Concomitant Mitral Valve Replacement Research Articles

Incidence and Risk Factors for Permanent Pacemaker Implantation After Tricuspid Valve Repair

BackgroundAlthough the likelihood of needing a permanent pacemaker (PPM) after tricuspid valve (TV) repair has been thought to be low compared with TV replacement, the incidence and determinants are controversial. This study aimed to evaluate the incidence and risk factors for PPM implantation after TV repair. MethodsA total of 1237 consecutive patients undergoing TV repair from 1997 to 2019 were reviewed using a prospectively maintained database, and 1058 patients were enrolled. ResultsIncidence of PPM implantation was 10.3% (n = 109). Median time to PPM implantation was 7 (range, 6-9) days. Indications for PPM implantation were heart block (n = 62, 56.9%), junctional or sinus bradycardia (n = 21, 19.3%), and ventricular arrhythmia (n = 17, 15.6%). Likelihood of PPM varied with concurrent procedures: left ventricular assist device (3.4%), mitral repair (11.2%), mitral valve replacement (13.7%), aortic and mitral valve replacement (19.2%), and isolated tricuspid repair (6.5%). Older age (odds ratio [OR], 1.020; 95% CI, 1.003-1.036), prior mediastinal radiation (OR, 4.106; 95% CI, 1.598-10.554), and concomitant mitral and aortic valve replacement (OR, 1.963; 95% CI, 1.046-3.683) were risk factors, and concomitant left ventricular assist device implantation (OR, 0.325; 95% CI, 0.139-0.759) was a protective factor for PPM implantation. PPM implantation did not affect the early outcomes, overall survival (P =.287), or cumulative incidence of recurrent moderate or greater tricuspid regurgitation (P =.890) or TV reoperation (P =.602). ConclusionsThe likelihood of PPM implantation after TV repair is relatively high, but PPM implantation does not affect the early and long-term clinical outcomes. Older age, prior mediastinal radiation, and concomitant mitral and aortic valve replacement are risk factors, and concomitant left ventricular assist device implantation is a protective factor for PPM implantation after TV repair.

Outcomes of Aortomitral Continuity Reconstruction During Concomitant Aortic and Mitral Valve Replacement

To describe outcomes of reconstruction of the aortomitral continuity (AMC) during concomitant aortic and mitral valve replacement (ie, the "Commando" procedure). A retrospective study of consecutive cardiac surgeries from 2010 to 2022. At a single institution. All patients undergoing double aortic and mitral valve replacement. Patients were dichotomized by the performance (or not) of AMC reconstruction. A total of 331 patients underwent double-valve replacement, of whom 21 patients (6.3%) had a Commando procedure. The Commando group was more likely to have had a previous aortic valve replacement (AVR) or mitral valve replacement (MVR) (66.7% v 27.4%, p < 0.001), redo cardiac surgery (71.4% v 31.3%, p < 0.001), and emergent/salvage surgery (14.3% v 1.61%, p = 0.001), whereas surgery was more often performed for endocarditis in the Commando group (52.4% v 22.9%, p = 0.003). The Commando group had higher operative mortality (28.6% v 10.7%, p = 0.014), more prolonged ventilation (61.9% v 31.9%, p = 0.005), longer cardiopulmonary bypass time (312 ± 118 v 218 ± 85 minutes, p < 0.001), and longer ischemic time (252 ± 90 v 176 ± 66 minutes, p < 0.001). Despite increased short-term morbidity in the Commando group, Kaplan-Meier survival estimation showed no difference in long-term survival between each group (p = 0.386, log-rank). On multivariate Cox analysis, the Commando procedure was not associated with an increased hazard of death, compared to MVR + AVR (hazard ratio 1.29, 95% CI: 0.65-2.59, p = 0.496). Although short-term postoperative morbidity and mortality were found to be higher for patients undergoing the Commando procedure, AMC reconstruction may be equally durable in the long term.

Anomalous papillary muscle insertion into the mitral valve leaflet in hypertrophic obstructive cardiomyopathy: a lip nevus sign in echocardiography.

