occurs. Case Report: We report a case of a 63-year-old female with end-stage heart failure awaiting a heart transplant. She was admitted to the hospital for worsening chronic heart failure and was inotrope dependent. While awaiting heart transplant, a decision was made to implant a left ventricular assist device (LVAD) as a bridge to transplant. She had a mechanical mitral valve (mMVR) which was exchanged to a bioprosthetic valve at the time of LVAD implantation. Post-operative course was complicated by bleeding while she was on anticoagulation but she survived. Objectives and methods: We searched PubMed for case studies of patients with LVAD having bioprosthetic valves. We found retrospective studies and case reports from 1982 to 2010 on patients with LVAD and prosthetic valves. Only patients with permanent LVAD were analyzed (n = 37). These patients were further subgrouped into bioprosthetic mitral valve replacement (bMVR) and aortic valve replacement (bAVR); mechanical mitral valve replacement (mMVR) and aortic valve replacement (mAVR); and combined mechanical and bioprosthetic MVR and AVR. Moreover, we analyzed different eras of anticoagulation. Outcomes analyzed were TE events, bleeding and death. Results: Majority patients were bridged to warfarin as their anticoagulation regimen. Nine patients with mMVR had a mean LVAD support time of 168.2 days. Four patients with bMVR had a mean LVAD support time of 229.6 days. No clinical TE events or bleeds were reported in both these subgroups. Seven patients with mAVR had a mean LVAD support time of 47.57 days. Thrombus was found in one of the explanted heart, but no clinical TE events were reported. One patient had bleed. Eight patients with bAVR had a mean support time of 223.7 days. Thrombus was found underneath the aortic valve of the explanted heart of one patient. No bleeding or clinical TE events were noted. In the combination group, mean LVAD support time was 96.3 days. One patient had a bleeding complication. One patient had a TE event. Overall mortality was high in all subgroups ranging from 25% to 37.5% unrelated to TE event or bleed. Conclusion: Our analysis showed no significant TE events or bleeding complications in these patients. LVAD in patients with pre-existing prosthetic valves is worth consideration given the shortage of heart donors. We prefer exchanging the mechanical valve to a bMVR as it carries a lesser risk of TE events. However, one should be mindful of the overall high mortality rate in these patients. Larger studies need to be conducted to confirm these findings.

Transcatheter aortic valve implantation in patients with a mitral prosthesis; single center experience and review of literature

ObjectivesFollowing the encouraging results of several registries and trials, transcatheter aortic valve implantation (TAVI) has been recognized as a valid option in patients with severe aortic stenosis deemed at high or prohibitive risk for surgical treatment. Good procedural success and good clinical outcomes have been showed and very limited data exist on TAVI in the setting of a preexisting mitral prosthesis regarding the technique, potential complications, and outcomes. MethodsHere, we report six cases of transfemoral TAVI with a self-expanding bioprosthesis (CoreValve; Medtronic, Inc) in patients who had previously undergone mitral valve replacement. Preprocedural, intraprocedural ve postprocedural outcome and data were analyzed and a brief literature review is also presented. Results and conclusionOur experiences show that transfemoral CoreValve implantation can be performed successfully in patients with mechanical and bioprosthetic mitral valves.

5. Mitral valve replacement for mitral stenosis: 15 years single center experience

Mitral valve replacement (MVR) with either a bioprosthetic or a mechanical valve is the treatment of choice for severe mitral stenosis. This study aimed to evaluate and compare the early and late outcome of mitral valve replacement (mechanical versus bioprosthetic) for severe mitral stenosis. A retrospective cohort study was performed on prospectively collected data involving mitral stenosis patients who have undergone MVR with either bioprosthetic (BMV) ( n =50) or mechanical (MMV) ( n =145) valves in our institute from 1999 to 2012. Data were analyzed for early and late mortality, NYHA functional classes, stroke, early and late valve-related complications, and survival. Chi Square test, logistic regression, Kaplan Meier curve, and dependent proportions tests were performed. A total of 195 patients were included in the study with a follow-up of 190 patients (97.5%). One patient died early post-operatively; twelve patients died late in the post-operative period, BMV group (6) and the MMV (6). The Late mortality had significantly associated with post-op stroke ( p p =0.002). Post-op NYHA class was significantly associated with age ( p =0.003), pulmonary disease ( p =0.02), mitral valve implant type ( p =0.01), and post-op stroke ( p =0.02); 14 patients had strokes in the MMV (9) and in the BMV (5) groups. NYHA classes were significantly better after the replacement surgeries ( p p =0.03), worse NYHA post-op ( p =0.01), and more re-operations ( p =0.006). Survival was significantly better with mechanical valves ( p =0.03). When the two groups were matched for age and mitral regurgitation, the analysis revealed that bioprosthetic valves were significantly associated with re-operations ( p =0.02) but not significantly associated with worse survival ( p =0.4) or worse NYHA ( p =0.4). Mechanical mitral valve replacement in mitral stenosis patients is associated with lower re-operation rate, but no difference in survival as compared to bioprosthetic mitral valve replacement. Furthermore, post-operative stroke occurrence (14%) is associated with late mortality and worse NYHA classes.

