Large Mitral Valve Research Articles

Anterior Leaflet Augmentation With CorMatrix Porcine Extracellular Matrix in Twenty-Five Patients: Unexpected Patch Failures and Histologic Analysis

This study reported on the treatment of Carpentier type IIIa and type IIIb mitral regurgitation (MR) with a large patch anterior mitral valve leaflet augmentation technique using CorMatrix (CorMatrix Cardiovascular Inc, Alpharetta, GA) extracellular matrix (ECM). A single-site chart review was conducted on patients who underwent anterior leaflet augmentation performed with the Da Vinci surgical robot (Intuitive Surgical, Sunnyvale, CA) or through a median sternotomy. Only patients who had anterior leaflet augmentation with porcine intestine ECM or autologous pericardium were included. Follow-up echocardiography was performed on all patients. Histologic specimens were available on ECM patches from a subset of patients who required reoperation. Between August 2011 and April 2014, 44 patients (mean age, 62.6 ± 12.2 years) underwent anterior leaflet augmentation with either porcine intestinal ECM or autologous pericardium at the Temple University Hospital in Philadelphia. Two (4%) late deaths occurred, one in each group. One patient who underwent ECMaugmentation died of non-cardiac-related causes 7months after discharge as a result of complications of chronic renal failure. The second late death occurred 5 months after discharge because of complications of a stroke in a patient in the pericardial augmentation group. Eight (32%) of the patients with ECM had recurrence of severe MR on echocardiography at an average time of 201 ± 98 days. Seven (28%) patients required reoperation because of failure of the ECM patch including perforation (4%), excessive patch dilation (20%), and suture line dehiscence (4%). In contrast, none of the patients with pericardial augmentation developed severe MR or required operation. Statistical analysis of the patients with ECM augmentation demonstrated no correlation of the following: age; sex; comorbid conditions such as diabetes, chronic obstructive pulmonary disease, and hypertension; left ventricular ejection fraction; surgical approach; annuloplasty size; or type of MR with patch failure. A lower body mass index was the only factor associated with recurrent severe regurgitation on univariate analysis (p= 0.039). Histologic study of the four available explants demonstrated intense inflammation without evidence of host integration. The remaining 15 (60%) patients had normal mitral leaflet structure and function on follow-up echocardiograms out to 12 months. For type III MR, a large anterior leaflet patch technique with porcine ECM was associated with a 32% recurrence rate of severe MR related directly to patch failure. Further research and development should be performed on the use of ECM materials with a goal to decrease the failure rate experienced in this study.

Functional Mitral Stenosis: A Result of Bacterial Endocarditis

A 72-year-old man presented with non-ST elevation myocardial infarction and received a drug eluting stent to mid RCA. Subsequent transthoracic echocardiogram demonstrated moderate mitral stenosis (MS) and a presumed rheumatic valve. He represented two weeks later with rigors and congestive cardiac failure. There was no peripheral stigmata of infective endocarditis (IE) but Streptococcus sanguinis (viridans) was grown in his blood cultures within 20 hours. Transoesophageal echocardiogram (TOE) revealed a large anterior mitral valve vegetation causing functional MS and he received a mechanical mitral valve replacement five days after diagnosis. IE classically results in cardiac valvular insufficiency. As it is rare for IE to cause functional or obstructive stenosis it is often not suspected clinically until later in its disease process and most of these cases occur in patients with pre-existing MS. This may occur if inflammation is confined to the surface of the valve causing endothelial damage whilst preserving tissue architecture. The resultant deposition of fibrin and platelets propagates further vegetation and aggregation. With bacterial growth the vegetations enlarge eventually becoming obstructive, leading to valvular stenosis. Valvular stenosis secondary to IE is challenging to treat medically and invariably leads to emergent surgery therefore early diagnosis and treatment are crucial. TOE is the current accepted diagnostic investigation. Heart failure secondary to valvular disease is the most common cause of death and therefore appreciation for early surgery is crucial for a good outcome.

Marvelous but Morbid: Infective endocarditis due to Serratia marcescens.

