Functional Mitral Stenosis Research Articles

Atrial Myxoma – A Rare Cause of Heart Failure

Abstract Atrial myxomas are rare cardiac tumors that usually present with diverse, unrelated symptoms. Conversely, heart failure (HF) is a common cardiac disorder that is mostly caused by uncontrolled systemic hypertension. It is a progressive cardiac disease that is managed with guideline directed medical therapy (GDMT). We present the case of a farmer who presented with typical symptoms of HF. Echocardiography however revealed an unusual cause of his symptoms—a huge mass in his left atrium (LA) prolapsing through the mitral valve, causing functional mitral stenosis. The mass is suspected to be an atrial myxoma. Surgical excision of this mass is proposed as the cure, which will obviate the need for continuous use of GDMT. This case report and literature review bring to fore the mechanisms by which atrial myxoma can cause HF and the other varied clinical presentations of atrial myxomas.

The Predictors and Outcomes of Functional Mitral Stenosis following Surgical Mitral Valve Repair: A Retrospective Analysis.

To optimize mitral valve repair outcomes, it is crucial to comprehend the predictors of functional mitral valve stenosis (FMS), to enhance preoperative assessments, and to adapt intraoperative treatment strategies. This study aimed to identify FMS risk factors, contributing valuable insights for refining surgical techniques. Among 228 selected patients, 215 underwent postoperative echocardiography follow-ups, and 36 met the FMS criteria based on a mean trans-mitral pressure gradient of >5 mmHg. Patients with FMS exhibited higher pulmonary systolic arterial pressure and increased late mortality during the follow-up. Univariable logistic regression analysis identified several risk factors for FMS, including end-stage renal disease, anterior leaflet lesion, concomitant aortic valve replacement, smaller ring size, ring type, and neochordae implantation. Conversely, resection alone and resection combined with neochordae implantation had protective effects against FMS. Multivariable logistic regression analysis revealed that smaller ring sizes and patch repair independently predicted FMS. When focusing on degenerative mitral regurgitation, the neochordae implantation without resection in leaflet repair, emerged as an independent predictor of FMS. Surgeons should weigh the substantial impact of surgical procedures on postoperative trans-mitral pressure gradients, emphasizing preoperative evaluation and techniques such as precise ring size assessment and effective leaflet management.

Abstract 16946: The Optimal Surgical Procedure of Mitral Valve Repair According to Risk Analysis of Postoperative Functional Mitral Stenosis

Background: Functional mitral stenosis (FMS) after mitral valve repair (MVr) is associated with pulmonary hypertension in the late period, increasing the risk of re-operation and deterioration of long-term outcomes. However, the risk factors for FMS after MVr, especially the impact of surgical procedures, have not been thoroughly investigated. Hypothesis: We hypothesize that procedures of valve repair, including prosthetic ring orifice area (ROA), may be associated with FMS in the late period. Methods: We retrospectively evaluated 205 patients who underwent MVr using full annuloplasty rings between 2011 and 2021 at our institution. FMS was defined as mean trans-mitral pressure gradient (TMPG) ≥8 mmHg measured by annual echocardiography. ROA was determined by calculating the internal area of each valve type and size. Perioperative factors such as repair techniques, ROA, and ROA divided by BSA (ROAi) were used to analyze risk factors for FMS. The mean follow-up period was 4.8±0.4 years. Results: MVr was performed using artificial chordae in 110 cases and intervention in valve leaflet in 83 cases (resection suture: 43, cleft closure: 26, plication: 12, and edge-to-edge repair: 8). We also utilized semi-rigid full ring in all cases (26 or less: 15, 28: 53, 30: 73, 32: 49, 34 or more: 15). We identified postoperative FMS in 23 cases (11.2%, 2.5±0.9 years after MVr) with TMPG of 9.0 ± 0.7 mmHg. In the FMS group, decreasing TR-PG in the late period was not achieved after MVr. TR-PG in the late period was also significantly higher in the FMS group (28.3 ± 5.8 vs. 20.3 ± 2.1 mmHg, p=0.01). The freedom from re-operation for MV and re-hospitalization for heart failure rate was not significantly different in the two groups (93.6% vs. 95.5%, p=0.32, 87.7% vs. 90.6%, p=0.36, respectively). However, the freedom from MACE rate was lower in the FMS group (81.4% vs. 86.3%, p=0.11). Univariate analysis demonstrated that intervention in valve leaflet (OR 2.53, p=0.04) and ROAi (OR 0.98, p=0.005) were significant risk factors for FMS. Conclusion: Although further follow-up is mandatory, these results suggested that the use of sufficiently large prosthetic ring and avoidance of intervention in valve leaflet are efficient for preventing FMS and improving clinical outcomes after MVr.

