Bioprosthetic Mitral Valve Research Articles

Clinical outcomes and hospital readmission rates in mechanical vs bioprosthetic mitral valves.

Recent national trends have demonstrated increased use of bioprosthetic mitral valves. The primary objective of this study was to compare clinical outcomes as well as readmission rates for mechanical vs bioprosthetic mitral valve replacement (mMVR vs bMVR). All patients undergoing MVR from 2011-2017 were included in a single center data set that was obtained retrospectively from a prospectively maintained cardiac surgical database. The total MVR patient cohort consisted of 828 patients, including bMVR (n = 522) and mMVR (n = 306). There was no significant difference in the operative (30-day) mortality between bMVR and mMVR (8.6% vs 6.5%; P = .31). The unadjusted estimated 1-year mortality was significantly higher for the bMVR group (19.8% vs 13.7%, P = .04) and this trend continued for the estimated 5-year mortality (35.1% vs 18.7%; P = .001). Valve prosthesis choice (bMVR vs mMVR) did not have a risk-adjusted impact on operative mortality at 30 days (P = .58); however 1-year (P = .05) and 5-year (P = .05) mortality remained significantly higher for the bMVR group. Propensity matching revealed a higher mortality rate on follow-up in the bMVR (26.7% vs 18.2%, P = .03) but no difference at 30 days or 1 year. There was no difference in hospital readmissions over 5 years CONCLUSIONS: Mechanical prostheses may confer a survival benefit in patients undergoing MVR. With emphasis on patient education and anticoagulation compliance, mMVR remains an efficacious option.

Impact of type 2 diabetes mellitus in the utilization and in-hospital outcomes of surgical mitral valve replacement in Spain (2001\u20132015)

BackgroundThe main aims of this study were to examine the incidence and in-hospital outcomes of mechanical and bioprosthetic surgical mitral valve replacement (SMVR) among patients with and without T2DM.MethodsWe performed a retrospective study using the Spanish National Hospital Discharge Database from 2001 to 2015. We included patients with SMVR codified in their discharge report. We grouped admissions by diabetes status. Propensity score matching (PSM) was used to compare outcomes of isolated SMVR.ResultsWe identified 42,937 patients (16.41% with T2DM). Incidence rates of mechanical and bioprosthetic SMVR were higher among T2DM patients than among non-T2DM patients. In both groups of patients, the use of bioprosthetic SMVR increased over time. The use of mechanical valves remained stable among T2DM patients. In T2DM and non-T2DM patients with mechanical SMVR, in hospital mortality (IHM) and MACCE decreased significantly (p < 0.001) from 2001 to 2015. T2DM patients had an overall 11.37% IHM, compared with 10.76% among non-T2DM patients (p = 0.176). Regarding MACCE figures were 14.72% vs. 14.22% (p = 0.320) after mechanical SMVR. Total crude IHM were 14.29% for T2DM patients and 15.13% for those without T2DM with bioprosthetic SMVR (p = 0.165) and 18.22 vs. 19.64%, for a MACCE (p = 0.185). Using PSM we found that the IHM and the MACCE of isolated SMVR did not differ significantly between patients with or without T2DM beside the type of valve replacement. Among T2DM patients, those who received bioprosthetic valves had higher IHM (14.29% vs. 11.37%; p = 0.003) and a higher rate of MACCE (18.22% vs. 14.72%; p = 0.001) than T2DM patients with mechanical SMVR.ConclusionsIn Spain from 2001 to 2015, the incidence rates of hospitalization to undergo mechanical or bioprosthetic SMVR were higher among the population suffering T2DM than among the non-T2DM population. In both groups of patients the use of bioprosthetic SMVR increased over time and the use of mechanical valves remained stable in T2DM. T2DM patients have IHM and MACCE after mechanical and bioprosthetic SMVR which are not significantly different to those found among non-diabetic patients. Among T2DM patients, the crude IHM was significantly higher in those who received a bioprosthetic SMVR than those with mechanical SMVR.

