Eccentric Mitral Regurgitation Research Articles

Coanda Effect Displayed in a Giant Intracranial Aneurysm.

The Coanda effect is a fluid dynamics phenomenon in which a fluid jet adheres to a convex or flat surface. This effect occurs when a liquid or gas jet emerging from an orifice clings to an adjacent surface and entrains the surrounding fluid, creating a lower-pressure region along its path that maintains its attachment to the surface. The Coanda effect accounts for the behavior of blood flow in the fetal right atrium and the dispersion of eccentric mitral regurgitation jets along atrial walls. This series of interesting images depicting a large 4 × 3.75 cm saccular intracranial aneurysm suggests that the Coanda effect may play a role in the pathophysiology of intracranial aneurysms and could be an underlying factor in their formation, progression, or rupture.

Structural and functional abnormalities of left-sided cardiac chambers in Barlow's disease without significant mitral regurgitation.

This study aims to explore the presence of left ventricular (LV) and left atrial (LA) morphological and functional abnormalities in patients with Barlow's disease (BD) without significant mitral regurgitation (MR) and to investigate whether these abnormalities may predict MR progression. Consecutive patients with BD were retrospectively identified from two tertiary centres; those with MR graded from trivial to mild-to-moderate were selected and matched with healthy controls in a 1:1 ratio. Conventional and speckle-tracking echocardiographic data were collected. The development of moderate-to-severe or greater MR was evaluated on follow-up echocardiograms. Patients with BD (n = 231) showed increased LV dimensions and indexed LV mass (LVMi) in comparison with controls (P < 0.001); LV remodelling worsened with higher MR severity and was accompanied by an increased prevalence of eccentric LV hypertrophy (eLVH). Moreover, BD patients had larger LA volumes and more impaired LA reservoir strain vs. controls (P < 0.001), while LV strain was similar between the two groups. Multivariable linear regression analyses in the overall population identified BD and MR grade as independent predictors of remodelling markers (LV dimensions, LVMi, and LA volume) and BD as independent correlate of LA strain. MR progression was observed in 51 BD subjects (out of 170 patients with available follow-up). On Cox regression analysis, age, eLVH, mild-to-moderate MR, and mitral annular disjunction (MAD) emerged as independent predictors of MR progression. BD patients without significant MR show early LV and LA remodelling, together with reduced LA strain. MR progression was associated with eccentric LV remodelling, MAD, and MR severity.

Abstract 12214: Large Left Atrial Infected Myxoma in a Healthy Patient With Intermittent Fever

Introduction: Infected myxomas represent a rare subset of cardiac myxomas. The diagnosis is classified as definite, probable, or possible based on microbiological and pathological findings. Prognosis is often favorable with early diagnosis and intervention. Case description: A 39-year-old female with a history of iron-deficiency anemia presented with three months of fever, poor exercise tolerance, 15-lb unintentional weight loss, and episodes of amaurosis fugax associated with upper extremity paresthesias. Her physical exam revealed tachycardia and a grade 3/6 apical holosystolic murmur. Her laboratory workup was notable for microcytic anemia, elevated inflammatory markers, and Streptococcus sanguinis bacteremia . Echocardiography showed left ventricular and left atrial dilation with normal systolic function and a 6.4x4.3 cm heterogenous left atrial mass adherent to the interatrial septum with prolapse across the mitral valve plane (Figure 1, panel A-B) associated with eccentric mitral regurgitation. She was managed with surgical resection and antibiotics. Pathology revealed myxomatous tissue and prominent plasma cell infiltrates, confirmatory of definite infected cardiac myxoma. Follow-up echocardiography showed residual mitral regurgitation due to mitral annular stretch from myxoma for which surgical intervention was deferred in the acute setting. Discussion: A definite diagnosis of infected myxoma is established with biopsy-proven myxoma, along with microorganism visualization or positive blood cultures with inflammatory cells on histopathology. Rare in occurrence, infected myxomas have been associated with a higher incidence of embolic events, sepsis, and shock compared to uninfected myxomas. Prognosis is favorable with prompt intervention. Increased awareness leading to earlier diagnosis and management is a priority for this subset of patients.

