Degenerative Mitral Valve Disease Research Articles

Comparison of automated fastener (Cor-Knot) versus manually tied knots in patients undergoing minimally invasive mitral valve replacement

Introduction: Automated knot fastener has been used in minimally invasive valve surgery to alleviate the longer total operating time and improve outcomes. Their advantages over manual knot tying remain questionable. This study aims to compare automated knot fasteners' efficacy with conventional knot-pushers in minimally invasive mitral valve replacements (MiMVR).
 Methods: Between 2016 and 2020, 50 patients underwent isolated mechanical mitral valve replacement via right mini-thoracotomy in rheumatic or degenerative mitral valve disease. The patients were grouped into two groups. Group I (n= 25) included patients who had MiMVR using the Cor-knot device, and Group II (n= 25) had MiMVR using the conventional knot-pusher. Primary endpoints were cross-clamp, cardiopulmonary bypass, and total operative times and the secondary outcomes were paravalvular leak and reoperation. There were no significant differences in the demographic data between the two groups.
 Results: Cross-clamp time (79± 1.11 vs. 98.88± 1.34 min; P<0.001), cardiopulmonary bypass time ( 132 (Q1- Q2: 129- 134) vs. 148 (140- 155) min; P<0.001) and operative times ( 206 (203- 209) vs. 228 (223- 234) min; P<0.001) were significantly shorter in Group I. There was no difference in postoperative complications between groups. The early paravalvular leak occurred in one patient (4%) in Group I and required valve re-exploration. In Group II, four patients (16%) had a paravalvular leak; 3 of them were severe and required valve re-exploration (P= 0.35). Transthoracic echocardiography at discharge revealed no evidence of a paravalvular leak in both groups.
 Conclusion: Automated fastener device (Cor-knot) could reduce operative times during minimally invasive mitral valve replacement. Operative complications are comparable between both techniques, and follow-up studies are recommended.

Equivalent outcomes with minimally invasive and sternotomy mitral valve repair for degenerative mitral valve disease.

Debate continues in regard to the optimal surgical approach to the mitral valve for degenerative disease. Between February 2004 and July 2015, 363 patients underwent mitral valve repair for degenerative mitral valve disease via either sternotomy (sternotomy, n = 109) or small right anterior thoracotomy (minimally invasive, n = 259). Survival, need for mitral valve reoperation, and progression of mitral regurgitation more than two gradeswere compared between cohorts using time-based statistical methods and inverse probability weighting. Survival at 1, 5, and 10 years were 99.2, 98.3, and 96.8 for the sternotomy group and 98.1, 94.9, and 94.9 for the minimally invasive group (hazard ratio: 0.39, 95% confidence interval [CI] 0.11-1.30, p = .14). The cumulative incidence of need for mitral valve reoperation with death as a competing outcome at 1, 3, and 5 years were 2.7%, 2.7%, and 2.7% in the sternotomy cohort and 1.5%, 3.3%, and 4.1% for the minimally invasive group (subhazard ratio (SHR) 1.17, 95% CI: 0.33-4.20, p = .81). Cumulative incidence of progression of mitral regurgitation more than two grades with death as a competing outcome at 1, 3, and 5 years were 5.5%, 14.4%, and 44.5% for the sternotomy cohort and 4.2%, 9.7%, and 20.5% for the minimally invasive cohort (SHR: 0.67, 95% CI: 0.28-1.63, p = .38). Inverse probability weighted time-based analyses based on preoperative cohort assignment also demonstrated equivalent outcomes between surgical approaches. Minimally invasive and sternotomy mitral valve repair in patients with degenerative mitral valve disease is associated with equivalent survival and repair durability.

Relationship of surgeon experience and outcomes of surgery for degenerative mitral valve disease