Incidence and Outcomes of Prosthetic Valve Thrombosis during Extracorporeal Membrane Oxygenation Support for Postcardiotomy Shock

Purpose In postcardiotomy shock patients with prosthetic valves , the use of venoarterial extracorporeal membrane oxygenation (VA ECMO) may induce prosthetic valve thrombosis due to blood stasis in cardiac chambers. Incidence and outcomes of prosthetic valve thrombosis during VA ECMO has not been previously described. Methods Between January 2007 and June 2018, a total of 171 patients underwent VA ECMO therapy after major cardiovascular surgery at our center. Of these patients, 89 had a prosthetic valve in place, and we conducted a retrospective review of this cohort. Results Of the 89 patients with prosthetic valves placed on VA ECMO, 37 (41.5%) had central VA ECMO cannulation , and the remaining 52 patients (58.5%) underwent peripheral VA ECMO cannulation. Median age was 66 years (interquartile range [IQR], 55-74) and 53 (59.6%) were men. Average duration of ECMO support was 5.1 days (IQR 3.0, 8.5). The majority of patients (76.4%, n = 68) were on therapeutic anticoagulation within 24 hours post-cardiotomy, and inotropes were used in all patients. A total of 8 patients (9%) developed prosthetic valve thrombosis: 5 involved the aortic valve (including one mechanical aortic valve prosthesis), 2 involved bioprosthetic mitral valves , and 1 involved a bioprosthetic pulmonary valve (Table). Overall cohort survival to discharge was 41.2% (n = 35), but was reduced to 9% (n = 1) amongst those patients that developed valve thrombosis. Conclusion Prosthetic valve thrombosis is relatively common complication while patients with prosthetic valves are placed on VA-ECMO, and it is almost uniformly fatal when it does develop.

TICK-BORNE ILLNESS AND INFECTIVE ENDOCARDITIS: A RARE CASE OF TULAREMIA

Identification of an underlying etiology remains a diagnostic challenge in some cases of infective endocarditis (IE). A 58-year-old man with history of severe mitral regurgitation status post bioprosthetic valve replacement (St. Jude, 31 mm Epic) presents with a 6-week history of daily fevers and

75-Year-Old Man With Chest Pain and Dyspnea

75-Year-Old Man With Chest Pain and Dyspnea

Mitral Valve Surgery in a Patient 50 Years after a Pneumonectomy

Background Patients who survive long after pneumonectomy may develop heart valve disease. The consecutive operations can be complex because of the challenging anatomical conditions and the limited physiologic reserves of the patient. Case Presentation The subject is a 78-year-old patient who underwent a left-sided pneumonectomy for a metastasized testicular tumor 50 years ago. At 32 and 37 years postpneumonectomy, mitral regurgitation was manifested, and valve repair was performed. Bioprosthetic mitral valve replacement and tricuspid valve reconstruction became necessary 44 years postpneumonectomy. The patient was fully recovered. Conclusion In case of relevant heart valve disease after pneumonectomies, heart valve surgeries are feasible.

The personalized approach to the rehabilitation of a severely ill patient presenting with a cardio-surgical problem

The ever increasing number of the patients presenting with the cardio-surgical problems referred for surgery emphasizes the importance of the treatment of the cases of post-operative complications based on the personalized approach. The present article was designed to report a clinical case of the successful surgical treatment and rehabilitation of a patient presenting with the dysfunction of the bioprosthetic mitral valve and complications of the post-operative course in the form of polyorgan insufficiency with the predominance of respiratory failure. Special attention is given to the post-operative complications among which the respiratory insufficiency prevailed that made necessary the long period of artificial pulmonary ventilation. The specific features of the intense personalized approach to the physical rehabilitation of the given severely ill patient based at the intensive care unit are considered, the description of the methods applied for the purpose is presented, and their effectiveness from the perspective of clinical and functional parameters is evaluated. The study has demonstrated that the application of the intensive personalized approach in the given case turned out to be a safe and effective method of rehabilitation. The use of the proposed approach allowed to shorten the duration of the post-operative rehabilitation period, facilitated the patient's transfer to autonomous breathing and expansion of the motor activity under conditions of the intensive care unit. In addition, the use of the continuity principle and continuation of rehabilitation measures based at the cardiac surgery department provided the opportunity for the further expansion of the motor activity.

