Concomitant Mitral Valve Disease Research Articles

Risk stratification by systemic manifestations secondary to hemodynamic disorders of patients with severe tricuspid regurgitation

BackgroundTricuspid regurgitation (TR) is a prevalent disease that triggers systemic pathological changes including cardiac, respiratory, hepatic and digestive, hematopoietic, renal and skin issues. The burden of extra-cardiac manifestations has not been well described in TR patients and the clinical impact is unknown.MethodsPatients with severe or more-than-severe TR during hospitalization, who did not have any previous cardiac procedures, hemodynamically significant congenital heart disease or concomitant severe aortic or mitral valve disease, were retrospectively analyzed. Pre-specified criteria and diagnosis of baseline characteristics were used to evaluate the presence of extra-cardiac manifestations secondary to TR after excluding comorbidities that may also lead to corresponding abnormalities. Extra-cardiac involvements encompass respiratory, hepatic and, digestive, renal, hematopoietic and dermatic system. Staging criteria are defined as no extra-cardiac system involvement in Stage 1, one in Stage 2, at least two extra-cardiac involvements in Stage 3 and any end-stage organ failure in Stage 4. A telephone follow-up was conducted to record the composite endpoint namely all-cause death or cardiac rehospitalization after the index hospitalization.ResultsA total of 258 patients were identified with a median age of 73 (interquartile range [IQR]: 62–83) years and 52.3% were female. Severe TR and more-than-severe TR patients accounted for 92.6% and 7.4% of the cohort. There were 20.5%, 27.5%, 37.6% and 14.3% of patients from Stage 1 to 4 respectively. The follow-up time was at a median of 251 (IQR: 183–324) days. TR Patients in Stage 3&4 were at an increased risk with borderline statistical significance to experience the composite endpoint compared to patients in Stage 1&2 (odds ratio [OR] 1.9, 95% confidence interval [CI] 1.0 to 3.7, P = 0.049).ConclusionsApproximately half of patients with at least severe TR presented with two or more extra-cardiac systemic manifestations, which may incur a 1.9-fold higher risk of all-cause death or cardiac rehospitalization than TR patients with one or less extra-cardiac involvement.

The impact of calcium and vitamin D supplement intake on survival in patients with concomitant moderate aortic and mitral valve disease

Abstract Background Calcium and vitamin D supplement intake has increased among the elderly population, who are prone to deficiency. We sought to assess the association between calcium and vitamin D supplementation and the long-term outcomes in patients diagnosed with concomitant moderate aortic and mitral valve disease. Methods We included 3257 patients (aged 71.7 ± 12.9 years; 55.2% male; 83.1% white), who presented to the Cleveland Clinic between 2010 and 2018, diagnosed with concomitant moderate aortic and mitral valves disease. The patients were followed up with a mean period of 21.8 months (range 1-155.8). Patients were stratified based on the supplementation with calcium and vitamin D. Focusing on the aortic component of the concomitant valvular disease, patients were further subdivided into two groups; Aortic Stenosis (AS) with either Mitral Regurgitation (MR) or Stenosis (MS)(group 1), and Aortic Regurgitation (AR) with either MR or MS(group 2). The primary endpoints were death and heart failure hospitalization. The data was analyzed using Kaplan Meier survival analysis on SPSS. Results Of the total 3257 patients included in this study, 2273 (70%) were not supplemented, and 984 (30%) were supplemented with calcium and vitamin D. Supplementation with calcium and vitamin D was significantly associated with a higher risk of all-cause mortality (HR=1.114, 95% CI [1.003-1.237]; p=0.043) (Figure 1). However, no significant association with heart failure hospitalization was noted (HR=1.003, 95% CI [0.884-1.139]; p=0.958). On further sub-group analysis of the aortic component, 1045 (32%) patients in group 1 and 2212 (68%) patients in group 2 were assessed. In group 1, 701 (67%) patients were not supplemented, and 344 (33%) were supplemented. Calcium and vitamin D supplementation was associated with a significantly higher risk of all-cause mortality in patients with AS (HR=1.203, 95% CI [1.017-1.425]; p=0.031). Conversely in patients with AR (group 2), 1572 (71%) patients were not supplemented, and 640 (29%) were supplemented, and no significant association was exhibited in this group (HR=1.044, 95% CI [0.913-1.193]; p=0.531) (Figure 2). Conclusion In our cohort of patients with concomitant moderate aortic and mitral valve disease, the intake of calcium and vitamin D supplements was associated with higher mortality specifically in patients with aortic stenosis.Figure 1Figure 2