To assess the impact of surgeon experience on the outcomes of degenerative mitral valve disease. We reviewed all patients who had surgery for degenerative mitral valve disease between 2011 and 2016. Experienced surgeon was defined as performing ≥ 25 mitral valve operations/year. Patient characteristics and outcomes were compared. Competing risk analysis was performed to identify factors associated with mitral regurgitation (MR) recurrence. Survival analysis for mortality was done using Kaplan Meier curve and Cox proportional hazard method. There were 575 patients treated by 9 surgeons for severe MR caused by degenerative mitral valve disease between 2011 and 2016. Three experienced surgeons performed 77.2% of the operations. Patients treated by less experienced surgeons had worse comorbidity profile and were more likely to have an urgent or emergent operation (p = .001). Experienced surgeons were more likely to attempt repair (p = .024), to succeed in repair (94.7% vs. 87%; p = .001), had shorter cross-clamp times (p = .001), and achieved higher repair rate (81.3% vs. 69.7%; p = .005). Experienced surgeons were more likely to use neochordae (p = .001) and less likely to use chordae transfer (p = .001). Surgeon experience was not associated with recurrence of moderate or higher degree of MR after repair but was an independent risk factor for mortality (HR = 2.64; p = .002). Techniques of degenerative mitral valve surgery differ with surgeon experience, with higher rates of repair and better outcomes associated with more experienced surgeons.

Atypical vasovagal syncope in Cavalier King Charles spaniel ocurring at rest

A 10-year-old male entire Cavalier King Charles Spaniel was referred for investigation of frequent episodes of transient loss of consciousness during periods of rest as well as severe stertor and inspiratory dyspnoea. Echocardiography revealed degenerative mitral valve disease in stage B1 ACVIM (Keene et al., 2019) without any evidence of pulmonary hypertension. Respiratory tract endoscopic examination revealed a significantly enlarged soft palate, laryngeal saccule eversion and severe laryngeal collapse. During syncopal episodes, Holter examination revealed progressive bradycardia with long periods of sinus and ventricular arrest, followed by paroxysmal runs of atrial fibrillation, suggestive of reflex syncope. This case describes a dog with reflex syncope occurring in an atypical situation of rest with spontaneous improvement of syncope frequency until its complete resolution 6 months after presentation. Un cavalier King Charles Spaniel mâle entier de 10 ans est référé pour l’investigation d’épisodes de perte de conscience fréquents au repos, ainsi que pour l’exploration d’un stertor et d’une dyspnée inspiratoire marqués. Une échocardiographie a mis en évidence une maladie dégénérative valvulaire mitrale en stade B1 ACVIM (Keene et al., 2019) sans hypertension pulmonaire. Une endoscopie respiratoire a révélé une élongation marquée du palais mou, une éversion des ventricules laryngés et un collapsus laryngé important. Lors des épisodes de syncope, l’examen Holter a révélé une bradycardie progressive avec de longues périodes d’arrêt sinusal avec une asystolie ventriculaire, suivies par une série de fibrillation atriale, évoquant une syncope réflexe. Ce cas décrit un cas de syncope réflexe sur un chien survenant au repos, avec une amélioration spontanée des crises jusqu’à sa complète résolution 6 mois après présentation.

ATRIAL SEPTAL ANEURYSM IN ADULTS – IS IT A DEGENERATIVE HEART DISEASE?

Objective: Atrial septal aneurysm (ASA) is a localised “saccular” deformity of the interatrial septum, generally at the level of the fossa ovalis, which protrudes to the right or the left atrium or on both sides. It is a well recognised cardiac abnormality that was previously diagnosed on autopsy only, but it is now frequently picked up on routine echocardiography or during evaluation of ischemic stroke. There is a dearth of data on atrial septal aneurysm in our environment, and the authors set out to find the common cardiac abnormalities associated with atrial septal aneurysm in adults who had transthoracic echocardiographic examination in Enugu, South-East Nigeria Design and method: Conquest Medical Imaging is a private medical diagnostic centre in Enugu, South-East Nigeria. The centre offers radiologic and ultrasonography diagnostic services. The echocardiographic records of 1390 patients done over a 4-year period were retrospectively reviewed. The examinations were done with a Logic 500MD Echocardiographic machine made by General Electric. Data obtained from the echocardiography register included presence of atrial septal aneurysm, age, gender, other cardiac abnormalities present. Results: A total of 1174 adults had echocardiographic examination during the period under review, and consisted of 667 males and 507 females. The mean age of the males was 43.1 ± 6.2 years, while the mean age of the females was 45.9 ± 7.1 years. Atrial septal aneurysm was present in 28 patients representing 0.2% of the total adult population, and made up of 11 males and 17 females. 25 patients had one or more additional cardiac abnormalities, representing 89.3% of all patients with atrial septal aneurysm. Degenerative aortic valve disease, degenerative mitral valve disease, and left ventricular diastolic dysfunction were the cardiac abnormalities noted in addition. Conclusions: The frequent association of degenerative valvular heart diseases with atrial septal aneurysm in adults may suggest that atrial septal aneurysm has a degenerative aetiology in adults.