A Systematic Review of Transcatheter Mitral Valve-in-valve Replacement for Failed Prosthesis

Transcatheter mitral valve-in-valve (TMVIV) for failed bioprosthetic valves is an emerging alternative to surgical re-operation in high risk patients. In this systematic review, we assessed the outcomes of mitral valve-in-valve replacement. Methods: A thorough computer-based search was performed using 4 major databases. We included studies utilising TMVIV replacement in failed bioprosthetic valves, mitral ring repairs and mitral clips. The 30-day and outcome of all-cause mortality, stroke, major bleeding and reintervention was analysed. Results: Seventeen observational studies were included in the analysis which comprised of 558 patients (437 bioprosthetic mitral valves, 110 mitral rings and 11 mitral clips). The mean age was 75 years with 39% of patients being male. 42.7% (238 patients) had New York Heart Association class 3 or 4 symptoms. The mean Society of Thoracic Surgeons score was 12.5%. Mean preoperative left ventricular ejection fraction was 55.5%. Patients with underlying mitral valve disease included 13.1% (73 patients) with mitral stenosis, 28% (158 patients) with mitral regurgitation and 10% (58 patients) with mixed mitral disease. Overall analysis demonstrated a low 30-day all-cause mortality of 2.5%. The rates of stroke and bleeding were also low at 0.7% (4 patients) and 6.8% (38 patients) respectively. 2.7% (16 patients) required reintervention with 0.4% (2 patients) needing surgical replacement and 0.4% (2 patients) with further valve-in-valve procedure. Conclusion: TMVIV is a safe and feasible option in patients with failed mitral valve prosthesis who are high surgical risk for re-operations.

An Ovine Model of Mitral Bioprosthetic Valve Induced Left Ventricular Outflow Tract Obstruction Due to Systolic Anterior Motion of the Fully Retained Native Anterior Leaflet

Aim: Mitral valvular–ventricular interaction includes the following mechanisms. 1. Chordal annulo-papillary connection preventing excessive diastolic dilatation. 2. Systolic closure of the valve during isovolumic left ventricular (LV) contraction causes shortening of the LV long axis. This effect “turbo-charges” the systolic function of the LV. 3. The diastolic baffle effect of the anterior leaflet improves laminar flow through the LV. 4. The dynamic action of the annulus improves diastolic LV filling (“lusitropy”). In chordal-sparing valve replacement the anterior leaflet (AML) is excised or modified, sacrificing the systolic turbo-charging and the diastolic baffle support of LV function. These losses are sufficient to explain equal survival for mitral repair versus replacement in ischaemic cardiomyopathy despite a high recurrence rate of mitral incompetence in the repair group. However, full retention of the native anterior leaflet risks the development of LV outflow tract obstruction (LVOTO).

Predictors of Left Ventricular Outflow Tract Obstruction After Transcatheter Mitral Valve Replacement

ObjectivesThe aim of this study was to evaluate the predictors of left ventricular outflow tract (LVOT) obstruction after transcatheter mitral valve replacement (TMVR). BackgroundLVOT obstruction is a major concern with TMVR, but limited data exist regarding its predictors and impact on outcomes. MethodsPatients with pre-procedural multidetector row computed tomography (MDCT) undergoing TMVR for failed mitral bioprosthetic valves (valve-in-valve), annuloplasty rings (valve-in-ring), and mitral annular calcification (valve-in-MAC) were included in this study. Echocardiographic and procedural characteristics were recorded, and comprehensive assessment with MDCT was performed to identify the predictors of LVOT obstruction (defined as an increment of mean LVOT gradient ≥10 mm Hg from baseline). The new LVOT (neo-LVOT) area left after TMVR was estimated by embedding a virtual valve into the mitral annulus on MDCT, simulating the procedure. ResultsAmong 194 patients with pre-procedural MDCT undergoing TMVR (valve-in-valve, 107 patients; valve-in-ring, 50 patients; valve-in-MAC, 37 patients), LVOT obstruction was observed in 26 patients (13.4%), with a higher rate after valve-in-MAC than valve-in-ring and valve-in-valve (54.1% vs. 8.0% vs. 1.9%; p < 0.001). Patients with LVOT obstruction had significantly higher procedural mortality compared with those without LVOT obstruction (34.6% vs. 2.4%; p < 0.001). Receiver-operating characteristic curve analysis showed that an estimated neo-LVOT area ≤1.7 cm2 predicted LVOT obstruction with sensitivity of 96.2% and specificity of 92.3%. ConclusionsLVOT obstruction after TMVR was associated with higher procedural mortality. A small estimated neo-LVOT area was significantly associated with LVOT obstruction after TMVR and may help identify patients at high risk for LVOT obstruction.