Predictors of long-term outcomes of patients with concomitant moderate aortic and mitral valves diseases: a single tertiary care center experience 2010-2018

Abstract Background To date, moderate concomitant valvular heart diseases have been scarcely studied. This study aimed to further define predictors of long-term outcomes in patients diagnosed with concomitant moderate aortic and mitral valve disease at a tertiary center. Methods In this cohort we included 3257 patients (aged 71.7 ± 12.9 years; 55.2% male; 83.1% white) diagnosed with concomitant moderate aortic and mitral valves diseases who presented to the Cleveland Clinic between 2010 and 2018. The patients’ demographic, clinical and echocardiographic variables were collected. The primary endpoint of the study was the long-term composite outcome defined as heart failure hospitalization or all-cause mortality. We then conducted a univariate and multivariate cox proportional hazard survival analysis for the primary endpoint. Results The patients were followed up for 21.8 months. Baseline demographic characteristics are presented in table 1. Multiple demographic, clinical, and echo variables were evaluated. Using a univariate Cox proportional hazard survival analysis, older Age, history of smoking, Diabetes, Hypertension, Chronic Kidney Disease (CKD), Coronary Artery Disease (CAD), Atrial Fibrillation (Afib), Dyslipidemia, higher Right Ventricular Systolic Pressure (RVSP), higher New York Heart Association (NYHA) class, and lower Left Ventricular Ejection Fraction (LVEF) were associated with worse long-term outcomes. Additionally, patients who underwent an aortic (39.1%) or a mitral valve intervention (29.4%) were associated with better long-term outcomes (HR, 0.710, 0.708; respectively). In comparison, on Multivariable Cox analysis, female sex was significantly associated with worse survival (HR of 1.151, p-value=0.019). However, older Age, history of smoking, Diabetes, CKD, higher RVSP, NYHA class 2, 3, and 4, and lower LVEF remained significantly associated with worse long-term (table 2). Aortic valve intervention remained significantly associated with better survival (HR, 0.861, P-value=0.021). Compared to the Aortic Stenosis/ Mitral Stenosis (AS/MS) group, univariate analysis showed that patients in the Aortic Regurgitation/Mitral Regurgitation (AR/MR), and the AR/MS groups were significantly associated with better long term outcomes (HR, 0.738, HR, 0.575; respectively). Conversely, on Multivariate Cox analysis, AR/MR and AS/MR groups were significantly associated with better survival compared to AS/MS group (HR, 0.580, HR, 0.716; respectively). Conclusion In patients diagnosed with concomitant moderate aortic and mitral valve diseases, female sex, older age, history of smoking, diabetes, CKD, RVSP, NYHA class, LVEF and aortic valve intervention are independent predictors of the composite endpoint of heart failure hospitalization or all-cause mortality.Table 1Table 2

TCT-278 Impact of Mitral Annular Calcification and Concomitant Mitral Valve Disease on Transcatheter Aortic Valve Replacement Outcomes: A Systematic Review and Meta-Analysis

TCT-278 Impact of Mitral Annular Calcification and Concomitant Mitral Valve Disease on Transcatheter Aortic Valve Replacement Outcomes: A Systematic Review and Meta-Analysis

Surgical Outcomes of Septal Myectomy With and Without Mitral Valve Surgeries in Hypertrophic Cardiomyopathy: a National Propensity-Matched Analysis (2005 to 2020)