Complex mitral valve regurgitation: surgical evaluation, approach and repair techniques

: The complexity of valve pathology in degenerative mitral valve disease has important implications in the operative approach and success of a reconstructive strategy. Originally described by Alain Carpentier’s pioneering concept of pathophysiologic triad, the type and burden of mitral valve lesions are specific to the etiology of valve disease. While fibroelastic deficiency for example, is likely limited to a single segment prolapse and a ruptured chord, Barlow’s valves lesions extend to involve multiple segments, clefts, chordae and the mitral annulus, requiring multiple repair techniques and an advanced level of surgical repair expertise. It is therefore important to assess disease etiology and lesion complexity during preoperative screening to plan operative approaches and anticipate operative complexity to maximize the opportunity for a successful mitral valve repair. While surgical repair techniques continue to evolve, over 95% of degenerative mitral valve lesions can be repaired successfully with targeted leaflet resection, leaflet resuspension using artificial chordae and/or native chordal transfer, and annular stabilization with a mitral annuloplasty device. With the exception of extensive annular/ leaflet calcification and some cases of significant fibrosis or inflammation which may prohibit a durable repair, most concomitant cleft, chordal, commissural and anterior leaflet pathology can be repaired successfully with a systematic lesion-specific approach, using a combination of techniques tailored to the individual valve pathology. The present article provides a state-of-the-art review of the systematic approach to complex degenerative mitral valve repair in our quaternary mitral valve reference center.

Complex mitral valve regurgitation: surgical evaluation, approach and repair techniques

: The complexity of valve pathology in degenerative mitral valve disease has important implications in the operative approach and success of a reconstructive strategy. Originally described by Alain Carpentier’s pioneering concept of pathophysiologic triad, the type and burden of mitral valve lesions are specific to the etiology of valve disease. While fibroelastic deficiency for example, is likely limited to a single segment prolapse and a ruptured chord, Barlow’s valves lesions extend to involve multiple segments, clefts, chordae and the mitral annulus, requiring multiple repair techniques and an advanced level of surgical repair expertise. It is therefore important to assess disease etiology and lesion complexity during preoperative screening to plan operative approaches and anticipate operative complexity to maximize the opportunity for a successful mitral valve repair. While surgical repair techniques continue to evolve, over 95% of degenerative mitral valve lesions can be repaired successfully with targeted leaflet resection, leaflet resuspension using artificial chordae and/or native chordal transfer, and annular stabilization with a mitral annuloplasty device. With the exception of extensive annular/ leaflet calcification and some cases of significant fibrosis or inflammation which may prohibit a durable repair, most concomitant cleft, chordal, commissural and anterior leaflet pathology can be repaired successfully with a systematic lesion-specific approach, using a combination of techniques tailored to the individual valve pathology. The present article provides a state-of-the-art review of the systematic approach to complex degenerative mitral valve repair in our quaternary mitral valve reference center.

Advances in Mitral Valve Repair for Degenerative Mitral Regurgitation: Philosophy, Technical Details, and Long-Term Results.

Degenerative mitral valve disease represents the most common cause of mitral regurgitation in industrialized countries. When left untreated, patients with severe degenerative mitral regurgitation show a poor clinical outcome. Conversely, a timely and appropriate correction provides a restored life expectancy and a good quality of life. Therefore, in this scenario, surgical mitral valve repair represents the gold standard of treatment. This review aims to analyze the indications, timing, and contemporary surgical techniques of mitral valve repair for degenerative mitral regurgitation. Moreover, the value of heart team approach and centers of excellence for mitral valve repair are also deeply discussed.

Multiple retrospective analysis of survival and evaluation of cardiac death predictors in a population of dogs affected by degenerative mitral valve disease in ACVIM class C treated with different therapeutic protocols.