Long-term thromboembolic and bleeding complications after isolated bioprosthetic mitral valve replacement: Incidence, predictors and clinical implications

Anticoagulation with vitamin K antagonists (VKA) is recommended after bioprosthetic mitral valve replacement, because of the anticipated risk of postoperative thromboembolism. The optimal management of antithrombotic therapy at long-term remains uncertain. Define long-term risk of thromboembolic and bleeding complications after bioprosthetic mitral valve replacement. From 1984 to 2016, 560 patients underwent mitral valve replacement using the same model of bioprosthesis. Baseline clinical, perioperative and follow-up data were recorded prospectively. We estimated the CHA2DS2-VASc and HAS-BLED risk scores. Incidence of postoperative thromboembolic and bleeding events were compared between various antithrombotic therapies. Mean age was 69 ± 11 years. The mean follow-up period was 7.3 ± 5.4 years for a total of 4034 valve-years. Follow-up was 98.9% complete. Operative mortality was 3.8%. Patients with AF at discharge were similar to those without AF in age, sex. Antithrombotic strategies at discharge included aspirin in 49%, VKA in 31%, non-VKA oral anticoagulant in 4%, low molecular weight heparin in 4%, none in 12% of patients. At 20 years, the overall actuarial survival rate was 16.9 ± 3.9%. Actuarial freedom from complication at 15 and 20 years was 91.5 ± 2.4% and 83.9 ± 7.6% for thromboembolism, and 91.6 ± 1.7% and 80.2% ± 10.8% for bleeding event. Age and postoperative atrial fibrillation were associated to higher thromboembolic risk ( P < 0.05). The risk was even higher in patients with AF at discharge and a CHA2DS2-VASc score ≥3 (HR = 4.2; P < 0.05). After bioprosthetic mitral valve replacement, patients with postoperative AF are at high risk of thromboembolism as well as bleeding. Our findings suggest a potential role for non-VKA oral anticoagulants and warrants further randomized study to define the optimal antithrombotic strategy in patients undergoing bioprosthetic mitral valve replacement.

Percutaneous Techniques, Limitations and Challenges for the Failed Surgical Mitral Intervention.

The advent of percutaneous therapies has significantly altered therapeutic options for patients with valvular heart disease. Building on the success of transcatheter aortic valve replacement, both expanded indications and purpose-built devices are now being used to address percutaneous approaches for mitral valve pathology. While surgical mitral valve repair remains the gold standard for addressing significant mitral valve pathology, there has been a progressive increase in the utilization of bioprosthetic valves despite their limited lifespan. The risks of reoperation to address mitral valve repair failure or bioprosthetic valve dysfunction is not insignificant. In light of the aging population and the potential for significant associated comorbidities, less invasive alternative techniques hold particular appeal. Utilization of commercially available transcatheter aortic valve replacement valves for failed surgical valves has been shown to have better short-term mortality than would be predicted for open reoperation. As a result, the US Food and Drug Administration approved the utilization of transcatheter mitral valve-in-valve replacement for the failed bioprosthetic valve in high surgical risk patients. Despite the favorable outcomes, transcatheter mitral valve-in-valve is not without procedural challenges and potential complications including malpositioning, embolization, paravalvular leak, and outflow tract obstruction. Awareness of these challenges, mitigation strategies, and therapeutic options is imperative to optimizing outcomes in this high-risk patient population.