Percutaneous transcatheter closure of an aorta to left atrium fistula with an Amplatzer septal occluder in a patient with a mitral bioprosthesis

We describe the case of a patient with a mitral bioprosthetic valve undergoing percutaneous closure with fluoroscopy and echocardiographic guidance of a rare left sinus of Valsalva‒left atrial fistula. The original aspect of this case is that the fistula was located at the level of the left sinus of Valsalva next to the mitral valve bioprosthesis with subsequent risk of prosthesis damage and/or occlusion of the left coronary artery at its origin during the procedure.

Variation in Warfarin Use at Hospital Discharge After Isolated Bioprosthetic Mitral Valve Replacement: An Analysis of the Society of Thoracic Surgeons Adult Cardiac Surgery Database

Anticoagulation with warfarin following bioprosthetic mitral valve replacement (BMVR) is recommended by multiple practice guidelines. We assessed practice variability and patient characteristics associated with warfarin prescription following BMVR. We analyzed 7,637 patients in the Society of Thoracic Surgeons Database (January 1, 2008 to June 30, 2011) who were discharged following isolated primary nonemergent BMVR. Patients requiring preoperative warfarin, those with preoperative atrial fibrillation, or those with a contraindication to warfarin were excluded. The association between patient, hospital, and surgeon characteristics and warfarin prescription were evaluated. Fifty-eight percent of this cohort (median age, 66 years; female sex, 58.7%) was prescribed warfarin. Patients receiving warfarin were older (67 vs65 years; P< .0001), were less likely to have had preoperative stroke (9.3%vs12.1%; P< .001), CHF (51.4%vs54.1%; P< .02), or dialysis (4.9%vs9.0%; P< 0.001), and had a longer postoperative length of stay (8.0 vs7.0days; P< 0.01). Warfarin was prescribed less often for patients with postoperative GI events (44.4%vs55.6%; P< .001) but more often for patients with postoperative myocardial infarction (75.8%vs24.2%; P< .001) or new atrial fibrillation (68%vs32%; P<.001) and those requiring blood transfusions intraoperatively (55.7%vs44.3%; P< .001) or postoperatively (57%vs43%; P< .03). Similar rates of warfarin prescription were observed in patients requiring reoperation for bleeding (54.9%vs45.1%; P= .20) and those with postoperative stroke (53.6 %vs46.4 %; P= .30). After adjusting for patient characteristics, significant surgeon and hospital variation in warfarin prescription at hospitals was observed. Although patient characteristics and postoperative events may be associated with the prescription of warfarin following BMVR, substantial surgeon and hospital variability remains. This variability largely ignores the established practice guidelines and warrants further study to define the optimal anticoagulation strategy in patients undergoing BMVR.

In Vitro 2D PIV Measurements and Related Aperture Areas of Tricuspid Bioprosthetic Mitral Valves at the beginning of Diastole

Besides ventricular parameters, the design and angular orientation of a prosthetic heart valve induce a specific flow field. The aim of this study was to know the inflow characteristics of a left ventricular model (LVM), investigating the behavior of tricuspid bioprosthetic mitral valves in terms of velocity profiles and related valve aperture areas at the beginning of diastole, under different conditions. 3 heart rates (HRs) were established in the LVM and each mitral bioprosthesis (27 and 31 mm diameter) was installed in 2 orientations, rotated by 180° . For each experimental setup, 2-dimensional particle image velocimetry (2D PIV) measurements and simultaneous mitral valve (MV) area detection were obtained from 50 samples. The results from the velocity profiles immediately downstream of mitral bioprostheses showed the influence of valve orientation for moderate HRs, although for a similar magnitude of mean velocity vectors. The geometries of MV open areas for each HR were similar regardless of valve orientation, except for the 27-mm valve at 90 beats per minute (bpm), and for the 31-mm valve at 60 bpm. Moreover, for each HR, similar percentages of valve open area were obtained regardless of MV nominal diameters. In conclusion, the experimental setup for the 2D PIV measurements synchronized with the MV area detection was a useful tool for knowing the inflow characteristics of the LVM.

Percutaneous Transvenous Transseptal Transcatheter Valve Implantation inFailedBioprosthetic Mitral Valves, RingAnnuloplasty, and Severe MitralAnnular Calcification.