Clinical records of dogs with spontaneous degenerative mitral valve disease (DMVD) with clinical signs related to congestive heart failure (CHF) recruited during routine clinical practice between 2001 and 2018 at the Cardiology Unit of the Veterinary Teaching Hospital (University of Milan) were included in this retrospective cohort study. Baseline echocardiographic data were evaluated. Median survival time (MST) was calculated. Data on therapeutic treatment, ISACHC (International Small Animal Cardiac Health Council) or ACVIM (American College of Veterinary Internal Medicine) classes were reviewed based on the inclusion period and type of endpoint (i.e. cardiac death or death for other causes). A univocal classification was needed, and the patients classified in ISACHC classes II, IIIa and IIIb, visited before 2009, were reallocated to ACVIM class C. The main goal of this data review was to retrospectively evaluate 259 clinical records of subjects belonging to ACVIM C class examined between 2001 to 2018 and 202 dogs examined between 2010 to 2018. In this way, in the second group, the bias of the reclassification was avoided. The MST (median survival time) of these subjects was 531 d (2001-2018) and 335.5 d (2010-2018), respectively. Univariate survival regression analysis for subjects included from 2010 to 2018 showed as significantly related to cardiac death (CD): left atrium to aorta ratio (LA/Ao) (HR 2.754, p=0.000), E wave (HR 2.961, p=0.000), E/A ratio (HR 1.372, p=0.000), end-diastolic (HR 1.007, p=0.000) (EDVI) and end-systolic (HR 1.012, p=0.026) (ESVI) volume indexes, allometric diastolic (HR 4.018, p=0.000) (LVIDdN) and systolic (HR 2.674, p=0.049) (LVIDsN) left ventricular internal diameters, age (HR 1.006, p=0.009) and pulmonary hypertension severity (HR=1.309, p=0.012) (PH). Multivariate analysis, adjusted for age, showed that the only variable that determined a statistically significant difference in MST was PH severity (HR 1.334, p=0.033). The type of therapeutic treatment within this class was not significant for the MST of the subjects.

Accuracy of history, physical examination, cardiac biomarkers, and biochemical variables in identifying dogs with stage B2 degenerative mitral valve disease.

BackgroundTreatment is indicated in dogs with preclinical degenerative mitral valve disease (DMVD) and cardiomegaly (stage B2). This is best diagnosed using echocardiography; however, relying upon this limits access to accurate diagnosis.ObjectivesTo evaluate whether cardiac biomarker concentrations can be used alongside other clinical data to identify stage B2 dogs.AnimalsClient‐owned dogs (n = 1887) with preclinical DMVD prospectively sampled in Germany, the United Kingdom, and the United States.MethodsDogs that met inclusion criteria and were not receiving pimobendan (n = 1245) were used for model development. Explanatory (multivariable logistic regression) and predictive models were developed using clinical observations, biochemistry, and cardiac biomarker concentrations, with echocardiographically confirmed stage B2 disease as the outcome. Receiver operating characteristic curves assessed the ability to identify stage B2 dogs.ResultsAge, appetite, serum alanine aminotransferase activity, body condition, serum creatinine concentration, murmur intensity, and plasma N‐terminal propeptide of B‐type natriuretic peptide (NT‐proBNP) concentration were independently associated with the likelihood of being stage B2. The discriminatory ability of this explanatory model (area under curve [AUC], 0.84; 95% confidence interval [CI], 0.82‐0.87) was superior to NT‐proBNP (AUC, 0.77; 95% CI, 0.74‐0.80) or the vertebral heart score alone (AUC, 0.76; 95% CI, 0.69‐0.83). A predictive logistic regression model could identify the probability of being stage B2 (AUC test set, 0.86; 95% CI, 0.81‐0.91).Conclusion and Clinical ImportanceOur findings indicate accessible measurements could be used to screen dogs with preclinical DMVD. Encouraging at‐risk dogs to seek further evaluation could result in a greater proportion of cases being appropriately managed.

Characterization of Degenerative Mitral Valve Disease: Differences between Fibroelastic Deficiency and Barlow's Disease.

Degenerative mitral valve disease causing mitral valve prolapse is the most common cause of primary mitral regurgitation, with two distinct phenotypes generally recognized with some major differences, i.e., fibroelastic deficiency (FED) and Barlow’s disease. The aim of this review was to describe the main histological, clinical and echocardiographic features of patients with FED and Barlow’s disease, highlighting the differences in diagnosis, risk stratification and patient management, but also the still significant gaps in understanding the exact pathophysiology of these two phenotypes.

Mitral valve repair rates in degenerative mitral valve disease correlate with surgeon and hospital procedural volume.