THE USE OF TISSUE PROSTHESIS FOR MITRAL VALVE REPLACEMENT: POSSIBILITY OF DISCONTINUATION OF ANTICOAGULATION

Aim. To evaluate the clinical efficacy of gradual sinus rhythm restoration, including the bioprosthetic mitral valve replacement combined with maze radiofrequency ablation, external cardioversion and catheter ablation.Methods.102 medical records of patients with mitral valve disease and long-standing atrial fibrillation (4,7±2,7 years) were restrospectively reviewed. Maze procedure was performed under extracorporeal circulation before the mitral valve replacement. The endpoints were monitored at the day of surgery, at discharge, and 3, 6 and 12 months after surgery.Results.Sinus rhythm was recorded in 65.7% of patients at discharge from the hospital. The completeness of the follow-up was 80.4%. Steady regular rhythm was maintained in 64.6 % of patients in the study group. Other patients (35.4%) underwent cardioversion with the efficacy rate of 41.4%. Anticoagulation therapy was withdrawn in 65.9% of patients three months after surgery. 18.3% of patients with symptomatic arrhythmia underwent catheter ablation, which allowed to restore sinus rhythm in 73.3% of cases. Sinus rhythm was recorded in 92.7% of cases within the 1-year follow-up. Importantly, 79.3% of patients were discontinued of indirect anticoagulants.Conclusion.Discontinuation of indirect anticoagulants proved its beneficial effects and safety on the restoration of sinus rhythm in patients after bioprosthetic mitral valve replacement.

Abstract 385: Characterization of Cellular Infiltrate in Bioprosthetic Aortic and Mitral Valves

Background: Bioprosthetic xenogeneic valves tend to deteriorate over time, termed structural valve deterioration (SVD), leading to valvular dysfunction. Several studies have hypothesized that SVD is a result of a chronic immune-mediated rejection process; however, a paucity of data exists demonstrating this conclusively. Objectives: Demonstrate that valves explanted for SVD contain a significantly greater burden of immune cellular infiltrate compared to normal human heart valves. Methods: Adult patients undergoing bioprosthetic aortic or mitral valve explantation secondary to a diagnosis of SVD were included in this study. A control arm included valves explanted from hearts without valvular disease considered for transplantation that were not utilized. Specimens underwent immunohistochemical staining using standard techniques utilizing the following primary monoclonal antibodies: anti-CD68, anti-CD20, and anti-CD3. Results: Eighteen valves explanted for SVD were analyzed along with 4 control valves. All valves were explanted from male patients with a mean age of 62-years. Overall, 12% (n=1) of patients had diabetes mellitus, 50% (n=4) had hypertension, 12% (n=1) had renal dysfunction and 38% (n=3) were on a lipid-lowering medication. Our results demonstrate that valves developing SVD have a cellular infiltrate containing significantly more immune cells than normal human valves. Specifically, there are significantly more CD3+ T-cells (p&lt;0.05) and CD68+ macrophages (p&lt;0.05) present in the cellular infiltrate of the SVD valves compared to the normal controls. Furthermore, while the cellular infiltrate of the SVD valves contains CD20+ B-cells, plasma cells, and neutrophils, none of these cells are present on the normal control valves (all p-values &lt;0.05). Conclusions: Our data suggest a significantly greater immune cell infiltrate can be found in explanted bioprosthetic valves developing SVD than normal human valves, providing support for the chronic-immune mediated rejection hypothesis. This study will ultimately lead to a better understanding of the immune mechanisms responsible for SVD in bioprosthetic xenograft valves and will contribute to our goal of developing novel therapeutic techniques to mitigate development of SVD.

Acute Thrombosis of Bioprosthetic Mitral Valve Secondary to Peri-Operative VA-ECMO; The Dangers of Flow Stasis in the Left Atrium