A 46-year-old man with HIV infection and active intravenous drug use presented with approximately two weeks of fevers and body aches. On physical examination he was somnolent, had a new systolic murmur, bilateral conjunctival hemorrhages, diffuse petechiae, and left-sided arm weakness. Echocardiography revealed a large mitral valve vegetation and brain imaging demonstrated numerous embolic infarctions. Blood cultures grew Serratia marcescens. Despite aggressive treatment with meropenem the patient died due to intracranial hemorrhage complicated by herniation. Serratia marcescens is an uncommon cause of infective endocarditis. While this disease has historically been associated with intravenous drug use, more recent reports suggest that it is now largely a consequence of opportunistic infections of the chronically ill. Our case highlights several characteristic features of this infection, including isolation of a non-pigmented strain of the organism, an antibiotic susceptibility profile suggestive of AmpC β-lactamase production, and rapid clinical deterioration with multiple embolic complications resulting in death. In this review we discuss the history, epidemiology, and management of endovascular infections due to Serratia spp., emphasizing the continued importance of considering this organism in the differential diagnosis of endocarditis among intravenous drug users and as a potential indication for surgical therapy.

TCT-158 Fully Percutaneous Transthoracic Left Atrial Entry and Closure to Deliver Large Caliber Transcatheter Mitral Valve Implants

TCT-158 Fully Percutaneous Transthoracic Left Atrial Entry and Closure to Deliver Large Caliber Transcatheter Mitral Valve Implants

P110 – 2513: Kingella kingae cerebral abscesses secondary to endocarditis following chickenpox: A case report

Introduction Kingella kingae endocarditis is an extremely rare but severe infection in childhood which may occur following chickenpox. It is associated with neurological complications and high morbidity, especially if not recognised promptly. Case A previously healthy 11 month old boy presented very unwell with fever and lethargy 7 days after the development of chickenpox. He was covered with IV ceftriaxone for suspected secondary bacterial sepsis. As he improved with the antibiotics, he was noted to have asymmetrical crawling with extension of his right leg. A soft grade 1/6 murmur was present on examination. Brain MRI demonstrated multiple bilateral cerebral abscesses, which appeared embolic in nature. CSF analysis was normal but blood cultures isolated the growth of Kingella kingae. An urgent cardiac ECHO revealed a large embolic mitral valve vegetation requiring rapid surgical intervention. His immunodeficiency screen was unremarkable. He is now neurologically back to his normal self but has significant residual mitral valve regurgitation, and remains under cardiac surveillance. Discussion Kingella kingae is a gram negative bacillus which is part of the normal upper respiratory tract flora. Pathogenic cases are starting to be identified over recent times, especially in children. The risk of severe bacterial infections following chickenpox has been established in literature previously. Endocarditis is a rare complication of Kingella and there are less than 10 reported cases in literature of Kingella endocarditis affecting a native valve in children under the age of 2 years. The detection of Kingella in the bloodstream should therefore never be discounted without further investigations. Conclusion Our case highlights the importance of recognising Kingella kingae endocarditis in a child presenting with fever and neurological complications following recent chickenpox. A cardiac ECHO should be considered despite normal cardiac examination to look specifically for endocarditis secondary to this pathogen, and urgent management tailored accordingly.

Surgical management of mitral valve infective endocarditis with annular abscess and calcification in the setting of a leaking mycotic intrarenal abdominal aortic aneurysm: A case report

We present the case of a previously well seventy-four year old male caucasian grazier who presented with mild back pain and was subsequently found to have a large posterior mitral valve leaflet perivalvular abscess associated with mitral annulus calcification and a mycotic infrarenal abdominal aortic aneurysm (AAA) of Staphylococcal origin. He underwent a right axillofemoral bypass with oversewn aorta and a right to left femoral crossover graft, and a subsequent mitral valve repair with decalcification/debridement of the annulus and extensive posterior leaflet reconstruction with pericardium patch. Despite multiple sequelae and an extended intensive care and hospital stay, the patient was discharged home after six months.