Anomalous papillary muscle (APM) insertion into the mitral valve leaflet is rare but clinically important in hypertrophic obstructive cardiomyopathy (HOCM). In this study, we report the detection rate of APM insertion into the mitral valve using preoperative imaging modalities and the surgical outcomes of the patients. By retrospectively reviewing the clinical records of patients with HOCM who underwent surgical treatment by a single operation group at our center from January 2020 to June 2023, patients with APM insertion into the mitral valve leaflet were identified. Baseline data, image characteristics, and surgical outcomes were analyzed. The incidence of APM insertion into the mitral valve leaflet was 5.1% (8/157). The insertion site was located at A3 in six cases, which was more common than at A2 (n = 2). Preoperative echocardiography was used to identify two patients (25%) with APM insertion. We observed a particular echocardiographic feature for APM in HOCM patients, which was noted as a "lip nevus sign", with a higher detection rate (62.5%). All patients successfully underwent septal myectomy with concomitant APM excision or mitral valve replacement via the transaortic (n = 5) or transmitral (n = 3) approach. The mean age was 49.0 ± 17.4 years and seven patients (87.5%) were female. Interventricular septum thickness (17.0 mm vs. 13.3 mm, P = 0.012) and left ventricular outflow gradient (117.5 mmHg vs. 7.5 mmHg, P = 0.012) were significantly decreased after surgery. Residual outflow obstruction, systolic anterior motion, and ≥3+ mitral regurgitation were negative. During the follow-up of 26.2 ± 12.2 months, there were no reported operations, adverse events, mitral regurgitation aggravations, recurrences of outflow obstruction, or instances of SAM. Papillary muscles inserted into the mitral valve leaflet are a subtype of subvalvular malformation in HOCM that requires surgical correction. The lip nevus sign on echocardiography is a characteristic of APM insertion in HOCM and may improve the preoperative detection rate. Adequate myectomy with anomalous papillary muscle excision has achieved good results in reducing the outflow gradient and eliminating mitral regurgitation, with good outcomes at short-to-intermediate follow-up.

Minimally invasive multi-vessel coronary artery bypass grafting and concomitant mitral valve replacement via bilateral mini-thoracotomy: An alternative to sternotomy

Minimally invasive methods continue to become increasingly common in cardiac surgery. In particular, the utilization of thoracotomy in multi-vessel coronary bypass grafting and valve surgery has accelerated, but sternotomy is still applied in combined pathologies. A 76-year-old male patient underwent multi-vessel coronary artery bypass grafting and mitral valve replacement without sternotomy using bilateral mini-thoracotomy, as the patient was old, frail, and had many comorbid factors. In conclusion, this minimally invasive approach can decrease all postoperative complications, accelerate patient recovery, and achieve good cosmetic results.

Tricuspid valve replacement outcomes in a diverse variety of valve replacement cases: Mortality, mechanical versus biological – A single-center study

Background: The initial trial in tricuspid surgery is repair; however, replacement is done whenever the valve is badly diseased. Tricuspid valve replacement (TVR) as an isolated procedure and combined with other valve replacements presents a challenge as these patients are in the high-risk subset. Materials and Methods: The present retrospective study was performed using the medical records of 42 cases who underwent TVR since 2017 at our institute. The mean age of the participants was 36.3 ± 13.2 years and male–female was 66.7% and 33.3%, respectively. Isolated TVR was done in 35.7% of cases, associated with mitral valve replacement (MVR) in 38.1%, with aortic valve replacement (AVR) in 4.8%, triple-valve replacement (MV, TV, and AV) in 19.0%, and TVR associated with pulmonary valve replacement in 2.4% of cases. This diverse variety of valve replacement cases is the highlight of our study. About 30.9% of participants were undergoing the procedure as a redo surgery. Trial of repair was given in 33.3% of cases. Moreover, bioprosthesis and mechanical valve prosthesis were used in 73.8% and 26.2%, respectively. Results: Early mortality occurred in 8 (19.0%) cases. Cause of death common in all deaths was right ventricular failure in all cases 8/8 (100%) seconded by multi-organ failure in 7/8 cases (87.5%), previous cardiac surgery was a factor in 4/8 (50%) cases, mediastinitis occurred in 2/8 (25%) cases, and both arrhythmias and cerebrovascular accident happened in 1/8 (12.5%) case each. Mortality rate was 3/15 (20.0%) in cases of isolated TV surgery. Mortality rate for concomitant MVR was 3/15 (20.0%), and for concomitant AVR with MVR (triple-valve replacement) was 2/8 (25.0%). No early mortality happened in the concomitant AVR and concomitant pulmonary valve replacement group. Late mortality happened in 11/42 (26.2%) cases during follow-up. Total mortality as per the valve types has been 5/11 (45.5%) in the mechanical valve replacement group and 14/31 (45.2%) for the biological valve group. Conclusions: The patients who require TVR are usually high-risk surgical candidates with high early and late mortality. The most common cause of death was right ventricular failure in this study. TVR associated with other heart valve replacement increases the risk strata of the patient which is the highlight of our study. In the end, we conclude that we had 19.0% early (0–30 days) and 26.2% late mortality (0–1 year) making a composite of 45.2% mortality at the end of 1 year. No difference in the effect of mortality as per the valve type has been observed.