Massive Left Atrial Myxoma Causing Functional Mitral Stenosis and Severe Pulmonary Hypertension

Massive Left Atrial Myxoma Causing Functional Mitral Stenosis and Severe Pulmonary Hypertension

What Is the Optimal Mitral Valve Repair for Isolated Posterior Leaflet Prolapse to Achieve Long-Term Durability?

Background This study assessed risk factors for mitral regurgitation (MR) recurrence or functional mitral stenosis during long-term follow-up in patients undergoing mitral valve repair for isolated posterior mitral leaflet prolapse. Methods and Results We assessed a consecutive series of 511 patients who underwent primary mitral valve repair for isolated posterior leaflet prolapse between 2001 and 2021. Annuloplasty using a partial band was selected in 86.3%. The leaflet resection technique was used in 83.0%, whereas the chordal replacement without resection was used in 14.5%. Risk factors were analyzed for MR recurrence ≥grade 2 or functional mitral stenosis with mean transmitral pressure gradient ≥5 mm Hg using a multivariable Fine-Gray regression model. The 1-, 5-, and 10-year cumulative incidence of MR ≥grade 2 was 7.8%, 22.7%, and 30.1%, respectively, whereas that of mean transmitral pressure gradient ≥5 mm Hg was 8.1%, 20.6%, and 29.3%, respectively. Risk factors for MR ≥grade 2 included chordal replacement without resection (hazard ratio [HR], 2.50, P<0.001) and larger prosthesis size (HR, 1.13, P=0.023), whereas factors for functional mitral stenosis were use of a full ring (partial band versus full ring, HR, 0.53, P=0.013), smaller prosthesis size (HR, 0.74, P<0.001), and larger body surface area (HR, 3.03, P=0.045). Both MR ≥grade 2 and mean transmitral pressure gradient ≥5 mm Hg at 1 year post surgery were significantly associated with the long-term incidence of reoperation. Conclusions Leaflet resection with a large partial band may be an optimal strategy for isolated posterior mitral valve prolapse.

Primary Left Atrial Intimal Sarcoma Disguised as Functional Mitral Stenosis: A Case Study

Primary Left Atrial Intimal Sarcoma Disguised as Functional Mitral Stenosis: A Case Study

Abstract 11708: Giant Myxoma Causing Severe Pulmonary Hypertension

Introduction: Myxomas are the most common primary cardiac tumor, with clinical manifestations depending on tumor size and location. We present a case of giant left atrial (LA) myxoma causing functional mitral stenosis and associated severe pulmonary hypertension. Case: A 75-year-old woman with newly diagnosed heart failure and atrial fibrillation presented to the emergency department with 2-months of chest pain and shortness of breath. She had left-sided chest pain during exertion and at rest, dyspnea, and 3-pillow orthopnea. She was normothermic, blood pressure of 93/57 mm Hg, HR 63 bpm, respiratory rate of 21, and 91% oxygen saturation on room air. Cardiovascular exam revealed no murmurs, elevated JVD and bilateral lower extremity edema. Chest CT revealed a large mass, measuring 9x4 cm, in the LA extending into the left ventricle. TTE demonstrated a large mobile mass in the LA measuring 9.4x3.9 cm. The mass extended through the mitral valve into the left ventricle, causing functional mitral stenosis with mean inflow gradient of 10 mmHg. Severe tricuspid regurgitation was demonstrated with a peak regurgitant velocity of 4.89 m/s, with estimated right ventricular systolic pressure of 101 mmHg. Pre-operative pulmonary artery systolic pressure was 100 mmHg. She underwent surgical excision. Histology confirmed diagnosis of myxoma, and the mass measured 7.2 x 5.0 x 4.7 cm. At follow up, she had no heart failure symptoms or additional episodes of atrial fibrillation. Repeat TTE demonstrated normal RVSP. Discussion: Symptoms of myxoma include cardiovascular, embolic and constitutional symptoms. While obstructive symptoms are common in large myxomas, only 10% have severe functional mitral stenosis. Despite this, sequela of pulmonary hypertension and tricuspid regurgitation is not well documented. Diagnosis is made by TTE, which also allows assessment of valvular and hemodynamic changes. Treatment requires surgical resection, with low rates of recurrence.