Case 5/2015 Late Outcome of Corrected Aortopulmonary Window in A 23-Year-Old Female Patient Who Underwent Surgery in Childhood

Clinical data: At 10 months of age, the patient underwent correction of a large aortopulmonary window and mitral valve regurgitation secondary to volume overload, which caused severe heart failure. The post-operative clinical outcome was favorable. Prior to operation, her clinical picture was of concern because of severe malnutrition (weight of 5,500 g), congestive heart failure (tachypnea of 60 bpm), hepatomegaly (liver palpable at 4 cm of the right costal margin), severe cardiomegaly, and increased pulmonary vasculature. Cardiovascular examination showed left ventricular (LV) enlargement; thrill and systolic murmur in the mitral area; accentuated S2; marked LV overload on electrocardiogram (ECG); mitral regurgitation due to incomplete leaflet coaptation; and pulmonary systolic pressure of 60 mmHg. At surgery, the 2-cm-diameter window between the pulmonary trunk and ascending aorta (Ao) was closed, and plication of the posterior ring of the mitral valve was performed. There was an immediate clinical response with hemodynamic stabilization, resolution of the heart murmur and heart failure, and subsequent normal weight gain. Medication for congestive heart failure was discontinued at 4 years of age, when the cardiac silhouette had returned to normal. To date, the patient tolerates routine exercises well and does not report any symptoms. Physical examination: good general state of health, normal breathing, acyanotic, normal pulses. Weight: 53 kg; height: 165 cm; blood pressure on right arm (BPRA): 105/75 mmHg; heart rate (HR): 76 bpm. Aorta not palpable on the suprasternal notch. The apical impulse was not palpable in the precordium, and there were no systolic impulses. Normal heart sounds, no heart murmurs. Liver not palpable.

Dual side-graft cannulation of the axillary artery and femoral artery for cardiopulmonary bypass in acute type a dissection involving aortic arch

We present the case of a previously well seventyfour year-old male Caucasian grazier who presented with mild back pain and was subsequently found to have a large posterior mitral valve leaflet perivalvular abscess associated with mitral annulus calcification and a mycotic infrarenal abdominal aortic aneurysm (AAA) of Staphylococcal origin. He underwent a right axillofemoral bypass with oversewn aorta and a right to left femoral crossover graft, and a subsequent mitral valve repair with decalcification/debridement of the annulus and extensive posterior leaflet reconstruction with pericardium patch. Despite multiple sequelae and an extended intensive care and hospital stay, the patient was discharged home after six months. Background:Mitral annulus abscess associatedwithmitral annulus calcification is a rare but serious form of endocarditis which, though little-reported, imposes a significant increase in technical difficulty ofmitral valve repair, has important implications regarding patient selection and operative technique, and carries an increase in morbidity and mortality. Treatment: Visual inspection of the valve revealed a gross distortion of the posterior leaflet with a large vegetation and P1/P2 abscess cavity in the setting of circumferential mitral annulus calcification (Figure 3) with the posterior annulus most severely affected. The diseased valve leaflet was detached, the adjacent abscess debrided, and the mitral Abstracts e39

Abstract 19824: Percutaneous Mitral Balloon Comissurotomy versus Surgical Comissurotomy in the Treatment of Severe Symptomatic Mitral Stenosis

Introduction: Percutaneous mitral balloon comissurotomy (PMBC) and surgical comissurotomy can be used for treatment of stage D mitral stenosis. Randomized controlled trials (RCTs) comparing PMBC and surgery have shown inconsistent results. Hypothesis: PMBC is associated with better hemodynamic and clinical results for the treatment of stage D mitral stenosis. Methods: Databases were searched for RCTs that compared double-balloon PMBC to surgical comissurotomy. Inclusion criteria were no left atrial clot, a favorable valve morphology and absence of significant mitral regurgitation. Clinical and hemodynamic outcomes were evaluated within short-term (less than 6 months) and long-term (over 6 months) follow up. Random-effects model was used due to anticipated heterogeneity. Results: A total of 6 RCTs with 474 patients were included, of whom 222 (46.8%) underwent PBMC. In short-term follow up, PMBC was associated with a larger mitral valve area (MVA) compared to surgical comissurotomy (mean difference 0.41 cm2; 95% CI 0.16-0.67; p=0.002; figure 1A), but also a higher incidence of moderate to severe mitral regurgitation (MR; OR 2.63; 95% CI 1.04-6.70; p=0.04; figure 1B). Short-term symptomatic (NYHA II-IV) heart failure (p=0.40) and new MR (p=0.32), as well as long-term MVA (p=0.23), restenosis (p=0.39), symptomatic heart failure (p=0.11), new MR (p=0.64) and need for reintervention (p=0.21) were not significantly different between groups. Conclusions: Our meta-analysis of RCTs suggests that PMBC is associated with an increased MVA as well as a higher incidence of moderate to severe MR when compared to surgery in the treatment of stage D MS. Therefore, the decision to proceed with PMBC or surgery in patients suitable for both procedures must rely on patient preferences, physician experience and risk of procedure-specific complications, such as left-to-right shunt with PMBC and wound infection/dehiscence with surgical comissurotomy.