Health status analysis is comparable in HM3 patients with different preoperative grades of mitral regurgitation

BackgroundThe guidelines for mechanical circulatory support of the International Society for Heart and Lung Transplantation do not recommend the routine replacement or repair of the mitral valve at the time point of left ventricular assist device (LVAD) implantation. We investigated different parameters of health status including exercise capacity, anxiety and depression after LVAD implantation in patients with different preoperative grades of mitral regurgitation (MR).MethodsA single-center analysis of health status was performed including 45 patients with HeartMate 3 (HM 3) implantation using the 12-items Short Form Health Survey (SF-12) and the Hospital Anxiety and Depression Score (HADS) questionnaires. The study groups were classified according to echocardiographically defined preoperative grade of MR. The group without severe MR comprised 33 patients; the group with severe MR comprised 12 patients.ResultsDemographic and preclinical characteristics as well as LVAD complications such as thrombosis and bleeding events were comparable between LVAD patients with severe and not severe MR (p > 0.05). Severe MR resolved in all patients after LVAD implantation and improved to moderate, mild or no MR in both groups in a period ranging from 6 months until 2 years. The analyses of SF-12 questionnaire revealed that the physical (p = 0.44) and mental health (p = 0.64) was comparable. The grade of anxiety (p = 0.34) and depression (p = 0.44) was comparable between the groups. Exercise capacity measured by the 6 min walk test correlated positively with the SF-12-determined physical health (p < 0.01, r = 0.518) and negatively with the HADS anxiety (p = 0.01, r = −0.399) and depression (p < 0.01, r = −0.570) scores.ConclusionsOur data showed that the health status is comparable in HM 3 patients with different preoperative MR severities in the post-LVAD period. Preoperative severe MR resolves in the majority of patients early after LVAD implantation and is not associated with concomitant mitral valve repair or replacement at the time of LVAD implantation.

Conventional Biological versus Sutureless Aortic Valve Prostheses in Combined Aortic and Mitral Valve Replacement.

Sutureless aortic valve prostheses have proven to provide a significant decrease in procedural, cardiopulmonary bypass and cross-clamp time, leading to a significant reduction in mortality risk in elderly high-risk cohorts. In this study, we sought to review our institutional experience on the sutureless aortic valve replacement (SU-AVR) and the concomitant mitral valve replacement (SMVR), comparing the combined conventional surgical aortic valve replacement (SAVR) with SMVR. Between March 2018 and July 2022, 114 consecutive patients underwent a combined aortic and mitral valve replacement at our institution. We stratified the patients according to the operative procedures into two groups and matched them 1:2: Group 1 underwent a combined conventional SAVR and SMVR (n = 46), and Group 2 included combined SU-AVR with Perceval prosthesis and SMVR (n = 23). No significant differences in the preoperative characteristics were present. SU-AVR combined with SMVR demonstrated excellent haemodynamic performance, comparable to that of SAVR plus SMVR, with median postoperative gradients over the aortic valve of 4 mmHg (IQR 3.0-4.0) in Group 1 and 4 mmHg (IQR 3.0-4.0) in Group 2 (p = 0.67). There was no significant difference in the occurrence of postoperative major adverse events such as death, stroke, myocardial infarction and kidney failure between the groups. There was also no significant difference in the permanent pacemaker implantation rate, paravalvular leakage or valve dislocation. We also could not detect any significant difference in postoperative mortality between the groups. SU-AVR has proven to be a reliable alternative to conventional valve prostheses in patients with multivalve disease undergoing combined aortic and mitral valve replacement, offering shorter procedural time and outstanding hemodynamic performance compared to the conventional surgical method.

Concomitant Mitral Valve Repair vs Replacement During Surgical Ventricular Restoration for Ischemic Cardiomyopathy.