Post-cardiac catheterization infective endocarditis with flail mitral valve leaflets: an interesting and rare case

Infectious endocarditis (IE) occurs after the colonization of the cardiac endocardium by virulent microorganisms, usually bacteria. Infective endocarditis causes significant morbidity and mortality, even in this era of antibiotics. Here we present a 52-year-old male patient with hypertension and ischemic heart disease who presented with shivering, fever, and confusion for two days, fourteen days after PCI. On further assessment, transesophageal echocardiography was done due to the patient’s fulfillment of 3 minor and 1 major of Duke's criteria. Flail posterior mitral valve leaflet of 1.1x0.60cm vegetation, and severe eccentric mitral regurgitation were observed in the transesophageal echocardiography.&#x0D; Post PCI infective endocarditis is rare and missed diagnosis so it should be haven high suspension for those present with signs and symptoms compatible with infective endocarditis.&#x0D; Keywords: PCI, infective endocarditis, vegetation, echocardiography, PCI, mitral regurgitation&#x0D;

Comparison of Chronic Rheumatic Mitral Regurgitation Severity between Cardiac Magnetic Resonance Imaging and Echocardiography

Abstract Background and Purpose Traditionally, echocardiography has been used for assessing mitral regurgitation (MR) severity. However, existing qualitative, semi-quantitative and quantitative parameters suffer from several limitations. The shortcomings of the current echocardiographic methods for MR severity assessment are especially pronounced in the context of eccentric MR jets. Cardiac magnetic resonance (CMR) imaging is useful for assessing valvular lesions as it is now the gold standard for assessing left ventricular and left atrial volumes. Therefore, we sought to study and compare echocardiography with CMR for assessment of chronic rheumatic MR severity. Methods Twenty-two patients with chronic rheumatic MR who underwent both CMR and echocardiography were studied. For the echocardiography part of the study, the MR severity was assessed as per current guidelines. The CMR measurements were performed per standard guidelines by a single operator experienced in this technique. Results The mean age of the study population was 36.3±13.9 years and 81% were females. There was overall poor agreement for the assessment of MR severity using the quantitative parameters for MR assessment between echocardiography and CMR. Although the measurements for end diastolic volume index (EDVi), end systolic volume index (ESVi), regurgitant volume (RV) and regurgitant fraction (RF) showed moderate correlation, these parameters displayed poor agreement between the two tests. We noted discrepant findings in terms of classification of valve lesion severity in seven patients. Six patients were reclassified after CMR to severe MR and one to moderate MR based on quantitative parameters of regurgitant volume (RV) and regurgitant fraction (RF). Conclusion In patients with severe chronic rheumatic MR with eccentric jets, when MR quantification by echocardiography is inadequate, CMR derived quantitative volumetric parameters may be useful for accurate classification of the severity of mitral regurgitation.

“Circumnavigation”: A Worthy Descriptor to Depict Torrential Mitral Regurgitation and a Reverence to Ferdinand Magellan

"Circumnavigation" is never used as a verb in cardiology. Hypertrophic obstructive cardiomyopathy is a complex entity that often involves the mitral valve leading to eccentric mitral regurgitation. Utilizing multimodality imaging, assessing the severity of mitral regurgitation, and phenotyping the type of myocardial hypertrophy are achievable with certainty. We describe a case of a 42-year-old male who presented with palpitations and was ultimately diagnosed with hypertrophic obstructive cardiomyopathy with a mitral regurgitation. The torrential mitral regurgitation jet was so severe that it was "circumnavigating" the left atrium. In addition, we also draw historical parallelism with Magellan's heroic "circumnavigation" of the globe as we celebrate 500 years of his journey. Furthermore, we also describe the multimodality assessment of hypertrophic obstructive cardiomyopathy utilizing transthoracic echocardiography and cardiac magnetic resonance imaging. We discuss the challenges in quantifying such severe mitral regurgitation with any individual imaging modality.