Abstract 20149: Effect of Mitral Valve Area Following Surgical Repair for Degenerative Mitral Regurgitation on Exercise Hemodynamics and Functional Consequences

Introduction: Mitral valve (MV) area is the key measure of mitral stenosis (MS) in rheumatic MV disease, but its role in the follow-up of patients who had MV repair for degenerative mitral regurgitation (MR) remains uncertain. Our objective is to evaluate the relationships of MV area with hemodynamic effects at rest and during exercise, and with functional measures in patients following MV repair for degenerative MR. Methods: We prospectively assessed 110 patients who had MV repair for degenerative MR and no more than mild residual MR. Patients with aortic valve disease and ventricular dysfunction were excluded. The patients underwent comprehensive echo assessment at rest and during supine bicycle exercise. Brain natriuretic peptide (BNP) levels and SF36 questionnaires were also performed. MV area was calculated using the continuity equation. The patients were divided into 2 groups for comparison (MV area < 1.5 cm 2 vs > 1.5 cm 2 ). Results: 22 patients (20%) had MV area < 1.5 cm 2 . The 2 groups were similar in age. Patients with MVR < 1.5 cm 2 had worse resting and exercise hemodynamics, more limited exercise capacity and higher BNP levels compared to those with larger MV area (Table). These patients also had lower scores in physical functioning, vitality (p=0.01) and social function (p=0.04), based on the SF36 questionnaires. Multivariate analysis showed that MV area is an independent predictor of exercise capacity (p=0.003). Conclusion: In patients following MV repair for degenerative MR, MV area is a useful measure of MS severity because it is associated with resting and exercise hemodynamics and functional consequences. MV area should be routinely measured in this clinical setting, and refinement in MV repair techniques is needed to optimize MV area in addition to eliminate MR.

Percutaneous mitral valve repair with the mitraclip® system

Objectives: The purpose of this study was to compare outcomes using standard clipping (SC) (one to two clips) or multiple clipping (MC) (more than two clips). Background: MitraClip® implantation using MC has been proposed to treat severe mitral regurgitation (MR) in high‐risk patients. Methods and Results: A tailored strategy was used implanting as many clips as required to eliminate MR. A total of 85 consecutive patients [78 ± 6 years, 48 men (56.5%) ] with MR (grade 3+ or 4+) were included. EuroSCORE was 24 ± 12 (2.5–56.3) and STS‐score 12 ± 7 (1.2–31.2). SC was used in 61 (71.8%) and MC in 24 (28.2%) patients. Patients in MC group had larger mitral valve (MV) annuli (P = 0.025), MV orifice areas (MVOA) (P = 0.01), and MR degree (P = 0.005). Successful clip placement was achieved in 82 patients (96.5%). At discharge, no patient had grade 4+ MR. MR 3+ presented in 4 patients (7.0%) in the SC group and in 1 (4.5%) in the MC group (P = 0.72). There were 3 (3.5%) in‐hospital deaths. Follow up (211 ± 173 days, range 4–652) echocardiography confirmed similar MVOA (P = 0.83) and MV gradients (P = 0.54) in the both groups. At linear regression there was no independent correlation between clips number and postoperative MVOA/gradient. One‐year survival was 71.1% without difference between groups (P = 0.74). Conclusion: Although the hemodynamic and anatomical basis of MR may differ, every procedure should aim at eliminating MR. In some patients this goal can be achieved using MC with minimized risk of MV stenosis if preoperative anatomy/mechanism of MV regurgitation are adequately assessed. © 2012 Wiley Periodicals, Inc.