There is no consensus regarding mitral valve management during surgical ventricular restoration (SVR) for ischemic cardiomyopathy. We compared the impact of SVR with mitral valve repair (MVr) vs replacement (MVR) on postoperative outcomes and long-term survival in ischemic cardiomyopathy and mitral regurgitation patients. This study included 112 patients who underwent SVR from 2009 to 2018 with MVr (n = 75) or MVR (n = 37). Patients who had MVR had higher Euro SCORE II, dyspnea class, a lower ejection fraction, higher pulmonary artery systolic pressure, higher grade of preoperative mitral and tricuspid regurgitation, and higher end-diastolic and end-systolic diameters. Intra-aortic balloon pump was more commonly used in patients with MVR. Hospital mortality occurred in 7 (9.33%) patients in the MVr group vs 3 (8.11%) in the MVR group (P > .99). Freedom from rehospitalization at 1, 5, and 7 years was 87%, 76%, and 70% in the MVr group and 83%, 61%, and 52% in the MVR group (P = .191). Survival at 1, 5, and 7 years was 88%, 78%, and 74% in the MVr group and 88%, 56%, and 56% in the MVR group (P = .027). Adjusted survival did not differ between groups.MVr or MVR are valid options in patients undergoing SVR, with good long-term outcomes.

Clinical Effects of Surgical Left Atrial Reduction and Concomitant Mitral Valve Replacement in Patients with Giant Left Atrium.

A giant left atrium may cause respiratory dysfunction and hemodynamic disturbance postoperatively. This retrospective study aimed to evaluate clinical effects of surgical left atrial reduction in concomitant cardiac valves operations. One hundred and thirty-five patients with heart valve diseases and giant left atriums from January 2004 to July 2021 were enrolled into this research. They were divided into the folded group (n=63) and the unfolded group (n=72). Patients in the folded group had undergone cardiac valve operations concomitantly with left atrial reductions. The perioperative characteristics were compared between both groups, and subgroup analysis was performed. There were five deaths in the folded group and 25 deaths in the unfolded group (P<0.001). Complications including pneumonia, sepsis, multiple organs dysfunction syndrome, low cardiac output syndrome, and the use of continuous renal replacement therapy were significantly fewer in the folded group. The receiver operating characteristic curve of left atrial max. diameter predicting mortality was significant (area under the curve=0.878, P=0.005), and the cutoff point was 96.5 mm. The stratified analysis for sex showed that more female patients died in the unfolded group. Logistic regression for mortality showed that the left atrium unfolded, left atrial max. diameter, cardiopulmonary bypass time, and mechanical ventilation time increased the risk of death. Surgical left atrial reduction concomitantly with valves replacement could decrease mortality and was safe and effective in giant left atrium patients.

The impact of concomitant mitral valve intervention on outcomes of aortic root replacement.

To investigate the impact of concomitant mitral valve repair (MVr) or replacement (MVR) at the time of aortic root replacement (ARR). We queried our aortic database for consecutive patients undergoing ARR in combination with MVr or MVR from 1997 to 2021. Patients undergoing valve sparing root replacement (VSRR) were excluded. We compared operative mortality (OM) and a composite of major adverse events (MAE) in those undergoing CVG both with (Group 2) and without a concomitant MV procedure (Group 1). We also analyzed outcomes between patients undergoing MV repair versus MV replacement. Sixty-one patients underwent ARR with concomitant MVr (29/47.5%) or MVR (32/52.5%). Compared to patients in Group 2 (n = 955), those in Group 1 presented with worse NYHA class, lower ejection fraction, higher rate of connective tissue disease, and underwent more frequently urgent/emergent procedures. Group 1 had higher incidence of postoperative MAE (8/61(13%) vs 51/955(5%), p = .03). There was no difference in operative mortality between the two groups (0/61(0%)vs. 3/955(0.3%), p = 1). Compared to the ARR + MVR subgroup, the ARR + MVr subgroup had higher incidence of postoperative MAE (5/29(17.2%) vs. 3/32(9.4%), p = 0.02). Multivariate analysis identified MVr (OR 2.78, 95% confidence interval [CI] [1.03;7.48], p = 0.04) as an independent predictor of MAE. Operative mortality remained low in both groups. The addition of MVR/MVr to composite valve-graft replacement of the aortic root does not increase OM in experienced hands. The incidence of MAEs was higher in those undergoing MVr but may be a reflection of greater preoperative comorbidity rather than issues related to a more complex operation.