One stone hits two birds: transcatheter mitral valve edge-to-edge repair for hypertrophic obstructive cardiomyopathy and severe mitral regurgitation.

A 68-year-old woman presented with dyspnoea on exertion and intermittent palpitation followed by near fainting. The transthoracic echocardiography (TTE) revealed asymmetric myocardial hypertrophy with an interventricular septal wall thickness of 15.2 mm at diastole, and elongated anterior leaflet (Panel B) with systolic anterior motion (SAM; Panels A and C, right). Left ventricular outflow tract (LVOT) obstruction with a peak flow velocity (Vp) of 5.18 m/s and a peak pressure gradient (PPG) of 107 mmHg (Panel D) and severe eccentric mitral regurgitation (MR) were observed (Panel E). The transoesophageal echocardiography (TEE) showed MR mostly originated from A2 and A3 (Panel F). The patient was finally diagnosed as hypertrophic cardiomyopathy (HCM). After the Heart Team discussion and share decision-making, the patient then received transcatheter mitral valve edge-to-edge repair (TEER) with MitraClip system and a single XTR clip. The intraoperative TEE displayed residual trace MR (Panel J and TTE Panel I), abolishment of SAM phenomenon (Panel G, right), and an LVOT Vp of 1.84 m/s and PPG of 13 mmHg (Panel H). After the procedure, the left ventricular global longitudinal strain and circumferential strain also increased (pre-operation Panel C, left; post-operation Panel G, left). The patient got rid of prior symptoms immediately after the procedure, and she was then safely discharged home within a week.

Abstract 15523: Breaking Bad - Severe Mechanical Hemolytic Anemia After Failed Mitral Valve Repair

Introduction: Hemolytic anemia is a rare complication of mitral valve repair surgery. Mechanisms include a high-velocity regurgitant jet striking the annuloplasty ring or displacement of the annuloplasty ring with para-annular leak. Case Report: A 66 year old man with a past history of coronary artery disease was found to have severe, eccentric mitral regurgitation (MR) due to anterior mitral valve leaflet prolapse/flail at the A2 segment. At another institution, he underwent surgical mitral valve repair involving chordal transfer from P2 to A2 segment, suture closure of the resulting P2 defect, and ring annuloplasty. Intra-operative transesophageal echocardiography confirmed the elimination of MR. Three weeks later the patient presented with fatigue and cola-colored urine. Physical examination revealed a murmur of MR. Lab tests were consistent with severe hemolytic anemia, including hemoglobin of 6 g/dL, indirect hyperbilirubinemia, elevated lactate dehydrogenase, and a low haptoglobin level. Peripheral blood smear showed dysmorphic red blood cells suggestive of mechanical lysis. The patient required multiple transfusions of packed red blood cells. Acute kidney injury developed and was attributed to pigment nephropathy. He was transferred to our institution. Decision-making: Recurrent MR from failure of recent mitral valve repair was suspected. Transthoracic and transesophageal echocardiography confirmed severe eccentric MR. The Heart Team recommended re-operation. In the operating room, the suture repair of the P2 defect was found to have dehisced. Re-repair was deemed infeasible, and the mitral valve was replaced with a porcine bioprosthesis. Post-operatively, hemolysis resolved and renal function recovered. Conclusion: This case illustrates the importance of suspecting hemolysis from recurrent MR in patients presenting with unexplained anemia after mitral valve surgery. Re-operation is generally required to treat this rare condition.