Leaflet Resection vs Preservation for Degenerative Mitral Regurgitation: Functional Outcomes and Mitral Stenosis at 12 Months in a Randomized Trial.

Mitral valve repair is the gold standard treatment for degenerative mitral regurgitation (MR). The Canadian Mitral Research Alliance (CAMRA) CardioLink-2 trial showed no significant association between repair strategy, that is, leaflet resection vs preservation, and risk of functional mitral stenosis. In this subanalysis, we compared outcomes and functional tests at 12 months. CAMRA CardioLink-2 was a multicentre randomized controlled trial that allocated patients with degenerative MR and posterior leaflet prolapse to leaflet resection (n= 54) or preservation (n= 50). Stress echocardiography and functional status assessments, including the 6-minute walk test, were compared 12 months after repair. Baseline demographics, stress echocardiographic findings, and mitral annuloplasty prosthesis size (33.0 ± 3.0 vs 33.6 ± 3.4 mm; P= 0.4) were similar between the two groups. There were no readmissions for heart failure or deaths during the follow-up period. At 12 months, a larger percentage of patients were in NYHA functional class ≥ 2 in the resection group compared with the preservation group (P= 0.01). Exercise capacity, rate-pressure product, 6-minute walk distance, and mean mitral valve gradients were not significantly different between the groups at 12 months. A more prominent increase in mean mitral gradient with smaller annuloplasty sizes was observed in the resection group at both rest (P= 0.03) and peak exercise (P= 0.005) in the linear regression model. At 12 months, there were no significant differences in mitral valve gradient, exercise capacity, and 6-minute walk test between repair strategies. Leaflet preservation may offer a larger mitral valve orifice with improved gradients in patients requiring smaller annuloplasty sizes.

Flow adjusted transmitral pressure gradient as a modified indicator of functional mitral stenosis after repair for degenerative mitral regurgitation.

Background and AimAfter repair of degenerative mitral regurgitation (DMR), the focus is on functional mitral stenosis (FMS) when there is a decline of mitral hemodynamics. Yet, the clinical impacts and a standardized definition are still undecided. Since common mitral hemodynamic parameters are influenced by transmitral flow, the aim of this study is to seek the impact of flow adjusted transmitral pressure gradient (TMPG) by left ventricular stroke volume (LVSV) on the midterm outcomes.MethodsThree hundred one patients who had undergone isolated mitral valve repair for degenerative lesions with annuloplasty prosthesis between October 2012 and June 2019 were included. Postoperative adverse events occurred in 20 patients (6.6%). Flow adjusted TMPG was defined as TMPG/LVSV.ResultsCommon mitral hemodynamic parameters were not associated with adverse events. By multivariable analysis, patients’ age, left ventricular ejection fraction (LVEF) and mean TMPG/LVSV were isolated as independent predictors (adjusted hazard ratio: 1.05, 0.95, and 1.16; p = .037, .005, and .035). Flow adjusted TMPG was significantly higher in the full ring group compared to the partial band group (0.051 mmHg/ml, [0.038–0.068] vs. 0.041 mmHg/ml, [0.031–0.056]; p < .001) and had a significantly negative correlation with the size of the annuloplasty prosthesis (r = −0.37, p < .001).ConclusionsConventional mitral hemodynamic parameters were not associated with adverse cardiac events after repair for DMR. Adjustment by flow has a potential to advance pressure gradient to a more sensitive indicator of FMS associated with clinical outcomes.

Sex Differences in Mitral Annular Calcification and the Clinical Implications.

Background: Heterogeneous mechanisms may contribute to the occurrence of mitral annular calcification (MAC), however, little is known about the sex differences in MAC and the clinical implications of these differences. This study aimed to investigate clinical and imaging differences of MAC according to sex.Methods: In total, 537 patients (221 men) with MAC were identified by transthoracic echocardiography at a single center from January 2012 to June 2016. Moderate-to-severe MAC was defined as calcification extent ≥120° of the mitral annulus. Significant functional mitral stenosis (MS) was defined as a transmitral mean diastolic pressure gradient ≥5 mmHg.Results: Women more frequently had moderate-to-severe MAC and concomitant mitral regurgitation than men; however, significant functional MS was comparable between sexes. In the logistic regression analysis, old age, uncontrolled hypertension, end-stage renal disease (ESRD), and obstructive hypertrophic cardiomyopathy were significantly associated with moderate-to-severe MAC in women, whereas ESRD and moderate-to-severe aortic stenosis were in men. In the Cox regression analysis, significant functional MS was associated with all-cause death in both sexes, although an independent association was found in only women.Conclusion: Women had more extended MAC than men. Significant functional MS was independently associated with unfavorable clinical outcomes in patients with MAC, which was more pronounced in women than in men.