Treatment of More Than Moderate Ischemic Mitral Regurgitation in Patients Undergoing Left Ventricular Reconstruction

Objective: While evidence-based clinical guidelines recommend chordal-sparing mitral valve replacement, rather than mitral valve repair, in patients with severe ischemic mitral regurgitation (IMR) undergoing coronary artery bypass grafting, there are no similar recommendations for patients undergoing left ventricular reconstruction (LVR). This study aimed to compare the clinical outcomes of mitral valve repair and replacement in patients undergoing LVR complicated by more than moderate IMR. Methods: In this single-center cohort study, a total of 74 consecutive patients who underwent LVR and mitral valve surgery (repair group: 59; replacement group: 15), during the period from March 2000 to March 2021 at Fuwai Hospital (Beijing, China) were retrospectively enrolled. Survival rates were calculated with the Kaplan-Meier method and compared using the log-rank test. Univariate Cox analysis was performed to evaluate possible confounders, followed by adjustment in multivariate analysis. The primary outcome was survival free of major adverse cardiovascular and cerebrovascular events (MACCE). Results: Median follow-up time was 59.4 months. Compared with mitral valve replacement, mitral valve repair was associated with increased risk of perioperative use of ventricular assist device (22.0% vs. 0, P = 0.045). There was no difference in overall survival (hazard ratio (HR), 1.10; 95% confidence interval (CI), 0.31–3.93; P logrank = 0.888) and MACCE-free survival (HR, 1.54; 95% CI, 0.65–3.65; P logrank = 0.319), even after multivariate Cox regression (HR, 1.35; 95% CI, 0.37–4.88; P Cox = 0.646; and HR, 1.41; 95% CI, 0.57–3.44; P Cox = 0.455, respectively). Furthermore, while no differences were observed in ejection fraction and left ventricular end-diastolic diameter on follow-up echocardiography, mitral valve repair was associated with an increased risk of recurrent mitral regurgitation (P = 0.041). Conclusions: In patients undergoing LVR complicated by more than moderate IMR, both concomitant mitral valve repair and replacement can be successfully achieved with comparable overall and MACCE-free survival outcomes; however, mitral valve replacement may be superior to mitral valve repair for persistent correction of mitral dysfunction.

Assessment of clinical, paraclinical characteristics of patients receiving concomitant mitral and aortic valve replacement with On-X mechanical prosthesis at Bach Mai Hospital

Objectives: To investigate clinical and paraclinical characteristics of patients undergoing concomitant mitral and aortic valve replacement with On-X mechanical valve at Bach Mai Hospital. Subjects and methods: This was a non-controlled, prospective, descriptive study on 100 patients with severe aortic and mitral diseases undergoing concomitant aortic and mitral valve replacement with On-X valve. Clinical and paraclinical parameters were selected based on Vietnam National Heart Association and ACC/AHA guidelines. Results: Clinical manifestations included history of rheumatic heart disease (70.0%), NYHA class II (36.0%), NYHA class III (64.0%), atrial fibrillation (67.0%). Echocardiography showed dilated left ventricle (LVEDd 55.2 ± 8.9 mm, LVEDs 37.3 ± 8.1 mm), preserved left ventricular ejection fraction (63.9 ± 9.5%), moderately pulmonary arterial hypertension (47.2 ± 13.8 mmHg), and dilated left atrium (53.8 ± 10.5 mm). Conclusion: Most patients undergoing concomitant On-X aortic and mitral prosthetic valve replacement presented with moderate and severe heart failure, dilated left ventricle and left atrium, and increased pulmonary arterial pressure.&#x0D; * Keywords: Mitral and aortic valve replacement; On-X valve.

Incidence and risk factors of acute kidney injury after maze operation in patients with rheumatic mitral valve disease.

BackgroundAcute kidney injury (AKI) is one of the most common complications after cardiac surgery. While current guidelines indicate that surgical ablation does not increase the risk of renal failure, recent studies have produced conflicting results. This study was conducted to evaluate the incidence of AKI after maze procedure in patients with rheumatic mitral valve disease and atrial fibrillation, and to elucidate risk factors associated with postoperative AKI.MethodsBetween 2011 and 2020, 203 patients with rheumatic mitral valve disease and atrial fibrillation (61.4±8.7 years, male:female =67:136) who underwent concomitant maze procedure and mitral valve replacement were retrospectively reviewed. Other combined procedures included aortic valve operations (n=64, 31.5%) and tricuspid valve procedures (n=149, 73.4%). The AKI was defined as an increase of serum creatinine level by 1.5 times after surgery based on the RIFLE (Risk, Injury, Failure, Loss, and End stage) criteria. A multivariable logistic regression analysis was performed to evaluate risk factors associated with postoperative AKI.ResultsPostoperative AKI developed in 76 patients (37.4%). The multivariable analysis demonstrated that age [odds ratio (OR), 95% confidence interval (CI): 1.065, 1.025–1.107; P=0.001], cardiopulmonary bypass (CPB) time (1.007, 1.002–1.013; P=0.009) and nadir hematocrit during CPB (0.854, 0.740–0.985; P=0.031) were associated with postoperative AKI.ConclusionsPostoperative AKI occurred in more than one thirds of patients with rheumatic mitral valve disease and atrial fibrillation who underwent combined mitral valve replacement and maze procedure. Optimization of CPB management might be needed to prevent postoperative AKI after maze procedure.

