Intervention In Valvular Heart Disease Research Articles

Cardiac Surgery and Transcatheter Intervention for Valvular Heart Disease in Carcinoid Syndrome: Risk Factors, Outcomes, and Evolving Therapeutic Strategies

Cardiac Surgery and Transcatheter Intervention for Valvular Heart Disease in Carcinoid Syndrome: Risk Factors, Outcomes, and Evolving Therapeutic Strategies

Potential Diagnostic and Prognostic Values of Left Atrial Strain in Valvular Heart Disease.

There has been increasing evidence supporting the importance of left atrial (LA) functional analysis and measurement in various physiologic and pathologic cardiovascular conditions due to its high diagnostic and prognostic values. Assessment of LA strain (LAS) has emerged as an early marker of subclinical LA dysfunction. Using speckle-tracking echocardiography, LAS can be measured in all phases of LA function (reservoir, conduit, and booster pump). In valvular heart disease (VHD), surgical and nonsurgical interventions should be performed before irreversible left ventricular (LV) and/or LA myocardial dysfunction. The current guidelines recommended using LV strain as a parameter for early detection and timely intervention. Currently, many published data have shown the diagnostic and prognostic values of LAS in VHD, which is encouraging to integrate LAS during echo assessment. In this review, we aim to collect the current data about the clinical utility of LAS changes in risk stratification, predicting outcome, and guiding the time of intervention in VHD. The review summarized these data according to the type of valve pathologies.

Protocolo de indicaciones en la intervención estructural de las cardiopatías congénitas del adulto

Intervention or reintervention in adulthood is frequently needed in the field of congenital heart disease (CHD). Current surgical and percutaneous techniques have a low mortality rate, although they require an adequate multimodality imaging study and must be performed by CHD experts. The indications for intervention in valvular heart disease are like those for acquired valvular heart disease. In the present protocol, we focus on the indications for intervention in shunts, left obstructive disease and right outflow tract disease.

Do we need cardiopulmonary exercise to determine the optimal time for intervention in valvular heart disease?

Abstract Introduction Cardiopulmonary exercise testing (CPET) is underused in many clinical conditions other than HF. In valvular heart disease (VHD), CEPT can aid in choosing the right timing for surgery. The goals of this study were to compare the assessment of functional capacity (FC) by CEPT and NYHA scale, and to analyze the relationship between ventilatory efficiency (VE) parameters and time to surgery. Methods 197 CPET were performed in 163 patients with moderate or severe VHD (51% female). Real METS (RM) were calculated as indexed peak VO2/3.5 (1 MET = 3.5 ml O2/kg/min) and compared to estimated METS (EM) derived by the exercise duration. An agreement analysis between RM, EM and NYHA was performed. The association among VE/VCO2 slope, pet CO2 at anaerobic threshold (AT), OUES and time to surgical indication was also studied using Cox logistic regression analysis. Results See Table. The RM and EM were 4,7±1,7and 6,2±2,9, respectively (p<0.01), and the correlation was low (ICC=0,7, p<0.001). The agreement between NYHA class and % of peak predicted V02 was very low (kappa index = 0.1, p<0.001). VE parameters were predictive of an earlier surgical indication: petCO2 AT (p=0.02), VE/VCO2 slope (p=0.069), OUES (p=0.014). Conclusions In asymptomatic VHD patients, the surgical indication should not rely solely in their FC assessed by either NYHA scale or EM derived by duration of exercise. In our series, these parameters clearly overestimated the FC of the population. Also, the ventilatory inefficiency may be a surrogate marker of advanced disease and lead to a closer surveillance for an earlier intervention. Real and estimated METS by type of VHD Funding Acknowledgement Type of funding source: None