Abstract 14522: Infective Mitral Valve Endocarditis in an Immunocompetent Patient Caused by Lactobacillus Species Transmitted by Intranasal Cocaine Use

A 59-year-old male with controlled DM2, HTN, tobacco abuse, and remote MSSA bacteremia secondary to longstanding intranasal cocaine use (never IV drug user) presented to the ER with acute onset of left leg pain. He was in extreme distress and examination showed a cold left leg with absent extremity pulses. Cardiac assessment was notable for an apical systolic murmur. Magnetic resonance angiography (MRA) of the leg revealed a thrombotic occlusion of the left common femoral artery extending into the popliteal artery prompting emergent successful femoral artery thrombectomy and compartment fasciotomy. An intraoperative TEE revealed mobile echodensities on the anterior and posterior MV leaflets with severe eccentric mitral regurgitation (MR) [Figure1]. Blood and thrombectomy debris cultures yielded Lactobacillus acidophilus vs. gasseri species. Further workup showed multiple small embolic infarcts on MRA head and chronic sinusitis on CT sinuses, while CT chest, abdomen and pelvis were unremarkable. He received IV ampicillin for 1 week with bacterial clearance, followed by bioprosthetic mitral valve replacement. Gram stain of the mitral valve revealed gram positive rods, cultures grew Lactobacillus species, and histopathology confirmed the presence of infective endocarditis. The patient completed 7 weeks of penicillin G intravenously with clinical recovery. Lactobacillus acidophilus and gasseri are normal flora of the human oral cavity, gastrointestinal and genitourinary tracts. Lactobacillus endocarditis is rare and has been identified in only 0.05-0.4% of endocarditis cases. Infections primarily affect the immunocompromised, but to the best of our knowledge this is the first case of Lactobacillus mitral valve endocarditis presenting with concomitant acute limb ischemia with infected thromboembolic debris in an immunocompetent individual with the suspected inciting event being intranasal cocaine use causing trauma to the nasal vasculature.

Abstract 11703: A Rare Case of Redo MitraClip Failure Requiring Salvage Mitral Valve Replacement

Presentation: A 74-year-old lady with history of hypertension, COPD, severe pulmonary hypertension, HFpEF, redo MitraClip placement for severe mitral regurgitation (MR) secondary to mitral valve (MV) prolapse presented with four months of progressive dyspnea and bilateral lower extremity swelling. Vitals were significant for hypotension and tachycardia. Examination revealed a holosystolic murmur at the apex, crackles in bibasilar lung fields, and 3+ bilateral pitting pedal edema. Work-up: TTE revealed EF of 65%, enlarged right ventricle, flattened interventricular septum, multiple mitral clips attached to the MV leaflets, and an eccentric MR jet. TEE revealed severe left atrial dilation, severe MR with eccentric and posteriorly directed regurgitant jet and mal-coaptation of MV leaflets with three MitraClips attached (Figure 1-3). Management: For recurrent severe mitral regurgitation resulting in decompensated heart failure, options included another redo MitraClip procedure versus surgical MV replacement. After extensive discussion with the multidisciplinary team and the patient, a decision was made to proceed with surgical MV replacement accepting a high operative risk with STS risk score of &gt;8%. Intraoperative findings revealed one inverted MitraClip with posterior leaflet detachment and two other clips that had densely scarred into the posterior leaflet leaving an unrecognizable MV (Figure 4). A 29 mm Epic Plus bioprosthetic MV was placed successfully. After a prolonged postoperative course, her clinical status improved. Conclusion: In patients who have failed the MitraClip procedure, significant destruction and fibrosis of the leaflets leaves surgical MV replacement being the only reasonable option. Surgical risk must be determined in conjunction with a multidisciplinary team as MV repair is performed at advanced centers in high-risk patients with good results. This can reduce the number of redo MitraClip and salvage MV surgery.