The management of concomitant mitral valve (MV) disease in patients with hypertrophic cardiomyopathy (HCM) remains controversial. The 2020 American Heart Association/American College of Cardiology HCM guidelines recommend that MV replacement (MVR) at the time of myectomy should not be performed for the sole purpose of relieving outflow obstruction. At the national level, limited data exist on the surgical outcomes of MV repair/replacement in patients with HCM who underwent septal myectomy (SM). Hospitalizations of patients with HCM who underwent SM between 2005 and 2020 were identified using International Classification of Diseases, Ninth and Tenth Revision codes (International Classification of Diseases, Ninth and Tenth Revision Clinical Modification/ProcedureCoding System). The 3 comparison cohorts were SM alone, MV repair, and MVR with concomitant SM. After propensity matching, 2 cohorts, SM+MVR versus SM+MV repair, were studied for surgical outcomes. Demographic characteristics, baseline co-morbidities, procedural complications, inpatient mortality, length of stay, and cost of hospitalization were compared between the propensity-matched cohorts. A total of 16,797 SM procedures were identified from 2005 to 2020. Among them, 11,470 hospitalizations had SM alone (68.2%), SM+MVR was seen in 3,101 (18.4%), and SM+MV repair comprised 2,226 (13.2%). After propensity matching, the MVR and MV repair formed the matched cohorts of 1,857. There were no significant differences in the odds of cardiogenic shock (adjusted odds ratio [aOR] 0.88, 95% confidence interval [CI] 0.63 to 1.24, p=0.49), mechanical circulatory support requirement (aOR 0.58, 95% CI 0.37 to 0.90, p=0.015), stroke (aOR 1.27, 95% CI 0.81 to 1.99, p=0.29), and major bleeding (aOR 0.52, 95% CI 0.34 to 0.79, p=0.0026) between the comparison groups. MVR, compared with MV repair, was associated with a higher risk of procedural mortality (8.02% vs 3.18%, aOR 2.98, 95% CI 2.05 to 4.33, p <0.0001), complete heart block (16.36% vs 12.15%, aOR 1.76, 95% CI 1.44 to 2.12, p <0.0001), and the need for permanent pacemaker (16.39% vs 10.62%, aOR 1.83, 95% CI 1.41 to 2.38, p <0.0001). The total length of hospital stay and median hospitalization cost was higher in the MVR group. SM in HCM concomitant with MVR is associated with higher procedural mortality and in-hospital complication risk. These real-world data support the 2020 American Heart Association/American College of Cardiology guidelines that in patients who are candidates for surgical myectomy, MVR should not be performed as part of the operative strategy for relieving outflow obstruction in HCM.

Transcatheter Valve Implantation in Patients with Multivalvular Heart Disease

Transcatheter Valve Implantation in Patients with Multivalvular Heart Disease

Surgical concepts for atrial fibrillation in patients with concomitant mitral valve disease

Surgical concepts for atrial fibrillation in patients with concomitant mitral valve disease

Prevalence and Hemodynamic Consequences of Mitral Valve Abnormalities in Atrial Septal Defect

Background: Atrial septal defect (ASD) is a common congenital heart disease in adults. Concomitant mitral valve disease in patients with ASD could have significant hemodynamic effects whit a great impact on managing this congenital defect. Objectives: This study evaluated the prevalence of mitral valve abnormalities and the hemodynamic burden associated with different types of ASD. Methods: This retrospective study reanalyzed 1,006 consecutive patients referred to Rajaie Heart Center in Tehran from March 2019 to February 2022. We evaluated adult patients with the diagnosis of a shunt at the atrial level. Diagnoses were made with 2D and 3D transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE). 3D analysis was performed with 3D zoom, mitral valve navigation (MVN), and full-volume and multi-planar reconstruction (MPR) modalities. We performed statistical analysis by SPSS version 22.0. The qualitative data were expressed as frequency and percentage. Data were compared between subgroups via Mann-Whitney U/Kruskal-Wallis tests for the interval variables, Pearson's chi-square test for nominal variables, and chi-square for trends test for ordinal variables. Results: The distribution of different ASD types was ostium secundum in 88.8% of cases, primum ASD in 0.9%, SVC-type sinus venosus ASD in 9%, IVC-type sinus venosus in 0.4%, and unroofed coronary sinus in 0.9%. We found mitral valve abnormalities in 21.1% of cases, and the most common mitral valve abnormality were prolaptic lesions (17.4%). Conclusions: Age, ASD size, estimated Systolic Pulmonary Artery Pressure (SPAP), and severity of mitral regurgitation (MR) were markedly higher were markedly higher among patients with MV anomalies, more over left ventricular ejection fraction (LVEF) was significantly lower among this group (P-value &lt; 0.05).