To determine the relationship between surgeon and hospital procedural volume, and mitral valve repair rates and 30-day mortality for degenerative mitral regurgitation (MR), in Australian cardiac surgical centers. A total of 4420 patients who underwent elective surgery for degenerative MR between January 2008 and December 2017 in the Australian and New Zealand Society of Cardiac and Thoracic Surgeons Database were retrospectively included. Univariate and multivariate regression analyses examined surgeon and hospital procedural volumes for associations with repair rate and mortality. Repair rates varied widely by caseload; from 62.57% to 79.53% for lowest to highest volume surgeons; and from 54.56% to 77.54% for lowest to highest volume hospitals. Compared to surgeons performing ≤5 procedures/annum, surgeons performing 10.1-20/annum were more likely to repair the valve (odds ratio [OR] 2.40, 95% confidence interval [CI] 1.09-5.28, p = .03), particularly if performing more than 20/annum (OR 2.88, 95% CI 1.09-7.60, p = .03). Compared to hospitals performing ≤10/annum, those performing any number of procedures more than 10 demonstrated an increased likelihood of repair (caseload 10.1-20/year OR 1.96, 95% CI 1.25-3.07, p = .003) though odds did not increase above this threshold. Low incidence of 30-day mortality (63 of 4414, 1.43%) limited analysis of contributing variables; procedural volume did not confer a survival benefit. Surgeon and hospital caseload were significantly associated with repair rates of degenerative MR. A threshold minimum of 10 procedures annually for surgeons and hospitals should be utilized to maximize repair rates, and ideally of 20 for surgeons. Mortality was low and may not be significantly impacted by procedural volume.

Analyzing and comparing the impacts and outcomes of two different types of surgeries - Minimally Invasive Surgeries (MIS) and Conventional Surgeries (CVS) on patients suffering from Degenerative Mitral Valve Diseases

Background: Degenerative Mitral Valve Disease (DMVD) is the most common cause of Mitral Regurgitation (MR) and the main reason for surgical intervention in patients with heart diseases. Traditionally, open-heart surgery or else sternotomy was the main surgical approach used until a few decades ago when Minimally Invasive Surgical (MIS) approaches came into existence. MIS approach is thought to have superior clinical outcomes while minimizing hospital and ICU stay; blood loss translating to fewer blood transfusions, and lower incidence of complications. Despite many promising institutional and regional results of benefits of MIS over the conventional surgery, the adoption of MIS worldwide in Mitral Valve Repair (MVR) has been so poor. There are still arguments on the surgical and clinical benefits of MIS and more importantly the cost and the expertise involved in conducting MIS. Objective: This study aimed at comparing the costs, clinical and surgical outcomes of MIS with conventional sternotomy MVR surgeries in patients with DMVD. Methods: Electronic databases such as MEDLINE, PubMed, Science Direct, and Google Scholar were searched for relevant peer-reviewed articles comparing costs and clinical outcomes of MIS with the conventional surgery/sternotomy in DMVD from January 2013 to November 2020. A total of 7 articles were identified as most relevant and therefore included in the meta-analysis. Results: Findings from the meta-analysis pointed out that repair of the mitral valve using MIS patients with DMVD has benefits such as short ICU, intubation and hospital duration; less loss of blood and therefore less need of blood transfusion; low postoperative infection rates; smaller incisions; early ambulation and return to activities of daily living over conventional surgery while maintaining similar costs of care and clinical outcomes as a sternotomy. Conclusions: Given the added advantages of MIS in mitral valve surgeries, cardiac surgeons should consider it over the conventional open surgeries in patients with DMVD. In this regard, more surgeons and nurses need to gain competency in conducting MIS through training and fellowships; hospitals need to acquire the needed infrastructure to enable the adoption of MIS.

Risk factors of persistent ventricular arrhythmias after mitral valve repair in Barlow disease patients: six-year follow-up