Anomalous origin of the left coronary artery from the pulmonary artery as a rare cause of mitral valve prolapse: a case report

Background Mitral valve prolapse (MVP) is an etiologically heterogeneous disorder. Early diagnosis and prompt treatment of the underlying disease are of great significance. Herein, we present a rare case of MVP caused by anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA).Case presentationA 22-year-old female presented with a 16-year history of anterior mitral leaflet prolapse. However, she had never experienced any discomfort before. At a routine follow-up, a transthoracic echocardiogram showed anterior mitral leaflet prolapse (A2) with moderate mitral regurgitation, and a retrograde blood flow from an extremely dilated left coronary artery (LCA). Further coronary angiography and coronary computed tomography angiography confirmed the diagnosis of ALCAPA. She subsequently underwent successful LCA reimplantation and concomitant mitral valve replacement. Intraoperatively, her mitral annulus was mildly dilated, anterior mitral valve leaflet appeared markedly thickened with rolled edges, and a chordae tendineae connecting the anterior leaflet (A2) was ruptured and markedly shortened.ConclusionsALCAPA is a rare and potentially life-threatening congenital coronary artery anomaly that may cause mitral valve prolapse. Echocardiogram is an important screening tool for this disorder.

P31 PERCUTANEOUS LEFT STELLATE GANGLION BLOCK AS PRE–TREATMENT STRATEGY FOR HIGH–RISK PATIENTS WHO ARE CANDIDATES FOR INVASIVE PROCEDURES POTENTIALLY ASSOCIATED WITH ADRENERGIC STIMULATION: AN HYPOTHESIS–GENERATING CASE REPORT

Abstract Introduction Percutaneous left stellate ganglion block (PLSGB) has been reported as a safety and effective procedure for the management of refractory arrhythmic storm (AS). In this report we present a case of a man with refractory AS effectively treated with PLSGB, subsequently candidate for an invasive procedure potentially associated with adrenergic stimulation and propose the use of this technique as pre–treatment strategy in this clinical setting. Case presentation A 57–year–old man was admitted to our hospital for AS. Past medical history revealed that two years earlier he had been treated with primary percutaneous coronary intervention for ST–segment elevation myocardial infarction. Four months before admission he underwent coronary artery bypass graft surgery with concomitant mechanical mitral valve replacement, closure of an interventricular defect and, considering the severe left ventricular disfunction, he was implanted with an automatic defibrillator in primary prevention. At the time of admission, he was treated with lidocaine infusion with remission of arrhythmic events. Comprehensive diagnostic workup revealed no overt triggers for AS. Five days after admission, the patient experienced recurrence of ventricular arrhythmias (VA), refractory to amiodarone, lidocaine, and magnesium infusion, increased pacing rate, and sedation with dexmedetomidine. PLSGB was then attempted with the injection of lidocaine and ropivacaine using an anatomical approach with complete remission of arrhythmic events. After a week free from VAs, a new AS was observed and PLSGB was repeated using the same modality with complete arrhythmic resolution. Considering the advanced heart failure, the patient was candidate to heart transplantation (HT) and, before undergoing gastro– and colonoscopy required for inclusion in the HT program, with the aim to reduce the risk of VA recurrences triggered by potential adrenergic stimulation, we pre–treated the patient with PLSGB using only ropivacaine, with successful induction of temporary Horner syndrome (Fig. A). The endoscopy procedures were performed successfully with no VA events and the patient was then discharged waiting for HT. Conclusion We propose the use of PLSGB as a pre–treatment strategy for patients at high–risk of VAs who are candidates for invasive procedures potentially associated with adrenergic stimulation. This report could be hypotheses–generating for further studies on this topic.