Clinical Impact of Flow Adjusted Transmitral Pressure Gradient After Surgical Annuloplasty for Functional Mitral Regurgitation

Downsizing of mitral annulus due to mitral annuloplasty for ischemic functional mitral regurgitation (FMR) raises a new issue, functional mitral stenosis (FMS), defined as a decline of mitral hemodynamics. However, common mitral hemodynamic parameters are influenced by transmitral flow, therefore, the clinical impacts are still controversial. The aim of this study is to seek mitral hemodynamic indices (including transmitlra pressure gradient [TMPG] adjusted by left ventricular stroke volume [LVSV]) relevant to the mid-term outcomes after annuloplasty for ischemic functional mitral regurgitation (FMR). This study is a retrospective evaluation of mitral valve hemodynamic status by resting echocardiogram at several weeks after surgery. Eighty-one patients underwent mitral annuloplasty for ischemic FMR between September 2012 and June 2019. Postoperative adverse events occurred in 28 patients (34.6%), and the overall 5-year freedom from adverse events rate was 55.9%. Common mitral hemodynamic parameters were not associated with adverse events, but flow adjusted TMPG can be a correlative factor. By multivariable analysis, postoperative systolic pulmonary artery pressure and peak TMPG/LVSV were detected as independent predictors (adjusted hazard ratio 1.07 and 1.08, P < 0.001 and < 0.001). Additionally, risk stratification by peak TMPG (cut-off: 10 mm Hg) and LVSV (cut-off: 35 mL/m2) reflected the mid-term outcomes, perceptively (P = 0.007). Conventional mitral hemodynamic parameters were not associated with adverse cardiac events after annuloplasty for ischemic FMR. However, flow adjusted TMPG was identfied as an independent predictor, and risk stratification by peak TMPG and LVSV reflected the mid-term outcomes, perceptively.

A SHORT RECURRENCE TIME OF LEFT ATRIAL MYXOMA: CASE REPORT AND LITERATURE REVIEW

Background: Recurrence of sporadic cardiac myxoma remains unusual but the seriousness of the situation justifies the realization of a surgical resection as complete as possible with post-operative clinical and echocargdiographic monitoring. Case presentation: We recall the case of myxoma of the left atriumin a 64-year-old women complicated by functional mitral stenosis and heart failure. She underwent urgent heart surgery, during which a friable tumor attached by a sessile base to the anterior atrial septum was removed. The postoperative effects were complicated by a pulmonary embolism. Eight months later, the patient consulted for exertional dyspnea with an echocardiographic image in favor of a recurrence of myxoma of the left atrium. Conclusion: Several mechanisms have been proposed to explain such recurrence, the most avoidable remain incomplete surgical resection and Implantation of embolic fragments of the original tumor in the myocardium due to a previous surgery.

Abstract 16830: Functional Stenosis After Undersizing Mitral Annuloplasty is Governed by Pre-Operative Mitral Valve Opening Geometry