Cardiovascular outcomes in patients with left atrial enlargement undergoing transcatheter aortic valve implantation.

BackgroundIncreased left ventricular afterload resulting from severe aortic stenosis (AS) leads to progressive cardiac remodeling. Left atrial enlargement (LAE) is an early manifestation in a series of maladaptive changes and may affect clinical outcomes after valvular replacement therapy. The aim of this study is to determine the impact of LAE on clinical outcomes in symptomatic patients with severe AS undergoing transcatheter aortic valve implantation (TAVI).MethodsIn a prospective single‐center TAVI registry, we analyzed LA dimensions measured by echocardiography before intervention. Patients with atrial fibrillation or concomitant mitral valve disease were excluded. LAE was defined as indexed LA volume >34 ml/m2. The primary endpoint was cardiovascular death (CVD) at 1 year.ResultsAmong 1663 patients undergoing TAVI between August 2007 and December 2016, 768 (46.2%) were eligible for the present analysis and 486 patients had LAE. The prevalence of LAE was higher in males (68.3%) as compared to females (58.8%). Patients with LAE were older (82.3 ± 6.7 years vs. 80.0 ± 6.4 years) and had a higher STS‐PROM score (6.1 ± 4.7% vs. 4.7 ± 2.9%). After adjustment, patients with LAE had an increased risk of CVD at 1‐year compared to patients with normal LA dimensions (49 [10.4%] vs. 8 [2.9%]; HRadj, 3.52; 95% CI, 1.66–7.44)]. In multivariable analysis, LAE was independently associated with an increased risk of CVD at 1‐year (HRadj, 3.52; 95% CI, 1.66–7.44).ConclusionsLAE secondary to AS was documented in a significant proportion of patients undergoing TAVI and was associated with a more than threefold increased risk of CVD at 1‐year.

Trend, predictors, and outcomes of combined mitral valve replacement and coronary artery bypass graft in patients with concomitant mitral valve and coronary artery disease: a National Inpatient Sample database analysis.

AimsCombined mitral valve replacement (MVR) and coronary artery bypass graft (CABG) procedures have been the norm for patients with concomitant mitral valve disease (MVD) and coronary artery disease (CAD) with no large-scale data on their safety and efficacy.Methods and resultsThe National Inpatient Sample database (2002–18) was queried to identify patients undergoing MVR and CABG. The major adverse cardiovascular events (MACE) and its components were compared using a propensity score-matched (PSM) analysis to calculate adjusted odds ratios (OR). A total of 6 145 694 patients (CABG only 3 971 045, MVR only 1 933 459, MVR + CABG 241 190) were included in crude analysis, while a matched cohort of 724 237 (CABG only 241 436, MVR only 241 611 vs. MVR + CABG 241 190) was selected in PSM analysis. The combined MVR + CABG procedure had significantly higher adjusted odds of MACE [OR 1.13, 95% confidence interval (CI) 1.11–1.14 and OR 1.96, 95% CI 1.93–1.99] and in-hospital mortality (OR 1.29, 95% CI 1.27–1.31 and OR 2.1, 95% CI 2.05–2.14) compared with CABG alone and MVR alone, respectively. Similarly, the risk of post-procedure bleeding, major bleeding, acute kidney injury, cardiogenic shock, sepsis, need for intra-aortic balloon pump, mean length of stay, and total charges per hospitalization were significantly higher for patients undergoing the combined procedure. These findings remained consistent on yearly trend analysis favouring the isolated CABG and MVR groups.ConclusionCombined procedure (MVR + CABG) in patients with MVD and CAD appears to be associated with worse in-hospital outcomes, increased mortality, and higher resource utilization compared with isolated CABG and MVR procedures. Randomized controlled trials are needed to determine the relative safety of these procedures in the full spectrum of baseline valvular and angiographic characteristics.