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Improvement in malignant ventricular arrhythmias (VA) has been reported after mitral valve surgery in some mitral valve prolapse patients (MVP) with severe degenerative mitral regurgitation. Mitral annular disjunction, posterior systolic curling, and mitral annular abnormal contractility are associated with arrhythmic MVP and underwent correction during the mitral valve repair. However, mitral valve disease progression and ventricular arrhythmic substrates (left ventricular fibrosis of papillary muscles and basal posterior wall) could be potential substrates for persistent malignant arrhythmias even after surgical correction. Our aim was to evaluate the risk factors of persistent VA after mitral valve repair in Barlow’s disease patients in six-year follow-up. Methods 30 consecutive patients (mean age 53.1 ± 9.4, 47% male) who underwent mitral valve repair for severe mitral regurgitation (MR) due to mitral valve prolapse were enrolled in our observational, prospective, single-center study. Resected abnormal segments of the mitral leaflets were examined by experienced pathologists for signs of myxomatous degeneration. Transthoracic echocardiography and 24-hour Holter monitoring were performed pre- and postoperatively annually. PVCs and nonsustained ventricular tachycardia (VT) runs were reviewed. Results All patients survived the operation. There was only one sudden cardiac death on sixth year of follow-up. During 173 person-years of follow-up 3 patients (10%) had developed recurrent moderate to severe (≥2) MR. The total number of PVCs and non-sustained ventricular tachycardia runs dropped significantly in 1st (p=.04, Wilcoxon matched pairs test) and 2nd (p=.03), years of postoperative follow-up. Postoperative incidence of PVCs and VT correlated strongly with postoperative end-diastolic LV diameter (EDD rs=.69; p=.005), moderate negatively with LV ejection fraction (EF rs=-.55; p=.001). Advanced myxomatous degeneration assessed by pathologists and MV posterior leaflet’s thickness ≥5 mm after repair assessed by echocardiographer associated with postoperative PVCs and VT (rτ=.58; p=.045 and rs=.62; p=.002, respectively). Recurrent MR also strongly associated with postoperative PVCs and VT (rs=.76; p=.0018). In univariate analysis, advanced myxomatous degeneration (p=.008), postoperative end-diastolic LV diameter (p=.001), and low EF (p=.003) were identified as risk factors of persistent PVCs/VT after surgery. Conclusions Advanced myxomatous degeneration assessed by pathologists or echocardiographer and postoperative left ventricular remodeling are associated with persistent malignant ventricular arrhythmias. Further investigation in larger cohorts to evaluate the association between degenerative mitral valve disease and ventricular arrhythmias is needed.

Atrial coupling index by standard echocardiography in degenerative mitral regurgitation: incremental determinant of survival

Abstract Funding Acknowledgements Type of funding sources: Public hospital(s). Main funding source(s): Mayo Clinic Foundation Background Left atrial (LA) volume is linked to outcome in degenerative mitral regurgitation (DMR) but does not encompass LA function assessment. Thus, we ought to determine the prognostic role of left atrial coupling-index (LACI), as left atrial volume-index (LAVI) by Tissue-Doppler-Imaging a’ (TDI-a’), in a large cohort of DMR. Methods All consecutive 4792 patients (61 ± 16 years, 48% women) with isolated degenerative mitral valve disease diagnosed at Mayo Clinic 2003-2011, comprehensively characterized, in whom LAVI and TDI-a’ in sinus rhythm was prospectively measured in routine practice, was enrolled and their long-term survival analyzed. Results LACI (5.8 ± 3.7–T1 < 3.8; T2 3.8-6.3; T3 > 6.3) was significantly higher through different DMR grades (no, mild, moderate, severe DMR: 3.77 ± 2.26, 5.08 ± 2.95, 6.54 ± 3.74 and 7.84 ±4.29 respectively; p < 0.0001). Independent determinants of LA dysfunction assessed by LACI were age, E/e’, left-ventricle (LV) end-systolic-diameter, mitral-regurgitation (MR) grade, and LV ejection-fraction (all P ≤ 0.0001). LACI > 6 was independently associated with dyspnea, edema, more severe functional tricuspid-regurgitation and elevated pulmonary artery pressure, irrespective of age, sex, Charlson-comorbidity-index, ventricular function and MR severity. Total follow-up was 7.03 ± 3.0 years, during which 1146 (24%) underwent mitral-valve surgery (94% repair-6% replacement) and 880 (18%) died, 780 under medical treatment and 100 after surgery. Overall survival throughout follow-up (10-year 76 ± 1%) was strongly associated with LACI (88 ± 1% vs. 78 ± 1% and 62 ± 2% for LACI <3.8, 3.8-6.3 and ≥6.3, P < 0.0001) even adjusting comprehensively, including for DMR severity (adjusted-hazard-ratio 1.23[1.07-1.43] for LACI > 5.79, P = 0.005). Mortality under medical management was profoundly affected by LACI (adjusted-hazard-ratio 1.11[1.05-1.18] per 3 unit increment; 1.35[1.15-1.58] for LACI > 5.79 vs. ≤5.79, both P = 0.0002). Survival improved after mitral surgery (time-dependent adjusted-hazard-ratio 0.40[0.28-0.65], P < 0.0001) but remained humbly linked to LACI (10-year 93 ± 3% vs. 90 ± 2% and 80 ± 3% for LACI tertiles, P = 0.0008). Most importantly, LACI provided incremental prognostic information over LAVI and other conventional determinants of survival (P < 0.0001) with Net-reclassification-improvement vs. LAVI of 0.21 ± 0.02, P < 0.0001. Conclusion LA function assessed by LACI in routine practice, by conventional echocardiographic measurements, displays incremental and independent link to excess-mortality, considerable under medical management and partially alleviated by mitral surgery. Thus, LACI is a simple tool of crucial interest in DMR risk-stratification. Abstract Figure. LACI in DMR