Robotic-assisted cryothermic Cox maze for persistent atrial fibrillation: Longitudinal follow-up

ObjectivesSurgical ablation of atrial fibrillation (AF) is recommended as a stand-alone therapy for patients refractory to medical or catheter-based treatment, or as a concomitant therapy when associated with structural disease. We report a single-therapy robotic approach to the Cox maze with longitudinal follow-up. MethodsConsecutive patients who underwent robotic biatrial cryothermic Cox maze for nonparoxysmal AF between November 2016 and January 2022 were examined at 1, 2, 3, 6, 9, 12, 18, 24, 36, 48, and 60 months. Freedom from atrial tachyarrhythmia was assessed with 24-hour continuous electrocardiogram or pacemaker interrogation in all patients after 6 months. Mean follow-up was 17 ± 14.5 months (range, 1-60 months). Time to event analysis with competing risks was used to determine risk-adjusted associations with late outcomes. ResultsPatients (n = 135) had a median AF duration of 4.0 years (interquartile range, 0.8-7.0), with 29.6% in whom 1 or more catheter ablations had failed. Stand-alone maze was performed in 25.2%, whereas 61.4% underwent concomitant robotic mitral valve surgery, 7.4% tricuspid valve repair, and 4.4% aortic valve replacement. No patients were discharged in AF. There were 3 operative mortalities (2.2%), none in stand-alone patients. One patient required catheter ablation at 8 months postoperatively, and one had a nonembolic stroke at 18 months. There were 9 late deaths. Freedom from atrial tachyarrhythmia and antiarrhythmic drugs at 9, 12, 18, 24, 36, and 48 months was 97.0%, 96.7%, 98.1%, 97.1%, and 100%, respectively. Lower ejection fraction and need for concomitant mitral valve replacement and/or aortic valve replacement were independently associated with worse survival. ConclusionsFor persistent AF, robotic biatrial cryothermic Cox maze offered greater than 90% 1-year longitudinal freedom from stroke, oral anticoagulation, repeat ablation, and recurrent AF without the need for antiarrhythmic drugs.

Prognostic value of MELD-XI and MELD-Albumin scores in double valve replacement

Abstract Background: Patients who undergo concomitant aortic and mitral double valve replacement (DVR) have poor postoperative clinical outcomes. The modified Model for End-Stage Liver Disease excluding international normalized ratio (MELD-XI) score and the modified Model for End-Stage Liver Disease score with albumin replacing international normalized ratio (MELD-albumin) score have been reported as predictors of adverse events in hepato-cardiac diseases. The objective of this study was to assess the clinical prognostic value of the two modified Model for End-Stage Liver Disease (MELD) scores in patients undergoing DVR. Methods: A total of 210 patients undergoing DVR were evaluated. Baseline clinical and laboratory parameters were recorded, and EuroSCORE II was calculated for each patient. The outcome of interest was the composite of heart failure hospitalization and cardiovascular mortality. Results: Patients undergoing DVR had a high prevalence of hepato-renal dysfunction. During a median follow-up of 71 months, the MELD-XI and MELD-Albumin scores independently predicted adverse outcomes (hazard ratio [95% confidence interval] = 1.09 [1.03–1.16] and 1.11 [1.06–1.16], P &lt; 0.01, respectively). Kaplan–Meier analysis demonstrated that high MELD-XI and MELD-Albumin scores were associated with an increased risk of adverse events. MELD-Albumin provided incremental prognostic value to clinical parameters and EuroSCORE II (net reclassification index [NRI] = 0.34; P &lt; 0.01). Conclusions: Both the MELD-XI score and MELD-Albumin score can provide useful information to predict adverse outcomes in patients undergoing DVR. The present study supports the monitoring of modified MELD scores to improve preoperative risk stratification for these patients.