Automatic quantitative measurement of left atrial pressure using mitral regurgitation spectrum: clinical study on comparison with floating catheter

IntroductionTo explore how to measure LAPEq accurately and quantitatively, that is, the left atrial pressure (LAP) measured and calculated by equation method using mitral regurgitation spectrum.MethodsThe mitral regurgitation spectrum, pulmonary arteriolar wedge pressure (PAWP) and invasive arterial systolic pressure of radial artery of 28 patients were collected simultaneously, including 3 patients with rheumatic heart disease, 15 patients with mitral valve prolapse and 10 patients with coronary artery bypass grafting, patients with moderate or above aortic stenosis were excluded. LAPBp (Doppler sphygmomanometer method), LAPEq (Equation method) and LAPC (Catheter method) were measured synchronously, and the measurement results of the three methods were compared and analyzed. A special intelligent Doppler spectrum analysis software was self-designed to accurately measure LAPEq. This study had been approved by the ethics committee of the Northern Theater General Hospital (K-2019-17), and applied for clinical trial (No. Chictr 190023812).ResultsIt was found that there was no significant statistical difference between the measurement results of LAPC and LAPEq (t = 0.954, P = 0.348), and significant correlation between the two methods [r = 0.908(0.844, 0.964), P < 0.001]. Although the measurement results of LAPC and LAPBP are consistent in the condition of non-severe eccentric mitral regurgitation, there are significant differences in the overall case and weak correlation between the two methods [r = 0.210, (−0.101, 0.510), P = 0.090]. In MVP patients with P1 or P3 prolapse, the peak pressure difference of MR was underestimated due to the serious eccentricity of MR, which affected the accuracy of LAPBP measurement.ConclusionsIt was shown that there is a good correlation between LAPEq and LAPC, which verifies that the non-invasive and direct quantitative measurement of left atrial pressure based on mitral regurgitation spectrum is feasible and has a good application prospect.

Pseudo Double-Walled Left Atrium: An Extreme Rare Case of Isolated Saccular Aneurysm of Noncoronary Sinus With Rupture into Left Atrium With Severe Eccentric Mitral Regurgitation Secondary to Impingement on Mitral Valve Apparatus in an Octogenarian

Pseudo Double-Walled Left Atrium: An Extreme Rare Case of Isolated Saccular Aneurysm of Noncoronary Sinus With Rupture into Left Atrium With Severe Eccentric Mitral Regurgitation Secondary to Impingement on Mitral Valve Apparatus in an Octogenarian

Peak Performance In Hypertrophic Cardiomyopathy

<h3>Background</h3> Progressive symptoms with exertion despite optimal medical therapy is common among patient with hypertrophic obstructive cardiomyopathy (HOCM). However, little is known about the exercise tolerance in this subset of patients. <h3>Case Description</h3> A 55 year old Caucasian male with long standing history of HOCM was referred for progressively worsening NYHA Class 3b symptoms. He denied any syncope or significant family history of sudden cardiac death. Baseline echocardiogram revealed normal LV systolic function with severe asymmetric septal hypertrophy to 21 mm, resting LVOT gradient of 27 mmHg, and severe pulmonary hypertension with right ventricular systolic pressure (RVSP) of 72 mmHg. He subsequently underwent stress echocardiography with resting LVOT gradient of 63 mmHg which markedly worsened with exertion to peak gradient of 218 mmHg. (Image 1A) He exercised for a total of 7 minutes and 37 seconds. The test was stopped due to dyspnea and 10 mmHg drop in blood pressure. Subsequent right and left heart catheterization which showed angiographically normal coronary arteries and normal cardiac outputs. The peak to peak gradient measured across the aortic valve was 79 mmHg. (Image 1B) After discussion with the heart team, the decision was made to pursue septal myectomy. Intraoperative transesophageal echocardiography prior to septal myectomy showed severe LVOT obstruction with mean gradient of 45 mmHg and peak gradient of 89 mmHg with associated moderate eccentric mitral regurgitation secondary to systolic anterior motion. Following myectomy, the LVOT gradient improved to a mean of 2 mmHg and peak of 5 mmHg. Patient was successfully discharged home within 4 days following surgery. <h3>Conclusion</h3> In patients with long standing HOCM, elevated gradients up to 218 mmHg may be well tolerated without syncope or ventricular arrythmias. Septal myectomy can provide dramatic improvement of LVOT gradient and long-lasting symptomatic relief.

Rescue transventricular off-pump mitral valve repair with artificial neochords for acute mitral regurgitation due to postinfarction papillary muscle rupture.