Prognostic role of right ventricular geometry and function in patients undergoing double valve surgery

Abstract Introduction Multiple valvular heart disease, a combination of stenotic and regurgitant lesions occurring on two or more valves, is a highly prevalent condition. For these patients, surgical correction is the only definitive treatment to improve prognosis, yet concomitant aortic and mitral (double) valve surgery is associated with poor post-operative outcomes. While current guidelines outline left ventricular dimensions and function as surgical triggers, little is known regarding the importance of right ventricular (RV) remodelling in these patients. Purpose We sought to evaluate the prognostic value of RV remodelling in patients undergoing double valve surgery. Methods RV remodelling was characterised by transthoracic echocardiography in 152 patients undergoing concomitant aortic and mitral valve replacement (n=118) or aortic valve replacement and mitral valve repair (n=34). Four patterns of RV remodelling were defined according to the presence of RV dilation (tricuspid annulus diameter&amp;gt;35mm) and RV systolic dysfunction (percentage RV fractional area change &amp;lt;35%): normal RV size and systolic function (pattern 1); dilated RV with normal systolic function (pattern 2); RV systolic dysfunction with normal RV size (pattern 3); and dilated RV with systolic dysfunction (pattern 4). Adverse events were defined as the composite of all-cause mortality and hospitalisation for heart failure. Results Overall, 62 (41%), 31 (20%), 35 (23%), and 24 (16%) patients were classified as RV remodelling patterns 1, 2, 3, and 4, respectively. Patients with advanced RV remodelling patterns were more frequently male, had worse renal function, and a higher EuroSCORE II. During a median follow-up of 43 months, 41 adverse events (22 heart failure hospitalisation and 19 deaths) occurred. Patients with patterns 3 and 4 RV remodelling had an increased risk of adverse events compared to pattern 1 (log-rank χ2 27.42; p&amp;lt;0.001; Figure 1). After adjustments for EuroSCORE II and significant tricuspid regurgitation, RV remodelling patterns 3 (Hazard Ratio [HR] 3.24, 95% Confidence Interval [CI] 1.27–8.24, p=0.014) and 4 (HR 6.18, 95% CI 2.49–15.32, p&amp;lt;0.001) were independently associated with poor post-operative outcomes. Importantly, RV remodelling patterns provided incremental prognostic value to EuroSCORE II (χ2 increased from 18 to 38, p&amp;lt;0.001). Conclusion In patients with concomitant aortic and mitral valve disease, RV remodelling is frequent and associated with poorer outcomes. Our study highlights the involvement of the RV in left-sided valvular heart disease and underlines the importance of preoperative assessment of RV geometry and function in patients undergoing double valve surgery. Funding Acknowledgement Type of funding sources: None. Figure 1

IMPULSE: the impact of gender on the presentation and management of aortic stenosis across Europe

AimsThere is an increasing awareness of gender-related differences in patients with severe aortic stenosis and their outcomes after surgical aortic valve replacement (SAVR) and transcatheter aortic valve implantation (TAVI).MethodsData from...

Mitral valve replacement after transcatheter aortic valve implantation in a patient with rheumatic heart disease and prior Ross procedure: a case report

BackgroundReoperations are required frequently after the Ross procedure in rheumatic patients. The use of transcatheter aortic valve implantation (TAVI) in those patients could decrease the risk of future open procedure; however, the outcome may be affected by the concomitant mitral valve disease, and subsequent mitral reoperation may distort the implanted aortic valve.Case presentationWe present a female patient who had a beating mitral valve replacement after valve-in-valve TAVI in a patient with prior Ross procedure. Weaning from cardiopulmonary bypass was difficult, and the patient needed extra-cardiac membrane oxygenation (ECMO) and intra-aortic balloon pump because of right ventricular dysfunction. The right ventricular dysfunction could be due to the concomitant coronary artery disease or air embolism during the beating mitral valve surgery. Recovery was gradual, and the patient was discharged after 33 days. Pre-discharge echocardiography showed a maximum gradient of 9 mmHg on the aortic valve and mild paravalvular leak.ConclusionsMitral valve replacement in a patient with prior TAVI and the Ross procedure was feasible; it decreased the operative risk and did not distort the implanted aortic valve.

Does isolated mitral annular calcification in the absence of mitral valve disease affect clinical outcomes after transcatheter aortic valve replacement?