Valvular heart disease in a patient taking 3,4‐methylenedioxymethamphetamine (MDMA, ‘Ecstasy’)

3, 4-methylenedioxymethamphetamine, (MDMA, ‘Ecstasy’), an amphetamine-derived drug, is a psychoactive stimulant used as a recreational drug. In vitro experiments have suggested that ecstasy can lead to fenfluramine-like proliferation of cardiac valves through activation of 5-hydroxytryptamine 2B (5-HT2B) receptors and can induce mitogenic responses in human valvular interstitial cells [1]. We report the first observation of valvular heart disease (VHD) with pathological confirmation after long term use of ecstasy. A 33-year-old male patient was admitted for shortness of breath and chest pain. The only risk factor reported was active smoking. He reported long lasting exposure to ecstasy (several pills week−1 since the age of 17 years). At examination a systolic and diastolic mitral murmur was diagnosed. Mean blood pressure was 106/70 mmHg. ECG showed sinus rhythm (91 beats min−1) with a right bundle branch block. Echocardiography revealed a slight left ventricular dilation (endiastolic diameter of 55 mm) with an ejection fraction of 55% and typical features of mitral valve disease. There was a left atrial enlargement (area of 42 cm2) thick mitral valve with decreased opening of the mitral valve leaflets. Mean pressure gradient across the mitral valve was of 14.7 mmHg with mitral valve areas of 1.56 cm2. These moderate to severe mitral stenosis features were associated with severe mitral regurgitation (regurgitant orifice area = 0.49 cm2) with a central blood jet. Other valves and heart chambers were normal. This patient had pulmonary hypertension (40 mm Hg) without right heart failure. Coronary angiogram showed normal coronary arteries with a decreased cardiac index and post capillary pulmonary hypertension. Surgery was decided. Macroscopic analysis made the surgeon hypothesize about a possible cardiac tumour. Mitral valve leaflets and the chordae tendinae were markedly thickened and fibrous. The chordae tendinae were retracted (Figure 1). After resection, the surgeon decided to perform mitral valve replacement with a mechanical Saint Jude prosthesis despite severe damage of the mitral annulus. At histology, the endocardium on both sides was fibrous up to 2 mm thick. It was stratified with layers of collagen bundles and spindle cells. Density of spindle cells was heterogeneous, but more frequently low. In this abundant extracellular matrix, rare foci contained abundant elastic fibres. No inflammation or myxoid matrix accumulations were observed, ruling out rheumatic and Barlow diseases (Figure 1B, C). Common disease (Osler endocarditis, carcinoid syndrome, rheumatic fever, autoimmune disease …) or intake of other drugs (ergot derivatives, appetite-suppressant drugs including benfluorex) known to affect cardiac valves were not found. One month later, the patient came back with chest pain, fatigue and loss of weight. Trans-thoracic echocardiography showed a para-prosthetic leak with prosthesis dehiscence. The patient underwent re-operation with fixation of his prosthesis. At follow-up there were no complications. Figure 1 Anatomical and histological findings. (A) a short leaflet mitral valve (left) and a large leaflet mitral valve with a part of the left ventricle which was also removed (right). (B) Gross pathology of the mitral valve: on this section the valve is markedly ... This is the first case of VHD with pathological confirmation related to long term exposure to ecstasy. Except for an in vitro study [1], few data are available [1]. Among 29 subjects using ecstasy, eight had abnormal mitral valve echocardiography vs. 0 in controls [2]. The fact that the lesions in our patient were very similar to those described with appetite-suppressant drugs [3] and the ability of ecstasy to activate 5-HT2B receptors, like fenfluramine [1, 4], suggests its role in the pathophysiology of this VHD. VHD is unusual in young subjects. The present work allows the addition of ecstasy to the list of substances able to induce VHD [5]. The data also underline the important (and probably underestimated) harm associated with the now large use of ecstasy in young subjects. Information must be given about this risk.