113 First in Man Anatomical Fitting Study of the BiVACOR Total Artificial Heart

The epidemiology of pulmonary hypertension (PH) is not well-defined in the Top End of Australia. Patients were identified from the Northern Territory (NT) cardiac echo database from January 2010 to December 2015. PH was defined as tricuspid regurgitation velocity ≥2.75 m/s by doppler echocardiography (equivalent to right ventricular systolic pressure ≥40mmHg with presumed right atrial pressure of 10mmHg). The aetiology for PH was determined by reviewing the electronic health records using published guidelines. There were 1764 patients extracted from 46,731 echos in the database. The cohort contained of 49% males and 45% Aboriginal and Torres Straight Islanders. The prevalence of PH was 972 patients per 100,000 population, approximately three times more than a previously reported Australian cohort. Hypertension, atrial fibrillation, diabetes and respiratory disease were present in 85%, 45%, 41% and 39% of patients. Left heart disease was the leading cause for PH (58%), the majority suffering from valvular disease (predominantly rheumatic). Pulmonary arterial hypertension (PAH), respiratory disease related PH, chronic thromboembolic PH (CTEPH) and unclear multifactorial PH represented 4%, 16%, 2.4% and 3.6% of the cohort. Underlying causes were not identifiable in 16% of the patients. Only 31% of potentially eligible patients were on advanced PH therapy. PH is common in the Top End and modifiable risk factors were highly prevalent. Preventive approaches such as early intervention for valvular heart disease are desirable. Gap in diagnosis (16%) and PAH specific therapies (69%) also need to be evaluated and addressed to improve outcomes.

2019 AATS/ACC/ASE/SCAI/STS expert consensus systems of care document: A proposal to optimize care for patients with valvular heart disease: A Joint Report of the American Association for Thoracic Surgery, American College of Cardiology, American Society of Echocardiography, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons.

This statement was commissioned as a Multisociety Expert Consensus Systems of Care Document by the American Association for Thoracic Surgery (AATS), American College of Cardiology (ACC), American Society of Echocardiography (ASE), Society for Cardiovascular Angiography and Interventions (SCAI), and

Mitral Valve Replacement After 10 Years of Closed Mitral Commissurotomy: A Case Report

Rheumatic mitral valvular heart disease is common in developing countries although its incidence is decreasing in western countries. Closed mitral commissurotomy (CMC) was the first effective intervention in valvular heart disease which provides excellent long-term hemodynamic and clinical improvement. In this study we are presenting a successful mitral valve replacement in reoperation of a case who had CMC operation 10 years ago. It shows when symptomatic deterioration occurs late after CMC, MVR restores clinical and hemodynamic improvement in many patients.Medicine Today 2014 Vol.26(2): 111-113

Trimetazidine improves health-related quality of life in operated valvular heart disease

Purpose: Successful surgical intervention in valvular heart disease has been shown to prolong and improve quality of life. We aimed to evaluate postoperative health-related quality of life (HRQoL) in patients following trimetazidine therapy. Methods: 120 patients [aged 53.2±2.1 years, 60% males] 2–4 weeks after conventional aortic (n=64) and mitral (n=56) valve replacement by mechanical prostheses (40% due to degenerative, 35% rheumatic, 10% myxomatous, 8.3% congenital valve diseases and 6.7% infectious endocarditis) were randomized 1:1 to receive either conventional therapy or trimetazidine (35 mg twice daily) added to standard treatment. HRQoL was assessed at baseline and 12 months using the Short Form (SF-36 v.1) Health Survey. Results: There were no significant differences between trimetazidine and control group at baseline. Patients reported poor postoperative HRQoL. In both groups, SF-36 scores substantially rose after follow-up. Trimetazidine patients had significant higher improvements in HRQoL over time compared to controls. One patient died in the control group (p=0.89). View this table: Health-related quality of life Conclusions: Mechanical valves patients commonly suffer from severe HRQoL impairment. Long-term trimetazidine, added to conventional treatment, greatly improves HRQoL. The results provide support for trimetazidine as a promising therapy for patients with heart valve prostheses.

Imaging for Transcatheter Valve Procedures

Percutaneous intervention for valvular heart disease is becoming a reality and is one of the fastest growing fields in interventional cardiology. As exposure and visualization are critical for surgical repair or replacement, adequate imaging is crucial for transcatheter interventions where direct visualization is not possible. X-ray and ultrasound are the fundamental modalities for imaging in this situation, although magnetic resonance related imaging is under development. In this review, we describe the use of fluoroscopic, computed tomographic, and echo imaging for rapidly evolving percutaneous valve technologies with a focus on providing clinical pearls and perspective on each imaging tool.