Introduction: Surgical repair of functional mitral regurgitation (FMR) with undersizing mitral annuloplasty (UMA) is a common practice. Though excessive annular downsizing can improve coaptation, it raises the risk of functional mitral stenosis (FMS). Predicting if certain patients can develop FMS after UMA, can help with surgical planning and inform the safe levels of downsizing. In this study, we sought to investigate that the pre-operative diastolic geometry of the mitral valve can predict the risk of developing FMS with UMA. Methods: Pig mitral valves (n=8) were excised and mounted into a left heart simulator with steady diastolic flow only [ Fig1A ]. Three leaflet tethering patterns were mimicked in this model: annular dilation (AD), AD + asymmetric tethering (Asym) and AD + symmetric tethering (Sym) [ Fig1B ]. Under each condition, the annulus was downsized to different levels by an adjustable UMA [ Fig1C ]. Millar pressure catheter and Echocardiography were used to measure MV pressure gradient and diastolic configuration under various conditions. Results: Under each tethering geometry (AD, AD + Asym and AD + Sym respectively), pressure gradient gradually increases as the downsizing level increases. Also, at each specific level of downsizing, pressure gradient increases as the subannular tethering increases. Similarly, at each specific level of downsizing, EOA decreases as the subannular tethering increases. Under each tethering geometry, EOA also decreases as the downsizing level increases [ Fig1D ]. In addition, it is demonstrated that at different flow rates, both pressure gradient and EOA correlates with anterior diastolic angle, which is impacted mainly by preoperative subannular tethering [ Fig1E ]. Conclusions: In FMR, the hemodynamic outcome of MV after UMA depends on both the extent of annular downsizing and preoperative leaflet tethering geometry, both of which should be taken into account when deciding the optimal surgical intervention.

Mitral Valve Repair: The Goal Is a Durable, Physiologically Normal Valve

In this issue of The Annals of Thoracic Surgery, Kim and colleagues1 report a 25-year experience with 792 patients with degenerative disease who underwent mitral valve repair, finding that 24% had late functional mitral stenosis (FMS). In a propensity-matched comparison, they found that use of a small annuloplasty ring (<30 mm) was associated with an increased risk of FMS. They demonstrated that patients with FMS developed more late atrial fibrillation, developed more late tricuspid valve insufficiency, required more reoperations, and had worse long-term survival.

A randomized surgical trial of mitral valve repair with leaflet resection versus leaflet preservation on functional mitral stenosis – primary results of the CAMRA CardioLink-2 trial

Abstract Background The gold standard treatment for mitral valve regurgitation due to prolapse involves surgery with annuloplasty and either leaflet resection or leaflet preservation, with placement of artificial neochordae. It has been suggested that leaflet resection may be prone to functional mitral stenosis, whereby a patient may have a higher mitral gradient at peak exercise compared to a leaflet preservation strategy. Although both techniques are widely used, there has been no prospective randomized study conducted to compare these two techniques, particularly in regard to functional mitral stenosis. Methods A total of 104 patients with posterior leaflet prolapse were randomized to undergo mitral repair with either leaflet resection (N=54) or leaflet preservation (N=50) at 7 specialized Canadian cardiac centers. Patient age, proportion of female patients, and mean Society of Thoracic Surgeons risk score was 63.9±10.4 years, 19%, and 1.4% for those who underwent leaflet resection, and 66.3±10.8 years, 16%, and 1.9% for those who underwent leaflet preservation, respectively. The primary endpoint was the mean trans-mitral repair gradient at peak exercise 12-months after repair. Results Baseline characteristics were similar between the groups. At 12-months, the mean trans-mitral repair gradient at peak exercise in patients who underwent leaflet resection and preservation was 9.1±5.2 and 8.3±3.3 mmHg (P=0.4), respectively. The two groups had similar mean mitral valve gradient at rest (3.2±1.9 mmHg following resection and 3.1±1.1 mmHg following leaflet preservation, P=0.7). There was no between-group difference for the 6-minute walk distance (451±147 m and 481±95 m for the resection and preservation groups, respectively, P=0.3). Conclusion We report the first prospective surgical randomized trial to evaluate commonly used mitral valve repair strategies for posterior leaflet prolapse. Leaflet resection and leaflet preservation both yield acceptable results with no difference in postoperative valve gradient and functional status 12-months after surgical mitral valve repair. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): Heart and Stroke Foundation of Canada

Long-term Clinical Impacts of Functional Mitral Stenosis After Mitral Valve Repair