Case report Veno-Arterial (VA) ECMO has been used to help patients recover from cardiogenic shock. VA-ECMO can complicate recovery due to the increase in afterload and decreased flow through the left sided chambers. We present a case of acute bioprosthetic mitral valve (MV) thrombosis in a patient who developed peri-operative cardiogenic shock. A 63 year-old male admitted for acute systolic heart failure found to have coronary artery disease and valvular heart disease underwent MV replacement, tricuspid valve repair and three vessel coronary artery bypass grafting. He developed intraoperative mediastinal bleeding requiring fresh frozen plasma, cryoprecipitate, and factor VII. The patient was unable to be weaned off cardiopulmonary bypass secondary to right ventricular failure. The patient remained centrally cannulated for VA-ECMO and had placement of a femoral intra-aortic balloon pump. The patient was transferred to the ICU in shock and on multiple vasopressors. Due to ongoing mediastinal bleeding, initiation of systemic anticoagulation was delayed by 48 hours. The intraoperative transesophageal echocardiogram (TEE) initially demonstrated a normally functioning bioprosthetic MV. The final intraoperative TEE images following conversion to VA-ECMO showed a poorly opening bioprosthetic MV, Image 1 . A TEE on postoperative day (POD) 2 demonstrated abnormal mobility of the bioprosthetic MV leaflets, left appendage thrombus and smoke-like echogenicity in the left atrium, Image 2 . On POD 5, a TEE demonstrated mean MV gradient of 22 mmHg and worsening of MV mobility secondary to thrombus, Image 3 . Because of concern for MV thrombosis, the patient was taken to the catheterization lab for placement of LV catheter to confirm MV stenosis. A thrombolytic agent was infused via a pulmonary artery (PA) catheter in order to attempt lysis of the MV thrombus. On POD 9, the PA systolic pressures reduced from 50 mmHg to 30 mmHg and the VA-ECMO flow requirements were reduced from 5 to 3.5 Liters per minute. Despite this small improvement in hemodynamics his overall clinical status did not improve. Ultimately the family decided to withdraw care. A post-mortem examination confirmed MV stenosis secondary to thrombosis of the valve extending into the left atrial appendage. Patients in cardiogenic shock who are placed on VA-ECMO are extremely sensitive to the high afterload created by retrograde arterial flow. Our patient developed severe thrombotic MV stenosis secondary to left atrial circulatory stasis when VA-ECMO was initiated. Maintaining adequate left sided flow is crucial to reduce the risk of thrombosis.

Medical Management of Rheumatic Heart Disease: A Systematic Review of the Evidence.

Rheumatic heart disease (RHD) is an important cause of heart disease globally. Its management can encompass medical and procedural (catheter and surgical) interventions. Literature pertaining to the medical management of RHD from PubMed 1990-2016 and via selected article reference lists was reviewed. Areas included symptom management, left ventricular dysfunction, rate control in mitral stenosis, atrial fibrillation, anticoagulation, infective endocarditis prophylaxis, and management in pregnancy. Diuretics, angiotensin blockade and beta-blockers for left ventricular dysfunction, and beta-blockers and If inhibitors for rate control in mitral stenosis reduced symptoms and improved left ventricular function, but did not alter disease progression. Rhythm control for atrial fibrillation was preferred, and where this was not possible, rate control with beta-blockers was recommended. Anticoagulation was indicated where there was a history of cardioembolism, atrial fibrillation, spontaneous left atrial contrast, and mechanical prosthetic valves. While warfarin remained the agent of choice for mechanical valve implantation, non-vitamin K antagonist oral anticoagulants may have a role in RHD-related AF, particularly with valvular regurgitation. Evidence for anticoagulation after bioprosthetic valve implantation or mitral valve repair was limited. RHD patients are at increased risk of endocarditis, but the evidence supporting antibiotic prophylaxis before procedures that may induce bacteremia is limited and recommendations vary. The management of RHD in pregnancy presents particular challenges, especially regarding decompensation of previously stable disease, the choice of anticoagulation, and the safety of medications in both pregnancy and breast feeding.

Contemporary outcomes of isolated bioprothestic mitral valve replacement for mitral regurgitation

BackgroundEarly experience with transcatheter mitral valve replacement (TMVR) highlighted several investigational challenges related to this novel therapy. Conclusive randomised clinical trials in the field may, therefore, be years ahead. In...