In-hospital outcomes of patients undergoing concomitant aortic and mitral valve replacement in Germany

OBJECTIVESTo evaluate in-hospital outcomes of concomitant mitral valve replacement (MVR) in patients undergoing conventional aortic valve replacement due to aortic stenosis in a nationwide cohort.METHODSAdministrative data from all patients with aortic stenosis undergoing conventional aortic and concomitant MVR (reason for MVR not specified) between 2017 and 2018 in Germany were analysed.RESULTSA total of 2597 patients with a preoperative logistic EuroScore of 9.81 (standard deviation: 8.56) were identified. In-hospital mortality was 6.8%. An in-hospital stroke occurred in 3.4%, acute kidney injury in 16.3%, prolonged mechanical ventilation of more than 48 h in 16.3%, postoperative delirium in 15.8% and postoperative pacemaker implantation in 7.6% of the patients. Mean hospital stay was 16.5 (standard deviation: 12.1) days. Age [odds ratio (OR): 1.03; P = 0.019], New York Heart Association class III or IV (OR: 1.63; P = 0.012), previous cardiac surgery (OR: 2.85, P = 0.002), peripheral vascular disease (OR: 2.01, P = 0.031), pulmonary hypertension (OR: 1.63, P = 0.042) and impaired renal function (glomerular filtration rate <15, OR: 3.58, P = 0.001; glomerular filtration rate <30, OR: 2.51, P = 0.037) were identified as independent predictors for in-hospital mortality.CONCLUSIONSIn this nationwide analysis, concomitant aortic and MVR was associated with acceptable in-hospital mortality, morbidity and length of in-hospital stay. The regression analyses may help to identify high-risk patients and further optimize treatment strategies.

Mitral Annular Calcification in Obstructive Hypertrophic Cardiomyopathy: Prevalence and Outcomes

BackgroundThe prevalence and clinical impact of mitral annular calcification (MAC) in patients with obstructive hypertrophic cardiomyopathy (HCM) are largely unknown. MethodsWe reviewed 2113 HCM patients who underwent septal myectomy from January 2000 to April 2016. Preoperative and intraoperative echocardiograms along with operative notes were reviewed to identify MAC. Survival was estimated and compared using Kaplan-Meier analysis and the log-rank test. Cox regression analysis was used to identify factors independently associated with mortality. ResultsMAC was identified in 390 (18.5%) patients. Older age, female sex, and presence of mitral valve leaflet calcification were strongly associated with higher odds of having MAC. Patients with MAC had higher resting left ventricular outflow tract gradients, were more likely to have worse mitral regurgitation preoperatively, and were more likely to undergo a concomitant mitral valve replacement (6% vs 1%; P < .001) compared with those without MAC. Postoperatively, patients with MAC had marginally higher residual mitral regurgitation (13% vs 8%). After a median follow-up of 6.95 (interquartile range, 3.7-12.1) years, survival of patients with MAC at 1, 5, and 10 years was 99%, 92%, and 69%, respectively. Adjusted analysis identified MAC as an independent predictor of poor survival (hazard ratio, 1.46; 95% confidence interval, 1.08-1.97; P = .014). ConclusionsMAC is a frequent finding in older patients with obstructive HCM, is more likely to be seen in females, and is associated with higher rates of concomitant mitral valve replacement. Despite the higher prevalence of comorbidities, MAC remained an independent predictor for overall mortality after septal myectomy.

Early post-septal myectomy outcomes for hypertrophic obstructive cardiomyopathy.

We aimed to evaluate early outcomes of septal myectomy in patients with hypertrophic cardiomyopathy. We retrospectively analyzed data collected over a 9-year period from 583 patients who underwent septal myectomy for hypertrophic cardiomyopathy at our institution. The mean age was 55.7 ± 13.1 years, and 338 (58%) patients were in New York Heart Association class III or IV. There were 11 (1.9%) early deaths, including 3 (0.5%) intraoperative deaths. Early mortality was lowest after isolated septal myectomy (0.8%) and highest after concomitant mitral valve replacement (6.1%). There were 4 (0.7%) and 9 (1.5%) patients with left ventricular wall rupture and ventricular septal defect, respectively, after myectomy. New pacemaker implantation caused by atrioventricular disturbances was required in 29 (5.0%) patients, and was associated with previous alcohol septal ablation (odds ratio 3.34, 95% confidence interval 1.02-11.0, P = 0.047). Left ventricular wall rupture, intraoperative residual (15.5% moderate, 0.3% severe) mitral regurgitation, and pre-discharge residual outflow tract gradient >30 mm Hg (4.6%) occurrences were surgeon-dependent. The early results are consistent with example targets reported in the 2020 American College of Cardiology/American Heart Association guidelines for septal reduction therapy outcomes. Septal myectomy safety and efficacy are surgeon-dependent. Previous alcohol septal ablation increases the risk of permanent pacemaker implantation due to postoperative complete atrioventricular block. Therefore, continuous education, mentoring, and learning by doing may play an important role in achieving reasonable septal myectomy safety and efficacy.