This study sought to examine the feasibility, safety, and intermediate-term outcomes in patients undergoing percutaneous transvenous transcatheter mitral valve implantation in failed bioprosthesis, ring annuloplasty, and calcific mitral stenosis. Surgical mitral valve replacement in patients with previous surgery or severe mitral annular calcification (MAC) is often associated with high or prohibitive risk. Percutaneous transfemoral antegrade transseptal implantation of Edwards SAPIEN prosthesis (Edwards Lifesciences, Irvine, California) was performed in 48 patients with degenerated mitral bioprosthesis (n= 33), previous ring annuloplasty (n= 9), and severe MAC (n= 6). The mean Society of Thoracic Surgeons risk score was 13.2 ± 7.4% with a mean age 76 ± 11 years. Acute procedural success was achieved in 42 of 48 patients (88%) in the overall group and 31 of 33 (94%) in the failed bioprosthetic mitral valve group and success rate of 11 of 15 (73%) in patients with failed annuloplasty rings and MAC. After successful procedure, no patients had > mild residual mitral prosthetic or periprosthetic regurgitation; mean transvalvular gradients were 6 ± 2.5 mmHg. Thirty-day survival free of death and cardiovascular surgery was 85% in the overall group and 91% in the failed bioprosthetic mitral valve subgroup. Transfemoral percutaneous transvenous mitral valve implantation in high-risk patients with degenerated bioprosthesis is safe, effective, and associated with rapid improvement in hemodynamics, short length of stays, and improved functional status. Percutaneous mitral valve implantation in patients with failed annuloplasty rings and severe MAC is a promising therapy with significant short-term morbidity and mortality that requires further study.

Valve-in-Valve Transcatheter Valve Implantation in the Nonaortic Position.

Transcatheter valve-in-valve (VIV) procedures are an alternative to standard surgical valve replacement in high risk patients. Cases in which a commercially approved transcatheter aortic valve replacement (TAVR) device was used for a nonaortic VIV procedure between November 2013 and September 2015 are reviewed. Clinical, echocardiographic, and procedural details, patient survival, and symptom severity by NYHA class at follow-up were assessed. All patients were heart-team determined high risk for conventional redo surgery (mean STS PROM = 6.8 ± 2.2%). Five patients underwent VIV replacement in the nonaortic position, four for bioprosthetic mitral valve dysfunction, and one for bioprosthetic tricuspid valve dysfunction. Bioprosthetic failure was due to stenosis in three patients and regurgitation in two others. A balloon-expandable device was used for all patients (Edwards Lifesciences, Irvine, CA, USA). Transcatheter VIV replacement was accomplished by the transapical (mitral) and transfemoral venous (tricuspid) approaches. Median postoperative length of stay was five days (range 3-12). No deaths occurred at a mean follow-up of 21 months. NYHA class at follow-up decreased from class IV at baseline to class I or II for all patients. No paravalvular leaks greater than trivial were encountered. Median mean gradient following mitral replacement was 6.5 mmHg (range 6-13 mmHg), and following tricuspid replacement was 4 mmHg. Postoperative complications included hematuria, epistaxis, acute kidney injury, and atrial fibrillation. Transcatheter VIV implantation in the nonaortic position for dysfunctional bioprostheses can be performed safely with favorable clinical outcomes using a balloon expandable TAVR device. doi: 10.1111/jocs.12745 (J Card Surg 2016;31:282-288).

LEFT VENTRICULAR OUTFLOW TRACT OBSTRUCTION RELATED TO MITRAL VALVE SURGERIES IN HYPERTROPHIC CARDIOMYOPATHY PATIENTS

Symptomatic left ventricular outflow tract (LVOT) obstruction in hypertrophic cardiomyopathy (HCM) patients may develop after mitral valve (MV) surgery. We present two such cases treated with alcohol septal ablation (ASA). A 77-year-old woman who had received bioprosthetic MV replacement presented

Transvenous Implantation of a Stent Valve in Patients With Degenerated Mitral Prostheses and Native Mitral Stenosis