BackgroundWe report 3 cases of rescue transventricular off-pump mitral valve (MV) repair in high-risk patients with acute mitral regurgitation (MR) due to post–myocardial infarction (MI) papillary muscle rupture (PMR).MethodsThe 3 patients presented with acute inferior ST elevation myocardial infarction, cardiogenic shock, and pulmonary edema. Their preoperative peak troponin I levels were 1909 ng/L, 16,963 ng/L, and 8299 ng/L. All 3 patients underwent successful percutaneous intervention to the culprit coronary artery, and antiplatelet therapy was initiated. All patients required inotropic support and had an intra-aortic balloon pump inserted preoperatively. Transesophageal echocardiography (TEE) demonstrated severe eccentric MR due to the leaflet prolapse secondary to PMR. The patients’ estimated EuroSCORE II scores were 16.03%, 16.68%, and 7.81%, and their Society of Thoracic Surgeons scores were 14.77%, 18.24%, and 9.8%, respectively. All 3 patients underwent urgent transventricular off-pump MV repair using artificial chords, with 2 or 3 three neochords implanted. The duration of operation was <2 hours, and intraoperative and postoperative drainage was minimal in all cases. MV function was assessed by qualitative and semiquantitative TEE.ResultsIntraoperative MR reduction to a mild level was achieved in all 3 patients. All patients had moderate MR at discharge, likely due to left ventricular remodeling. Severe MR recurred in all patients, at 5, 4, and 2 months of follow-up, respectively. All 3 patients underwent an elective MV reoperation via conventional approach.ConclusionsOff-pump transventricular MV repair may offer a safe and feasible alternative to stabilize high-risk patients with acute MR due to post-MI PMR. Although early MR recurrence is concerning, urgent transventricular MV repair may serve as a bridge to conventional surgery in such unstable patients.

Eccentric mitral regurgitation through the LAmbre closure device

Eccentric mitral regurgitation through the LAmbre closure device

Prognostic value of mitral regurgitation in patients with asymmetric hypertrophic cardiomyopathy

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Since mitral regurgitation (MR) is a very common finding in patients with hypertrophic cardiomyopathy (HCM), the evaluation of the mitral valve anatomy and the degree of MR is of utmost importance in this population. However, data regarding the prognostic value of different degrees of MR in HCM remains scarce. Purpose The aim of this study was to determine whether the presence of a higher degree of MR affects: 1) long term prognosis; 2) clinical and echocardiographic presentation of HCM patients. Material and Methods We included prospectively 102 patients, diagnosed with primary asymmetric HCM. The degree of MR was determined echocardiographicaly according to current recommendations of the American Association of Echocardiography. According to the MR severity, patients were divided into 2 groups: Group 1 (n = 52) with no/trace or mild MR and Group 2 with moderate or moderate to severe MR. All patients had clinical and echocardiographic examination, 24-hour Holter ECG and NT pro BNP analysis performed. The primary outcome was a composite of: 1) HCM related death or sudden death; 2) hospitalization due to acute heart failure; 3) sustained ventricular tachycardia; 4) ischemic stroke. Results Patients with higher MR degree had more frequent chest pain (p = 0.039), syncope (p = 0.041) and NYHA II functional class (p &amp;lt; 0.001). Group 2 patients had mostly obstructive form of HCM (p &amp;lt; 0.001) with more frequent presence of previous atrial fibrillation (AF) (p = 0.032), as well as the new onset of AF (p = 0.014) compared to patients in Group 1. Patients with higher MR degree had significantly more SAM (p &amp;lt; 0.001) resulting in a more frequent eccentric MR jet (p &amp;lt; 0.001), along with calcified mitral annulus (p = 0.007), enlarged left atrial volume index (p &amp;lt; 0.001), and elevated right ventricular pressure (p = 0.001). As a result of higher MR grade, Group 2 had higher E/e" values (p &amp;lt; 0.001), elevated LV filling pressure (lateral E/e’ &amp;gt;10), as well as higher levels of NT pro BNP (p = 0.001). By Kaplan-Meier analysis we demonstrated that the event free survival rate during follow up of median 75 (IQR 48-103) months was significantly higher in Group 1 compared to the Group 2 (79% vs. 46%, p &amp;lt; 0.001), Figure 1. After adjustment for relevant confounders, moderate/moderate to severe MR remained as an independent predictor of adverse outcome (hazard ratio 2.58, 95% CI: 1.08-6.13, p &amp;lt; 0.001). Conclusion Presence of moderate, or moderate to severe MR was associated with poor long-term outcome of HCM patients. These results indicate the importance of an adequate MR assessment and detailed evaluation of the mitral valve anatomy in the prediction of complications and adequate treatment of patients with HCM. Abstract Figure.