A Mıtral Valve Reconstructıon Case After 16 Years Of Closed Mıtral Commıssurotomy

Mitral stenosis is the most frequently encountered valvular pathology and may require surgical intervention when the lesion is severe in rheumatic etiology.It is now clearly established that restoration of a normal mitral valve function with reconstructive surgery is preferable to replacement with a device,whether bioprosthetic or mechanical. Closed mitral comissurotomy(CMC) was the first effective intervention in valvular heart disease. In this study we're presenting a new valve reconstruction technique used successfully in reoperation of a case who had CMC operation 16 years ago and symptomless up to last 4 months and the first patient repaired successfully after CMC.Mitral valve repair in rheumatic disease is technically difficult.From a purely surgical point of view,a safe myocardial protection,excellent valve exposure,and a direct visual testing method for competence are also essential.However excellent long-term results support flexibility in mitral valve repair.

Redo Valvular Surgery in Elderly Patients

Elderly patients older than the age of 75 constitute 13% of the population that undergoes cardiac surgery at our institution and represent the fastest growing population in Ontario. We have witnessed an increasing proportion of elderly patients being referred for repeat surgical intervention for valvular heart disease. We determined the perioperative and long-term outcomes in elderly patients undergoing redo cardiac valve surgery. A retrospective review of our institutional database identified 112 patients aged 75 years or older (mean age, 78 +/- 3 years; range, 75 to 89 years) who underwent redo valve surgery between 1990 and 2004. All patients presented with a previous surgical intervention on the valve of interest. The mean follow-up was 5 +/- 4 years and was 100% complete. Eighty-eight patients (79%) had isolated valve surgery at their primary operation whereas 24 patients (21%) had concomitant coronary artery bypass grafting at the time of their initial valve surgery. At reoperation, 74 patients (66%) underwent single valve surgery (40 aortic valve, 34 mitral valve), 33 patients (29.5%) required double valve surgery, and 5 patients (4.5%) had triple valve surgery. Thirty-three patients (29.5%) required concomitant coronary artery bypass grafting, among whom 14 patients had a previous coronary artery bypass graft surgery. There were 12 operative (10.7%) and 47 late deaths (42%). Cardiovascular events were the cause of death in 32 patients (54% of all deaths). Overall survival at 5 years was 67% +/- 5%. The freedom from valve-related mortality and morbidity was 86% +/- 4% at 5 years. Mean intensive care eunit stay was 3.7 +/- 4.5 days, and postoperative hospital stay was 15 +/- 12 days. Redo valvular surgery in an elderly cohort can be performed with acceptable morbidity and mortality. Although 5-year survival is lower than that observed with a younger patient population, it is still likely higher than expected survival without surgical intervention. Despite increased resource utilization, elderly patients should be offered redo surgical intervention for valvular heart disease.

Mitral Valve Replacement After 14 Years Of Closed Mitral Commissurotomy

Mitral stenosis is the most frequently encountered valvular pathology and may require surgical intervention when the lesion is severe in rheumatic etiology. Closed mitral comissurotomy (CMC) was the first effective intervention in valvular heart disease. CMC provides excellent long-term hemodynamic and clinical improvement in appropriately selected patients. In this study we're presenting a successful mitral valve replacement in reoperation of a case who had CMC operation 14 years ago. We think also,when symptomatic deterioration occurs late after CMC, MVR restores clinical and hemodynamic improvement in many patients

Percutaneous implantation of the pulmonary and aortic valves: indications and limitations

Percutaneous transcatheter intervention for valvular heart disease is the new horizon in transcatheter therapeutics. Balloon dilatation has been used successfully for treatment of congenital and acquired stenotic lesions of semilunar and atrio-ventricular valves. Although attempts have been made to repair and replace cardiac valves without cardiopulmonary bypass and through percutaneous techniques, this has only recently become a reality. The semilunar valves have preceded atrioventricular valves in successful application in animals and humans. Morphological features play an important role in determining the design of the valve and technique and site of implantation. The major deviations in research and development in artificial or tissue valves have included attempts at delivery of these valves to the site of implantation without open heart surgery. Successful implantation needs long-term follow-up for the durability of the valve and freedom from re-intervention.