Mitral annular calcification (MAC) has been associated with adverse outcomes in patients undergoing transcatheter aortic valve replacement (TAVR) but has been investigated in isolation of co-existent mitral regurgitation or mitral stenosis, which may represent important confounders. This study sought to investigate the effect of MAC with and without concomitant mitral valve disease (MVD) on clinical outcomes in patients treated with TAVR. Computed tomography (CT) and echocardiographic data in consecutive TAVR patients enrolled into a prospective registry were categorized according to presence or absence of severe MAC and significant MVD, respectively. A total of 967 patients with adequate CT and echocardiography data were included between 2007 and 2017. Severe MAC was found in 172 patients (17.8%) and associated with MVD in 87 patients (50.6%). Compared to TAVR patients without severe MAC or MVD, all-cause mortality at 1 year was significantly increased among patients with severe MAC in combination with MVD [adjusted hazard ratio (HRadj): 1.97, 95% confidence interval (CI): 1.12-3.44, P = 0.018] and patients with isolated MVD (HRadj: 2.33, 95% CI: 1.56-3.47, P < 0.001), but not in patients with isolated severe MAC in the absence of MVD (HRadj: 0.52, 95% CI: 0.21-1.33, P = 0.173). We found no effect of isolated MAC on clinical outcomes following TAVR in patients with preserved mitral valve function. Patients with MVD had an increased risk of death at 1 year irrespective of MAC.

Impact of Tricuspid Regurgitation in Patients With Heart Failure and Mitral Valve Disease from a Nationwide Cohort Study

Concomitant heart failure (HF) and mitral valve disease (MVD) portend significant morbidity and mortality. Although associated Tricuspid regurgitation (TR) is a common occurrence in this scenario, it is not well known whether there are additional prognostic implications. We sought to assess whether coexistent TR is associated with higher readmission rates or increased mortality in patients with HF and MVD. We identified 1,520,871 encounters with a primary diagnosis of HF in the 2013 to 2014 Nationwide Readmission Database. We excluded patients without MVD, patients <18 years old, those with rheumatic heart disease and infective endocarditis. We also excluded patients who were discharged in December, hospital transfers, and cases where follow-up or outcomes were missing. Logistic regression was used to evaluate the association between baseline characteristics (including the presence of tricuspid valve disease), mortality as well as 30-day readmission rates. A total of 221,127 admissions with HF and MVD were identified. Median age was 79 years (IQR, 67 to 87), 55% were female, 2.7% died during hospitalization, and the 30-day readmission rate was 20.3%. Nearly 1/3 had concomitant TR (n = 78,356, 35%). The presence of TR was neither associated with elevated risk of mortality (hazard ratio 0.98, 95% confidence interval 0.93 to 1.04) nor 30-day readmission rate (odds ratio 1.01, 95% confidence interval 0.98 to 1.03). HF accounted for 33% of 30-day readmissions, while combined cardiac causes accounted for 54%. In conclusion concomitant TR in patients with HF and MVD was not associated with worse short-term outcomes in terms of inpatient hospital mortality and 30-day readmission rates.

Left atrial maze efficacy for treatment of concomitant atrial fibrillation with mitral valve disease

Objective This study aims to compare the efficacy of mitral valve surgery with left atrial maze versus isolated mitral valve surgery. Background Atrial fibrillation (AF) is the most common arrhythmia in clinical practice, especially with mitral valve disease. It represents a significant health burden especially with the associated thromboembolic complications. Several surgical approaches have been developed. The most effective one is Cox-Maze III procedure using cut-and-sew technique. Recently, surgical ablation has been transformed into an easier and faster procedure using radiofrequency, microwave, and cryothermal energy. Patients and methods This is a prospective cohort study conducted after the approval of the Human Ethics Committee of Faculty of Medicine, Menoufia University. A total of 100 patients with permanent AF and concomitant mitral valve disease have been recruited. The patients were allocated into two equal groups. Group A included mitral valve surgery and left atrial maze procedure, whereas group B included mitral valve surgery without left atrial maze. Results Group A had significant longer bypass and clamp times than group B (P Conclusion Left atrial maze with mitral valve surgery results in a better outcome in terms of myocardial function and dimensions. In addition, sinus rhythm restoration has the potential benefit of reducing the incidence of thromboembolic complications.