The purpose of this study was to report the use of a transvenous transseptal approach using a stent valve in patients with degenerated biological mitral valve prostheses, regurgitation after mitral repair, and native mitral stenosis. Ten patients (median age, 74 years; range, 20-89 years; 5 men and 5 women) with degenerated mitral bioprosthetic valves (n= 7), failed mitral repair (n= 1), or calcified native stenotic valves (n= 2) underwent transvenous implantation of a stent valve. The procedure was initially successful in all patients. Predilation was performed for balloon sizing only in the 2 patients with native mitral stenosis. The stent valve was deployed during 1 period of rapid pacing. A guidewire, as a loop from the right femoral vein andthrough the left ventricular apex, facilitated a good angle and secure positioning of the stent valve. An ultrasonographically guided puncture of the apex was carried out in 6 patients, and in the other 4 we performed a minithoracotomy before apical puncture. All valves were implanted in a good position with improved function and without significant paravalvular leakage (PVL). There were no periprocedural deaths. The 30-day survival was 80% (8 of 10 patients), and 60% (6 of 10) of patients were still alive a median time of 290 days after the procedure. Transvenous transseptal implantation of a stent valve was performed in 10 patients with mitral valve disease, with good early functional results. These high-risk patients must be carefully selected by a multidisciplinary team because the procedure carries a high mortality.

Stuck Mitral Bio-Prosthetic Valve

A 26-year-old lady was evaluated at our hospital for rheumatic mitral valve disease in March 2007. She underwent Mitral Valve Replacement (MVR) with a bio-prosthetic valve (Bio-cor 27 mm) in April 2007. She was discharged on the 9th day with stable hemodynamics and optimized INR values. During follow up she had optimal INR values and normal gradients across the valve. After three months of adequate anticoagulation her warfarin was stopped since she was in sinus rhythm. She continued to take aspirin and remained in sinus rhythm. She was advised infective endocarditis prophylaxis. Eleven months after MVR she developed breathlessness over one week, which gradually worsened to orthopnoea. On admission she had pulmonary edema and the gradients across the bio-prosthetic mitral valve were increased (Maximum of 34 mmHg and Mean of 24 mmHg). Her previous echocardiogram in July 2007 showed normal gradients across the valve. Her transthoracic and transesophageal echocardiograms were suggestive of a stuck mitral prosthesis (Echo figures). There was a mobile membranous structure that appeared like a detached valve apparatus but could not be clearly delineated pre-operatively. We assumed that it was an unstable prosthetic structure. The intra-operative echocardiogram also showed similar features.

Severe Bioprosthetic Mitral Valve Stenosis and Heart Failure in a Young Woman with Systemic Lupus Erythematosus.

A 23-year-old African American woman with a past medical history of systemic lupus erythematous (SLE), secondary hypertension, and end stage renal disease (ESRD) on hemodialysis for eight years was stable until she developed symptomatic severe mitral regurgitation with preserved ejection fraction. She underwent a bioprosthetic mitral valve replacement (MVR) at outside hospital. However, within a year of her surgery, she presented to our hospital with NYHA class IV symptoms. She was treated for heart failure but in view of her persistent symptoms and low EF was considered for heart and kidney transplant. This was a challenge in view of her history of lupus. We presumed that her stenosis of bioprosthetic valve was secondary to lupus and renal disease. We hypothesized that her low ejection fraction was secondary to mitral stenosis and potentially reversible. We performed a dobutamine stress echocardiogram, which revealed an improved ejection fraction to more than 50% and confirmed preserved inotropic contractile reserve of her myocardium. Based on this finding, she underwent a metallic mitral valve and tricuspid valve replacement. Following surgery, her symptoms completely resolved. This case highlights the pathophysiology of lupus causing stenosis of prosthetic valves and low ejection cardiomyopathy.

Treatment of porcine bioprosthetic mitral valve thrombosis with anticoagulation

A 70-year-old man underwent mitral valve replacement using a porcine bioprosthesis for infective endocarditis. Transthoracic echocardiography revealed thickened leaflets with increased transprosthetic pressure gradient and new regurgitation, 6 months after surgery. He was followed up medically with the diagnosis of early valve degeneration. He ultimately presented with worsening orthopnea 13 months after surgery. Transesophageal echocardiography revealed an immobile round mass attached to the ventricular aspect of the leaflets, which hampered valve opening, suggesting bioprosthetic valve thrombosis. Anticoagulation with heparin and warfarin were effective and transthoracic echocardiography showed normal transprosthetic pressure gradient and disappearance of regurgitation 2 months later.

Fibroelastoma Recurrence in Left Ventricle: Rarity of Primary Cardiac Tumor

Cardiac papillary fibroelastoma (CPF) is a primary cardiac neoplasm usually detected by echocardiography. Left ventricular fibroelastomas are extremely rare. The incidence of CPF is between 0.0017 and 0.33% during autopsy studies. We report a 70-year-old man who had papillary fibroelastoma discovered and resected in 2005 that recurred in 2013. The tumor grew rapidly from 2013 to 2014. A bioprosthetic mitral valve was placed in 2014. Due to the location and nature of the recurrent tumor, mitral valve replacement was the treatment of choice to prevent a third recurrence of the fibroelastoma. The patient was discharged from the hospital on postoperative day 9.