The relationship between functional mitral stenosis (MS) after mitral valve (MV) repair and long-term clinical outcomes is not fully understood. Therefore, we reviewed an institutional series to identify the determinants of functional MS and its effect on long-term clinical outcomes after MV repair for degenerative mitral regurgitation. Between January 1990 and December 2015, 792 patients who underwent MV repair for degenerative mitral regurgitation were retrospectively enrolled and divided into 2 groups: functional MS (n= 192) (≥5 mm Hg mean diastolic pressure gradient across the MV) and nonfunctional MS (n= 600) (<5 mm Hg mean diastolic pressure gradient). Mean follow-up was 11.6 ± 5.8 years. After propensity-score matching, patients' characteristics were comparable between groups (n=192/group). At 20 years, the functional MS group had significantly lower rates of freedom from new-onset atrial fibrillation (73.0% ± 5.6% versus 93.2% ± 2.3%; P= .003), overall survival (72.1% ± 4.6% versus 85.6%±4.3%; P= .010), and freedom from MV reoperation(82.8% ± 4.1% versus 92.5% ± 4.2%; P= .019) than the nonfunctional group. The functional MS group also had a significantly greater postoperative left atrialvolume index and tricuspid regurgitation grade. A small left ventricular end-diastolic dimension (hazard ratio= 0.975; 95% confidence interval, 0.955-0.996; P=.022) and annuloplasty ring (hazard ratio= 0.757; 95% confidence interval, 0.685-0.837; P < .001) were independentrisk factors for functional MS. A small left ventricle and annuloplasty ring increased the risk for functional MS after MV repair and was associated with progressive left atrial enlargement and tricuspid regurgitation exacerbation. As a result, functional MS increased the risk for new-onset atrial fibrillation, MV reoperation, and decreased long-term survival.

FUNCTIONAL MITRAL STENOSIS SEEN AFTER TRANS-JUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNT IN A PATIENT WITH PRIOR HISTORY OF MITRAL VALVE REPAIR WITH ANNULOPLASTY RING

We report a case of functional mitral stenosis after trans-jugular intrahepatic portosystemic shunt (TIPS) in a patient with prior history of mitral valve repair with annuloplasty ring. A 47-year-old male with history of CAD, severe mitral regurgitation status post repair with 26mm Physio

Morphological and functional characteristics of mitral annular calcification and their relationship to stroke.

BackgroundMitral annular calcification (MAC) is associated with risk of stroke. This study aimed to define the morphological and functional characteristics of MAC that are related to stroke.MethodsA total of 460 subjects with MAC from transthoracic echocardiography in a single center from 2012 to 2016 was retrospectively reviewed. Subjects were classified into two groups according to history of stroke [Group 1 (n = 366): without stroke; Group 2 (n = 94): with stroke]. Morphological and functional features of MAC on echocardiogram were scored from 0 to 3 according to MAC mobility, presence of echodense mass with central echolucencies in the periannular region suggesting caseous necrosis, and functional stenosis.ResultsSignificantly more patients in group 2 were men and had history of diabetes mellitus, dyslipidemia, atrial fibrillation, or infective endocarditis. Although MAC thickness and extent did not differ between the two groups, group 2 showed a considerably higher MAC score than group 1 (0.50 ± 0.77 vs. 0.23 ±0.52 p<0.001) as a result of the higher prevalence of each component in group 2 [mobility (22 vs. 11%, p = 0.003), echodense mass with central areas of echolucencies suggesting caseous necrosis (23 vs. 7%, p<0.001), and functional mitral stenosis (12 vs. 7%, p = 0.042)]. On logistic regression analysis, MAC score was independently associated with stroke and showed significant incremental value to demographic factors and comorbidities in association with stroke in a consecutive manner.ConclusionsIn conclusion, morphological and functional characteristics of MAC had incremental value in association with stroke over traditional risk factors. MAC score consisting of MAC mobility, typical echodense mass with central echolucencies suggesting caseous necrosis, and functional mitral stenosis was independently associated with stroke. MAC with high-risk features may act as a source of stroke or more potent composite surrogate markers for stroke-related risk factors.

Novel Trigone-Based Sizing Method for Mitral Ring Annuloplasty

We devised a novel trigone-based sizing method, setting the trigones at one-quarter of the annular circumference, and used it for mitral annuloplasty in patients with mitral regurgitation (MR). Between 1999 and 2017, 436 patients with degenerative (n= 192), nonischemic functional (n= 124), or ischemic (n= 120) MR underwent mitral valvuloplasty at our institution using an incomplete ring. The intertrigonal distance and prerepair and postrepair annular diameter were measured. Then the diameters predicted from body surface area, the intertrigonal distance, and the ratios of these diameters to observed data were computed. We investigated the influence of these measurements on MR recurrence, transmitral pressure gradient, and systolic anterior motion. Initial repair was successful in 433 patients (99%), but 3 patients with systolic anterior motion and MR required conversion to valve replacement. After 1, 5, and 10 years (mean follow-up, 6.3 years), the rate of freedom from grade 2 or higher recurrent MR was 96%, 92%, and 86% in the degenerative group, 99%, 97%, and 90% in the nonischemic functional group, and 95%, 90%, and 79%, respectively, in the ischemic group (P= .052). The observed/body surface area predicted diameter ratio was negatively correlated with the mean transmitral pressure gradient (mm Hg); 12.3 - 8.2× (ratio) (R=-0.37, P < .001), despite a smaller ratio (<0.9) not being associated with less recurrence of MR. In the degenerative group, systolic anterior motion developed in 7 of 71 patients (10%) with an observed/intertrigonal distance predicted diameter ratio of less than 0.9 (P < .001). Our trigone-based sizing method achieved satisfactory control of MR, while avoiding functional mitral stenosis and systolic anterior motion.