IMMEDIATE AND LONG-TERM OUTCOMES AFTER BIOPROSTHETIC MITRAL VALVE REPLACEMENT WITH THE PRESERVATION OF THE SUBVALVULAR APPARATUS

Aim. To assess the immediate and long-term outcomes after bioprosthetic mitral valve replacement with the preservation of the subvalvular apparatus. Methods. 304 patients who underwent primary bioprosthetic mitral valve replacement in the period from 2001 to 2009 were included in the study. Patients were enrolled into two groups with either preserved subvalvular structures (Group 1. n = 142, 47%) or resected structures (Group 2, n = 162) during bioprosthetic mitral valve replacement. For the unbiased assessment of the efficiency of valve-preserving approach, randomly selected patients from Group 1 (n = 75) and Group 2 (n = 40) underwent preoperative and postoperative invasive monitoring of the central hemodynamics using the Swan-Ganz thermodilution catheter. Results In-hospital mortality was 1.4% (n = 2) in Group 1 and 4.3% in Group 2. The most common cause of death was acute left ventricular failure. We found that the preservation of subvalvular structures allows ensuring the optimal linear and volumetric echocardiography parameters in the immediate postoperative period, despite the hemodynamic profile of the defect. However, the positive effects were more pronounced in patients with more severe mitral regurgitation. Patients with preserved subvalvular structures had more durable surgical mitral valve replacement according to the echocardiographic findings in the long-term period. The invasive monitoring of central hemodynamics allowed determining that total subvalvular apparatus preservation was associated with more significant pressure decline in the pulmonary circulation (mean pulmonary arterial pressure and pulmonary capillary wedge pressure) and improved cardiac index and output. Posterior leaflet preservation was associated with less pronounced changes and patients who underwent routine mitral valve replacement had the worst intermediate outcomes. Conclusion The results of the presented study suggest that the preservation of subvalvular apparatus, unless otherwise indicated, is associated with improved immediate and long-term outcomes after mitral valve replacement.

Very late presentation of anomalous origin of the left coronary artery from the pulmonary artery: case report

BackgroundAnomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) is a rare congenital coronary anomaly. The enlarged right coronary artery provides retrograde collaterals to supply the left ventricle then preferentially directs into the lower pressure pulmonary artery system causing coronary steal phenomenon. Few patients who survive through adulthood without surgery must have abundant, well-formed functioning collaterals with adequate perfusion of the left ventricle. We present the oldest reported patient with ALCAPA to undergo corrective surgery.Case presentationA 79-year-old woman presented with a 3-months history of worsening shortness of breath and orthopnea. Physical examination discovered a soft continuous murmur at the left upper chest. Transthoracic echocardiography demonstrated an unusual, tubular-like structure inside the interventricular septum with a turbulent flow from color Doppler. Moreover, there was a severe mitral regurgitation from posterior mitral leaflet restriction associated with ventricular remodeling in combination with mitral annular dilatation. Coronary angiography and coronary computed tomography angiography established the diagnostic hallmark of ALCAPA syndrome. Stress cardiovascular magnetic resonance perfusion imaging demonstrated no myocardial ischemia suggesting adequate collateral circulation. Remarkably, there was a left coronary ostial stenosis, which served as a protective mechanism against myocardia ischemia by limiting the steal effect. The patient successfully underwent the ligation of anomalous artery at its origin in combination with bioprosthetic mitral valve replacement. Her postoperative course was uneventful.ConclusionsThis case utilized multimodality imaging for delineating the course of abnormal vessels and helping to formulate therapeutic decision.

Interventional Echocardiography of the MV: What the Interventionalist Wants to Know.

The past 2 decades have seen a proliferation of transcatheter mitral valve (MV) therapies, which are less invasive and distinct from surgical MV repair or replacement. The commonly used MV transcatheter therapies include (1) percutaneous mitral balloon commissurotomy (PMBC) for rheumatic mitral stenosis; (2) edge-to-edge repair with the MitraClip for mitral regurgitation; (3) valve-in-valve implantation in bioprosthetic MV, native MV, or mitral ring; and (4) closure of paravalvular leaks (PVLs). This article will focus on the use of echocardiography in the diagnosis, patient selection, procedural guidance, and postprocedural follow-up for PMBC, with notes on the role of transesophageal echocardiography in transcatheter interventions for prosthetic valve degeneration and PVL closure.