Understanding the Atrioventricular Dissociation

A 56-year old male patient was addressed to our intensive cardiac care unit with a diagnosis of “complete atrioventricular (AV) block”, 4 days following surgical treatment of symptomatic obstructive hypertrophic cardiomyopathy including large septal resection and mitral valve replacement. We noted no relevant medical history. On physical examination, at admission, the patient presented normal hemodynamic, regular heart rate about 60 bpm, no signs of right heart failure. An abnormal transient jugular vein pulse was noted. The EKG on admission is presented in Fig. 1. Do you agree with the diagnosis of complete AV block? Diagnosisof considered “complex”EKG features appears tobe reserved for cardiologists or even to electrophysiologists, although good sense and simple logical approach allowmaking the diagnosis yourself in a number of cases. Let‘s go for a typical case of a suspected AV conduction disorder following cardiac surgery. First, let’s review some elementary considerations on the cardiac conduction physiology. Sinoatrial node is a part of a specialized type of myocardial network which has the particularity of being also pacemaker myocyte cells. This specialized network is represented by sinoatrial node, AV node, His and bundle branch as well as distal Purkinje fibers. Unlike the rest of themyocytes, these pacemaker cells may initiate action potential through spontaneous diastolic depolarization. Because of a higher depolarization slope, the impulse initiated from sinoatrial node depresses the activity of subsidiary pacemaker sites, and also automatically generates electrical pulses that spread as waves of electrical excitation over the atria and then to ventricles via AV node. Interruption of the conduction at any level enables subsidiary pacemakers to emerge usually at a slower rate (the lower andmore distal is the block, the slower is the rate). On the opposite, enhanced automaticity in any part of this specialized myocardial network may overdrive normal sinus node activity, particularly when the latest is slower.

Left Ventricular Pseudoaneurysm

Left ventricular (LV) pseudoaneurysm is rare in children. This report describes the case of a 2-year-old previously healthy girl who was diagnosed with endocarditis and underwent resection of a large mitral valve vegetation from the posterior mitral leaflet. One month after this surgery, she was diagnosed with a large LV pseudoaneurysm based on echocardiography performed during routine outpatient follow-up. Cardiac surgery was performed urgently to address the pseudoaneurysm, given its potential to rupture spontaneously. This case emphasizes the need for a close follow-up of children with endocarditis for development of pseudoaneurysms, which is a rare but potentially fatal complication of endocarditis.

¿Debe operarse la trombosis protésica mitral grande no oclusiva?

Large prosthetic thrombosis, thrombus >5 mm or >0.8 cm 2, is associated with high morbidity and mortality. We present a series of 9 cases of large non-obstructive prosthetic thrombosis in the mitral position. The initial treatment was anticoagulation therapy in 4 patients, fibrinolysis in 3 and surgery in 2. Surgery was required as the definitive treatment in 8 of the 9 patients (89%). The mean time to surgery was 6.7 days from hospital admission and 70.2 days for patients who were readmitted, with a mean increase in the Euroscore of 9.05% and a surgery success rate of 63%. Total early mortality was 33%, reaching 55% during follow-up. Surgery is probably the most effective treatment for large prosthetic mitral valve thrombosis, and delay in therapeutic decision-making implies an increase in mortality. Optimal anticoagulant and fibrinolytic therapy are often not definitive and not without complications.

Initial experience of mitral valve repair using the Carpentier-Edwards Physio II annuloplasty ring