The Impact of Spontaneous Echocardiographic Contrast in Patients With Left Atrial Enlargement Undergoing Cardiac Valvular Surgery

The aim of this study was to evaluate the impact of either left atrial or aortic spontaneous echocardiographic contrast (SEC), as identified on intraoperative transesophageal echocardiography, on short-term morbidity and mortality in patients with left atrial enlargement undergoing cardiac valvular surgery. Retrospective and observational. Single-center, university teaching hospital. The authors identified 197 patients (105 males and 92 females; mean age, 68 +/- 14 years) with left atrial enlargement who underwent surgical intervention for valvular heart disease from January 1, 2004 to January 1, 2005. Of the total population, 40 patients (20.3%) showed left atrial SEC, and 10 patients (5.1%) showed aortic SEC. On multivariate analysis, increasing left atrial size and the absence of mitral regurgitation were independent predictors for the presence of left atrial SEC. On multivariate analysis, the presence of atrial fibrillation and a dilated descending aorta were predictive of aortic SEC. Although the identification of left atrial SEC was an echocardiographic marker of an increased risk for thromboembolic events postoperatively, this finding did not hold true for the presence of aortic SEC. Intraoperative identification of left atrial dilatation or aortic dilatation is predictive of SEC in the left atrium or descending aorta, respectively. The identification of left atrial SEC is an echocardiographic marker of an increased risk for thromboembolic events in this high-risk population.

New developments in catheter interventional treatment of heart valve disease: percutaneous valve replacement and percutaneous valve repair

BACKGROUND: Until recently, percutaneous intervention in valvular heart disease was restricted to balloon valvotomy for stenotic lesions. Although this technique has proven to be effective in mitral stenosis, pulmonic and tricuspid stenosis, balloon valvotomy of the aortic valve has been abandoned in calcific aortic stenosis, the most common valve disease in adults, and is successfully performed only in children and adolescents. Recently, percutaneous valve replacement has been developed. METHODS: Review on percutaneous valve replacement and percutaneous valve repair. RESULTS: Most clinical experience has so far been gained in pulmonic position mainly for stenosed conduits. The technique has also been attempted in patients with calcific aortic stenosis who were no candidates for surgery. The largest reported group now comprises 41 patients. Although valve migration and perivalvular regurgitation remain problems, current acute and short-term results are promising. Percutaneous valve repair for mitral regurgitation has been proposed by two techniques: (1) egde-to-edge repair with clips simulating the surgical technique proposed by Alfieri and (2) annuloplasty by placing ring devices in the coronary sinus. While for the latter, human experience is still awaited, edge-to-edge repair has been shown to be feasible and first promising results of a multicenter trial have been presented. CONCLUSIONS: In conclusion, percutaneous valve replacement and valve repair have been shown to be feasible. However, extensive further studies and longer follow-up will be necessary to define the eventual role of these techniques in the management of valvular heart disease.

On the Future of Adult Cardiac Surgery

Considerable uncertainty exists about the role that will be played by cardiac surgery for acquired heart disease in the coming decade. In many institutions the volume of surgery for ischemic heart disease has already been affected by advances in interventional cardiology; the impact of those advances can only increase with the inexorable advance of technology. Percutaneous catheter intervention for valvular heart disease is also being pursued aggressively. Yet, like so many medical and surgical specialties, cardiac surgery has been forced to accept reduced reimbursements, and was also the first (and in many states is still the only) specialty to be required to submit to public audits and arbitrary standards for surgery volumes and outcomes. Hospital support for cardiac surgery programs has become less generous, and inevitably, the specialty has lost much of its desirability as a career choice. There is considerable concern about the specialty's ability to continue attracting the best surgical talent to its residencies, and in each of the last 2 years, 20 of 140 training positions did not fill in the initial match. (The implications of this phenomenon are made more confusing by uncertainty about the number of trainees that will be needed in the next decade.).

Can heart failure be prevented, delayed, or reversed?

A review of the clinical course of chronic heart failure demonstrates that current outcomes remain highly unsatisfactory both in mortality and perhaps more important in morbidity. The extraordinary satisfactory functional responses seen in patients who undergo cardiac transplantation clearly identify the primary cause as the status of the heart itself, whatever the pathophysiologic adjustments of the neuroendocrine system, and interventions of the wide variety of drugs. Since donor hearts are unlikely to be available even from younger sufferers of these clinical syndromes, prevention must be the hallmark. Protection of the viability of myocytes, such as in acute myocarditis and acute infarction, is essential. Myocardial collagen undergoes continual synthesis, and production is greatly stimulated in the presence of hypertrophy caused by increased wall stress. It is possible that excess collagen is intimately involved with diastolic ventricular dysfunction, but that this may be a reversible process if the collagen-producing stimulus is removed. Thus reduction in wall stress and reversibility of ventricular hypertrophy appear to be promising directions. However, to limit the catastrophic effects of chronic heart failure, early recognition of the precursors of these syndromes, prevention of progression, and surgical intervention in valvular heart disease at an optimal point in time are essential.