Diagnostic value of mitral regurgitant jet volume in the assessment of mitral regurgitation severity by general imaging three-dimensional quantification

Accurate quantification of mitral regurgitation (MR) severity is critical for appropriate clinical decision making regarding surgical intervention. General imaging three-dimensional quantification (GI3DQ) method allows for direct measurement of mitral regurgitant jet volume (MRJvol) with the help of three-dimensional (3D) color flow Doppler imaging. The aim of this study was to evaluate diagnostic value of MRJvol by GI3DQ for MR grading severity, using the guideline recommended integrated approach as a reference. The study included ninety-seven patients with varying degree of MR, and all MR cases were divided into central MR group (n = 44) and eccentric MR group (n = 53). The MRJvol was measured by GI3DQ. The severity of MR was graded on the basis of recommended integrated approach as mild, moderate, or severe. As assessed by receiver operating characteristic analysis, MRJvol by GI3DQ at a cutoff value of 43.4ml yielded 76.9% of sensitivity and 86.9% of specificity to differentiate moderate from severe MR in all cases, a cutoff value of 47.5ml yielded 98.9% of sensitivity and 94.4% of specificity to differentiate moderate from severe MR in central MR, and a cutoff value of 40.7ml yielded 80.0% of sensitivity and 78.6% of specificity to differentiate moderate from severe MR in eccentric MR. MRJvol measured by GI3DQ could assess MR severity, especially in central MR group, which has higher sensitivity and specificity to differentiate moderate from severe MR.

Iliac Vein Rupture During Transcatheter Edge-to-Edge Mitral Valve Repair With MitraClip

The patient was an 84-year-old man who had moderate-to-severe eccentric mitral regurgitation due to a prolapsed P1 segment ([Figures 1A and 1B][1], [Videos 1][2] and [2][3]). MitraClip implantation (Abbott Vascular, Santa Clara, California) was performed via the right femoral vein. When the guiding

P1297 Rupture of a Broken Heart: A rare case of acute mitral regurgitation due to papillary muscle rupture complicating Takotsubo cardiomyopathy