The Carpentier-Edwards (CE) Physio II ring is a new prosthetic ring designed to accommodate the changing pathology seen in the spectrum of degenerative valve disease, particularly the larger anterior leaflet in repair of the Barlow valve. The aim of our study was to assess the safety and efficacy of mitral valve (MV) repair with the CE Physio II ring. Between April 2009 and March 2010, 100 patients underwent MV repair using the Physio II ring. Median age of patients was 70 years (54-85 years). The left ventricle (LV) was moderately (30-50%; n=21) or severely (<30%; n=6) impaired in 27 patients preoperatively. Mitral regurgitation (MR) was due to degenerative disease in 87 patients (bileaflet prolapse: 34 patients). Mean logistic EuroSCORE was 10.07 ± 8.9 and mean follow-up was 6.3 ± 2.4 months. Seventeen patients were non-elective (eight emergencies), five were re-do operations and 23 Maze ± pulmonary vein isolations, and 14 tricuspid annuloplasties were performed. Neo-chordae were inserted in 50 patients (50%), whereas sliding annuloplasty was performed only in three patients. The median ring size was 32 mm (range 26-40 mm). On-table trans-oesophageal echocardiography (TOE) showed trivial/no MR in 87 patients, and mild in 13 patients, and there were no cases of systolic anterior motion (SAM). There were two re-explorations for bleeding and two patients required haemofiltration. There were no strokes or deep sternal wound infections (DSWIs). There was one hospital death (1%). At discharge, mean left ventricular end-diastolic (LVEDD) was 4.8 ± 0.7 cm compared with 5.5 ± 0.8 cm preoperatively (p=0.03) and mean left ventricular end-systolic (LVESD) was 3.3 ± 0.5 cm as compared with 3.6 ± 0.8 preoperatively (p=0.4). There was no MR in 87 patients and mild MR in 13 patients. The mean mitral valve area (MVA) was 2.8 ± 0.7 cm(2). The mean systolic pulmonary artery pressure (SPAP) was 26.6 ± 7.3 mmHg as compared with 50.9 ± 17.2 mmHg preoperatively (p=0.02). During follow-up, there were no thrombo-embolic complications, re-operation, endocarditis or deaths. MV repair with the Physio II ring has excellent short-term results, including subgroups with large anterior mitral valve leaflet (AMVL). Moreover, the dimensional ratios of the ring may allow it to be used for MV repair for degenerative MV disease, irrespective of anterior leaflet size.

Percutaneous Transcatheter Closure of a Paravalvular Leak in a 20-Month Old Child

A 20-month-old boy was referred to the cardiac catheterization laboratory for closure of a large prosthetic mitral valve paravalvular leak. At birth, the boy had an unbalanced atrioventricular septal defect with borderline hypoplasia of the mitral component of the common atrioventricular valve and the left ventricle. At the age of 3 months, the boy underwent complete (two-ventricle) repair. The intraoperative findings included deficient left-sided atrioventricular valve tissue. As a result of the surgical septation, the coronary sinus ostium was located in the left atrium. The boy initially did well, but 6 weeks after his initial surgery, progressive and severe mitral regurgitation developed, necessitating mitral valve replacement with a 19-mm St. Jude prosthetic valve in the supraannular position. A small (posteromedial) paravalvular prosthetic mitral leak was noted approximately 6 months after surgery. This leak became progressively worse, resulting in moderate to severe functional mitral regurgitation and worsening left ventricular dilation. A dilated structure posterior to the left atrioventricular groove also was noted to be expanding. This structure was interpreted by echocardiography as an aneurysm of the coronary sinus. Three-dimensional (3D) echocardiography helped to define the anatomy of the leak (Fig. 1a/Movie 1a in supplementry material). At the age of 20 months, the boy was referred for cardiac catheterization with planned closure of the leak.

Austrian Syndrome Associated with Pandemic (H1N1) 2009 in Child

Austrian Syndrome Associated with Pandemic (H1N1) 2009 in Child

An Unusual Case of Endocarditis—A Rare Occurrence with Unique Etiology

The seeding of endocarditis directly to the non-valvular areas of the heart is extremely rare. We report a case of a 36-year-old woman presenting with sudden-onset lower-extremity pain and swelling, who was found to have mitral valve endocarditis with pulmonary vein vegetation. Echocardiography showed a large linear mitral valve mass coming into contact with the base of the left inferior pulmonary vein with each ventricular contraction. Spread into the atrium from mitral valve endocarditis is generally thought to be caused by jet lesions, whereas direct seeding as in this case is not well described. The location in the pulmonary vein is also unique, with no case reports being found in the literature, although the significance remains to be ascertained.

Successful removal of a very large left atrial organized infected thrombus (weight 200 gram) and Mitral valve replacement: A case report.

Successful removal of a very large left atrial organized infected thrombus (weight 200 gram) and Mitral valve replacement: A case report.