Minimally invasive approach for double and triple valve surgery

Background: Although benefitsof minimally invasive cardiac surgery have been described when compared with astandard approach through a median sternotomy, few experience and data exist inthe setting of double and triple valve surgery, whose annual incidence is 3% to25% of all valve surgery. We describe our experience with minimally invasivemultiple valve surgery through a right minithoracotomy. Methods: All patients scheduled for aminithoracotomy approach underwent a preoperative evaluation, includingcomputed tomography scan and epiaortic and femoral vessels ultrasound. Mitraland tricuspid valve disease is treated through a right minithoracotomy performedthrough a 4–5 cm lateral skin incision at the level of the fourth intercostalspace. In case of mitro-aortic or triple valve disease, the procedure iscarried out through a 5–7 cm incision in the 3rd intercostal space at 2–4 cmfrom the sternal edge. A femoral platform is generally used for cardiopulmonarybypass estabilishment, but, in selected patients, a central aortic cannulationcould be also performed to allow an antegrade perfusion. Results: We have started our minimally invasiveprogram in 2003. Gaining experience with the minithoracotomy, all patients witha concomitant mitral and tricuspid valve disease were treated with this kind ofapproach. In 1,604 patients undergoing minimally invasive mitral valve surgeryover a 10-year period, concomitant tricuspid valve repair was performed in 234patients (14.6 %), with good early and long-term outocomes. The next step,especially after the introduction of sutureless aortic prostheses, wasrepresented by the minimally invasive treatment of mitro-aortic and triplevalve disease. Sixty-nine patients underwent concomitant mitral and aorticvalve surgery through a right minithoracotomy, and a triple valve surgery wasperformed 12 (17.4%) of them. Good results were obtained in terms ofpostoperative mortality and morbidity. Conclusions: Double and triplevalve surgery through a right minithoracotomy is a feasible approach in thissubgroup of high-risk patients.

Transcatheter aortic valve replacement in patients with degenerative calcified rheumatic aortic stenosis: A 10-patient case series

BackgroundTranscatheter aortic valve replacement (TAVR) for patients with rheumatic heart disease (RHD) has not been well-known. This study aimed to assess characteristics and computed tomography (CT) findings of the aortic valve in old patients with RHD and to investigate the safety and efficacy in the patients who underwent TAVR. Methods and resultsOf 352 consecutive patients with severe aortic stenosis (AS) who underwent TAVR at the Sakakibara Heart Institute between 2013 and 2016, 10 patients (2.8%) were considered to have degenerative calcified rheumatic AS by transthoracic echocardiography. Young patients with rheumatic AS without any calcification were not indicated for TAVR in this study. They were likely to have previous pacemaker implantation, atrial fibrillation, anticoagulants, diuretics, reduced ejection fraction, mitral valve involvement, and high pulmonary artery pressure. CT was able to clearly visualize irregular valve thickening, commissure fusion, and a relatively small amount of calcification from the tip of the leaflet to the base of the aortic valve. Mortality at 30 days after TAVR was 0%, with a mean Society of Thoracic Surgeons Score of 7 ± 4%. Device success was 90%, and no patients met the safety endpoint at 30 days. ConclusionsCT was able to visualize the calcified aortic valve in old patients with RHD, and we demonstrate the safety and efficacy of TAVR in this specific population. Care should be taken for procedural success in particular characteristics with marginal calcified aortic valve, anticoagulant use with low body mass index, or concomitant mitral valve disease.

Rheumatic Mitral and Aortic Valve Disease- A Case Report from USA

Although virtually eradicated in the United States, rheumatic heart disease still carries a sinister outcome causing significant mortality and morbidity in developing countries in Asia, Africa and the Pacific Islands where it still remains in endemic form. Our case involves a 35-year-old female patient born and raised in India who recently migrated to the United States. Her echocardiogram revealed severe combined aortic and mitral valve stenosis and severe aortic regurgitation. We hereby analyze echocardiographic findings in concomitant rheumatic aortic and mitral valve disease with preserved left ventricular (LV) systolic function. We also discuss treatment implications with combined surgical replacements of both valves with mechanical prostheses.Cardiovasc. j. 2018; 11(1): 81-85

TCT-743 The "multivalvular score" online app for the assessment of patients with concomitant mitral and aortic valve disease candidates to transcatheter aortic valve implantation: Prospective validation

Persistent concomitant mitral regurgitation (MR) following TAVR increases the mortality. We previously determined independent predictors of MR improvement and with them, we created the Multivalvular Score to predict its persistence following TAVI and developed an online electronic tool to help