Patient owner surveys in small animal medicine - importance, benefits and pitfalls in planning, execution and analysis

In the present study, the benefits and difficulties of planning and conducting patient surveys in veterinary medicine were examined using 2 examples. One focus was placed on the comparison of the subjective assessment and perception of patient owners with regard to long-term investigation of disease progression. An owner survey was conducted in dogs with chronic enteropathy (CE) and degenerative mitral valve disease (DMVD). In both surveys, the case system of the Clinic for Small Animals of the University of Veterinary Medicine Hannover was used to identify suitable cases based on appropriate diagnoses. Owners were contacted and invited to complete (digitally or postally) a multipart questionnaire on their dogs. The results of the survey were evaluated regarding their agreement with literature data. Based on the results of this evaluation, the study design, reliability of owner perception and the benefit of the survey were examined critically. The search in the clinic's case system provided 125 suitable cases for CE and 145 for DMVD. A total of 81 (CE, response rate 64.8 %) and 72 (DMVD, response rate 49,7 %) owners answered the questionnaire. The owners provided considerably different information concerning the diagnostic examination of their animals. While the statements on the course and forms of disease in CE corresponded to the information from the literature, this was not always the case with DMVD. Patient owner surveys may provide important information about disease progression from the owner's perspective. This is particularly valuable in chronic diseases, the management of which requires good owner compliance. An identical approach to patient selection may lead to results differing in their informative value depending on the disease.

The Right WAYS to Repair the Mitral Valve

Mitral valve repair is preferred to mitral valve replacement in patients with degenerative mitral valve disease (ie, mitral valve prolapse). Countless studies support this assertion, demonstrating that repair confers superior clinical outcomes when compared with mitral valve replacement. Whereas recent reports document that the majority of patients with degenerative mitral valve disease receive repair, a substantial proportion of patients with repairable valves undergo valve replacement. Surgeon experience and comfort with repair techniques certainly impact the likelihood of valve repair.

Morphological Evaluation of Mitral Valve Based on Three-dimensional Printing Models: Potential Implication for Mitral Valve Repair

Abstract Objective: This study aimed to analyze the morphological characteristics of rheumatic (RMVD) and degenerative mitral valve diseases (DMVD) based on three-dimensional (3D) printing model before and after surgery and to explore the potential implication of the 3D printing model for mitral valve (MV) repair. Methods: 3D transesophageal echocardiography (TEE) data of the MV were acquired in 45 subjects (15 with RMVD, 15 with DMVD, and 15 with normal MV anatomy). 3D printing models of the MV were constructed by creating molds to be printed with water-soluble polyvinyl alcohol, then filled with room temperature vulcanizing silicone. The parameters of the annulus and leaflet of the MV were acquired and analyzed using the 3D printing model. Mitral valve repair was simulated on 3D printing models of 10 subjects and compared with the actual operation performed on patients. The effects of surgery were assessed by evaluating the changes in coaptation length (CL) and the annular height to commissural width ratio (AHCWR) before and after MV repairs. The correlations of the grade of mitral regurgitation with CL and AHCWR were analyzed. Results: 3D silicone MV models were all successfully constructed based on 3D TEE data. Compared with the normal groups, the mitral annulus size in the RMVD groups showed no significant differences. In contrast, mitral annulus in DMVD groups was dilated and flattened with diameters of anteroposterior, anterolateral-posteromedial, commissural width, annular circumferences, and area increased. Mitral repair was successfully simulated on 10 models with significant increase in leaflet coaptation area both in vivo and in vitro. Good agreement was observed in CL and AHCWR after surgery in the 3D printing model compared with real surgery on the patient valve. The grade of mitral regurgitation correlated inversely with CL (r = –0.87, P < 0.01) and AHCWR (r = –0.79, P < 0.01). Mitral valve repair was performed twice in one model to assess which provided a better outcome. Conclusions: 3D printing models of the MV based on 3D TEE data could be used in morphological analysis of the MV before and after surgery in RMVD and DMVD. Surgery simulation on 3D printing models could provide valuable information concerning morphological changes after surgery, with are closely associated with clinical outcomes.