Abstract Clinical Case An 89-year old lady presented with symptoms of chest pain and dyspnea, without a significant cardiovascular history, regular medical therapy nor any cardiac risk factors. The electrocardiogram (ECG) demonstrated hyper-acute T waves, and moderate troponin T elevation which peaked at 998 ng/ml. Transthoracic echocardiography (TTE) demonstrated apical ballooning, with hyperdynamic function of the basal left ventricle (LV). These findings were suggestive of a diagnosis of Takotsubo’s cardiomyopathy (TTC), further supported by the coronary angiogram, which confirmed the absence of obstructive coronary artery disease. Notably, her symptoms had not occurred in the setting of emotional or physical stress. The initial recovery was uncomplicated, with no recurrence of symptoms, arrhythmias or cardiac failure. Five days after her presentation, she suddenly experienced severe chest pain and dyspnea associated with profound hypotension. The ECG demonstrated widespread, deep T wave inversion which had evolved over the preceding days, without new ischaemic ST segment changes. Bedside TTE demonstrated severe eccentric mitral regurgitation (MR) with an anteriorly directed jet, not present on earlier TTE, and a hyperdynamic LV. Stability was re-established with intravenous vasopressors, and subsequently with an intra-aortic balloon pump. Transoesophageal echocardiography to evaluate the aetiology of the acute MR demonstrated rupture of the antero-medial papillary muscle with a resultant flail posterior mitral valve leaflet. She was managed with a palliative, non-surgical approach following consideration of her advanced age, frailty, and wishes, and passed away the following day. Discussion TTC is characterized by transient LV impairment, typically due to apical ballooning, with a modest troponin elevation and ECG changes that can mimic acute myocardial infarction. There is, however, an absence of obstructive coronary artery disease. It is most common in post-menopausal females. The overall prognosis is favourable, but can be complicated by cardiac failure, ventricular arrhythmias, and thrombo-embolic phenomena, which carry a significant in-hospital mortality. Rarely, acute MR due to systolic anterior motion of the mitral valve with LV outflow tract obstruction can complicate TTC. Acute MR due to papillary muscle rupture, as in this case, is unusual and has only been reported on a few occasions. The mechanism is not well understood as this pathology is usually found in the context of myocardial infarction, which is excluded on coronary angiography as part of the diagnostic evaluation TTC. Two potential mechanisms have been proposed. As is the case in dilated cardiomyopathy, dilatation of the LV in TTC may create abnormal tension on the tendinae chordae and papillary muscle, or microvascular ischaemia, which has been postulated as a cause for TTC, either of which may then lead to spontaneous papillary muscle rupture. Abstract P1297 Figure.

P1256 Salvage mitraclip implantation for postmyocardial infarction mitral regurgitation: 2 case reports

Abstract Introduction Acute mitral regurgitation (MR) secondary to AMI is associated with a poor clinical outcome. The role of MitraClip implantation (MCI) in this population is still not well established. We report two successful cases of salvage MCI in acute ischaemic MR. Case Report 1: A 66-year-old diabetic woman was admitted to our institution due to extensive anterior STEMI with cardiogenic shock. Urgent cardiac catheterization (CC) revealed 100% occlusion of the left anterior descending and critical stenosis of the obtuse marginal artery, with successful PCI of both vessels and implantation of an intra-aortic balloon pump. Early transthoracic echocardiogram (TTE) revealed a dilated left ventricle with severe systolic dysfunction (LVEF – 35%), apical and anterior wall akinesia and functional grade IV MR (EROA - 40mm2 and regurgitant volume - 45mL), that was later confirmed by transesophageal echocardiography (TEE). 48h after AMI, the patient developed an arrhythmic storm requiring multiple shocks and a prolonged period of mechanical ventilation. Due to an extremely slow clinical improvement, with the need for prolonged inotropic support and refractory pulmonary congestion (NYHA IV), she was submitted to MCI, resulting in post-procedural grade I MR (EROA 7mm2 and regurgitant volume 11mL) and a marked clinical and hemodynamic improvement. An ICD for secondary prevention was implanted. At the 3 month follow-up the patient presented in NYHA II functional class without congestive symptoms. Case Report 2: An 82-year old female patient was admitted with an inferior STEMI, with CC documenting severe 3 vessel disease with a calcified occlusion of the right coronary artery, not amenable to PCI, so the patient was submitted to emergent CABG. There was a prolonged period of post-operatory mechanical ventilation with an extremely difficult weaning process, including the need for re-intubation due to acute pulmonary edema. TTE revealed LVEF of 39% with a large inferobasal aneurysm and severe eccentric MR due to tendinous cord rupture. The patient was submitted to MCI with immediate significant improvement of the MR, allowing successful extubation 36 hours after the procedure. In the end of first month of follow-up, the TTE revealed a well-positioned clip with mild-to-moderate MR (EROA – 21.5mm2 and regurgitant volume – 38mL) with the patient being completely asymptomatic. Conclusion Treatment of acute MR following AMI with MCI may be a safe and effective approach in critically ill patients. In our experience, it can lead to a rapid clinical recovery and resolution of cardiogenic shock.