BREATHTAKING DIAGNOSIS: ATRIAL MYXOMA

SESSION TITLE: Monday Abstract Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: 10/21/2019 02:30 PM - 03:15 PM INTRODUCTION: Primary cardiac tumors are one of the least investigated subjects in oncological medicine. Among these primary cardiac tumors, atrial myxoma is one of the most common primary cardiac tumors mostly arising in the left atrium.We present a unique case of atrial myxoma that will highlight the broad importance of differential diagnosis in inpatient and outpatient setting. CASE PRESENTATION: A 57-year-old female presented for outpatient CT scan of the chest to rule out pulmonary embolism due to continued dyspnea at rest and orthopnea following upper respiratory tract infection. A CT scan of the chest was negative for pulmonary embolism; however, it revealed a 4.9 x 4.8 cm low-density mass in the left atrium (Panel A, arrow). A transesophageal echocardiogram showed a large heterogeneous left atrial mass attached to the interatrial septum with characteristic "plop” across the mitral valve causing functional mitral stenosis (Panel B, arrow). Cardiac catheterization revealed non-obstructive left anterior descending and right coronary arteries; however, left circumflex coronary artery was not visualized despite aortic root angiography indicating congenital absence (Panel C, arrows [LAD and RCA denote left anterior descending and right coronary arteries, respectively]). The patient underwent surgical resection of the mass (Panel D). Biopsy of the mass revealed tumor cells with elongated and fusiform stellate with bland nuclei and eosinophilic cytoplasm with dense lymphocytic aggregation consistent with myxoma (Panel E and F). The postoperative course was unremarkable. DISCUSSION: Myxomas are the most common benign primary cardiac tumors and occur predominantly in the left atrium and in women. Patients typically present with symptoms of heart failure secondary to mitral inflow obstruction; however, one-third of the patients, especially men present with the embolic phenomenon. Cardiac myxoma disproportionately affects the female population with 65% of myxomas occurring in them. Secondary of myxomas being familial in 4.5 to 10% of the cases it is recommended to screen first degree relatives [2]. Multiple theories have been proposed regards to the origin of these tumors. The initial thought process was to classify them as organized thrombotic structure but histological and molecular investigations reported the expression of different cardiac myocytes and transcription factors lead to propose that these lesions might have mesenchymal cardiomyocyte progenitor cells [3]. Cardiac myxomas even though classified as benign tumors have a tendency to seed in other locations causing inflammation, embolism, or intra-cardiac obstruction leading to mortality and significant morbidity. CONCLUSIONS: Prompt diagnosis is crucial since the results of surgical resection are excellent with dramatic symptoms improvement and rapid postoperative recovery. Reference #1: Lam, K. Y., Dickens, P., & Chan, A. C. (1993). Tumors of the heart. A 20-year experience with a review of 12,485 consecutive autopsies. Archives of pathology & laboratory medicine, 117(10), 1027-1031 Reference #2: Ekmektzoglou, K. A., Samelis, G. F., & Xanthos, T. (2008). Heart and tumors: location, metastasis, clinical manifestations, diagnostic approaches and therapeutic considerations. Journal of Cardiovascular Medicine, 9(8), 769-777. Reference #3: Amano J, Kono T, Wada Y, Zhang T, Koide N, Fujimori M, Ito K. Cardiac myxoma: its origin and tumor characteristics. Ann Thorac Cardiovasc Surg. 2003;9(4):215–221 DISCLOSURES: No relevant relationships by Pranjal Boruah, source=Web Response No relevant relationships by Gaurav Patel, source=Web Response No relevant relationships by Muhammad Siddique Pir, source=Web Response No relevant relationships by najam saqib, source=Web Response