ВСЁ НОВОЕ – ЭТО ХОРОШО ЗАБЫТОЕ СТАРОЕ: АННУЛОПЛАСТИКА МИТРАЛЬНОГО КЛАПАНА АУТОПЕРИКАРДОМ ПРИ ДЕГЕНЕРАТИВНЫХ ПОРОКАХ

Objective: To present the first-hand results of a modified mitral annuloplasty (MA) with an autopericardial strip (APS) in degenerative mitral valve disease (DMVD). Methods: Fifty-three patients with DMVD (mean age, 54.9±9.5 years (36-78 years); n=32 men (60.4%) and n=21women (39.6%)) undergoing MA with an APS, between January 2017 and January 2020 were retrospectively studied. In the overwhelming majority of cases, triangular and quadrangular resections of the P2 segment were performed. In addition, in some cases, neochords were implanted to the A2 segment. Intraoperatively, the result of MA was considered satisfactory if, according to transoesophageal echocardiography, the degree of mitral regurgitation (MR) did not exceed grade 1. Results: No in-hospital mortality was observed. One female patient had an early relapse caused by the rupture of one of the neochords at the A2 segment. However, the MR did not exceed grade 2, and the patient was actively followed up. Conclusion: Individual APS length selection avoids overcorrecting and achieves adequate systolic and diastolic mitral valve performance. Keywords: Annuloplasty, mitral regurgitation, autopericardium, mitral regurgitation.

Prevalence and Involvement of Different Valves in Rheumatic Heart Disease- An Observational Echocardiographic Study in a Tertiary Care Centre, Bengaluru, India

Introduction: Rheumatic Heart Disease (RHD) is a non suppurative sequelae of group A beta haemolytic streptococci, resulting from inadequately treated streptococcal sore throat or scarlet fever and leading to valvular heart disease. Rheumatic heart disease is a major cause of morbidity and mortality in younger population in developing countries. The present study was done at a tertiary care medical college hospital with the objective of establishing prevalence and involvement of different valve patterns by Echocardiography (ECHO). Aim: To analyse the valvular pattern of RHD over a period of four years in a tertiary care centre and highlight the importance of ECHO in the definitive diagnosis of RHD, and to know the continuing burden of RHD. Materials and Methods: This was a hospital based retrospective observational study conducted at Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, India. A total of 518 cases of RHD were selected as a study population among the ECHO performed between January 2016 and January 2020 after an exclusion criterion of degenerative mitral and aortic valve disease, congenital aortic and mitral valve disease, myxomatous mitral valve disease, trivial and functional regurgitation. Analysis of valvular pattern was performed. Data analysis was done by tables, charts, percentages and ratio. Results: A total of 518 patients were diagnosed to have RHD by 2-Dimensional ECHO. Among them 276 (53%) were females and 242 (47%) were males. The average age was 41.9 years. The most common valve involved independently and in combined lesions was the mitral valve. Of the study population, 446 patients had Mitral Stenosis (MS) and 393 had Mitral Regurgitation (MR). Aortic Stenosis (AS) was found among 111 patients and 304 patients had Aortic Regurgitation (AR). Tricuspid Stenosis (TS) (organic) was found in seven cases. Multiple valves were involved in 204 cases. Among them 104 of the cases had MS, MR and AR, 69 cases had MS, MR, AS and AR, 21 cases had MS, AS and AR, seven cases had MR, AS and AR and three cases had MS, AS, AR and TS. Though aortic valve was involved in multi valvular lesions, significant AR (moderate and severe) was seen in 109 patients and significant AS (moderate and severe) was seen in 67 patients. Conclusion: RHD continues to be a major burden to population in developing countries. In the present study, various patterns of valvular involvement were noted. Drastic measures are to be taken primary and secondary prevention of RHD.