Displacement Of Leaflets Research Articles

Myocardial Fibrosis in Patients With Primary Mitral Regurgitation With and Without Prolapse

BackgroundRecent studies reported left ventricular (LV) fibrosis in patients with primary mitral regurgitation (MR) thought to be principally due to mitral valve prolapse (MVP). ObjectivesThis study sought to evaluate the prevalence, characteristics, and prognostic implications of LV fibrosis in a large cohort of primary MR patients with and without MVP using cardiovascular magnetic resonance (CMR). MethodsPatients referred for contrast CMR assessment of chronic primary MR were enrolled and underwent comprehensive assessment of cardiac remodeling, severity of MR, and LV replacement fibrosis. Primary MR patients were stratified into: an MVP group if there was >2 mm mitral leaflet displacement on cine-CMR, or a non-MVP group. Patients were followed for arrhythmic events (sudden cardiac death, aborted sudden cardiac arrest, and sustained or inducible ventricular arrhythmia). ResultsA total of 356 primary MR patients (177 MVP and 179 non-MVP) were enrolled. LV fibrosis was more prevalent in the MVP group than the non-MVP group (36.7% vs. 6.7%; p < 0.001). The presence of MVP had the strongest association (odds ratio: 6.82; p < 0.001) with LV fibrosis even after adjustment for clinical variables, measures of cardiac remodeling, and MR severity. During follow-up (median 1,354 days), MVP patients with LV fibrosis had the highest event rate for arrhythmic events. ConclusionsIn primary MR patients, LV fibrosis is more prevalent in MVP than non-MVP, suggesting a unique pathophysiology beyond volume overload in MVP. LV fibrosis in primary MR may represent a risk marker of arrhythmic events.

High resolution three-dimensional strain mapping of bioprosthetic heart valves using digital image correlation

Transcatheter aortic valve replacement (TAVR) is a safe and effective treatment option for patients deemed at high and intermediate risk for surgical aortic valve replacement. Similar to surgical aortic valves (SAVs), transcatheter aortic valves (TAVs) undergo calcification and mechanical wear over time. However, to date, there have been limited publications on the long-term durability of TAV devices. To assess longevity and mechanical strength of TAVs in comparison to surgical bioprosthetic valves, three-dimensional deformation analysis and strain measurement of the leaflets become an inevitable part of the evaluation. The goal of this study was to measure and compare leaflet displacement and strain of two commonly used TAVs in a side-by-side comparison with a commonly used SAV using a high-resolution digital image correlation (DIC) system. 26-mm Edwards SAPIEN 3, 26-mm Medtronic CoreValve, and 25-mm Carpentier-Edwards PERIMOUNT Magna surgical bioprosthesis were examined in a custom-made valve testing apparatus. A time-varying, spatially uniform pressure was applied to the leaflets at different loading rates. GOM ARAMIS® software was used to map leaflet displacement and strain fields during loading and unloading. High displacement regions were found to be at the leaflet belly region of the three bioprosthetic valves. In addition, the frame of the surgical bioprosthesis was found to be remarkably flexible, in contrary to CoreValve and SAPIEN 3 in which the stent was nearly rigid under a similar loading condition. The experimental DIC measurements can be used to characterize the anisotropic materiel behavior of the bioprosthetic heart valve leaflets and validate heart valve computational simulations.

Copy number variants in Ebstein anomaly

BackgroundEbstein anomaly (EA) is a rare congenital defect characterized by apical displacement of the septal tricuspid leaflets and atrialization of the right ventricle. The etiology of EA is unclear; however, recurrence in families and the association of EA with genetic syndromes and copy number variants (CNVs) suggest a genetic component.ObjectiveWe performed a population-based study to search for recurrent and novel CNVs in a previously unreported set of EA cases.MethodsWe genotyped 60 EA cases identified from all live births (2,891,076) from selected California counties (1991–2010) using the Illumina HumanOmni2.5–8 array. We identified 38 candidate CNVs in 28 (46%) cases and prioritized and validated 11 CNVs based on the genes included.ResultsFive CNVs (41%) overlapped or were close to genes involved in early myocardial development, including NODAL, PDLIM5, SIX1, ASF1A and FGF12. We also replicated a previous association of EA with CNVs at 1p34.1 and AKAP12. Finally, we identified four CNVs overlapping or in close proximity to the transcription factors HES3, TRIM71, CUX1 and EIF4EBP2.ConclusionsThis study supports the relationship of genetic factors to EA and demonstrates that defects in cardiomyocytes and myocardium differentiation may play a role. Abnormal differentiation of cardiomyocytes and how genetic factors contribute should be examined for their association with EA.

The role of papillary muscle approximation in mitral valve repair for the treatment of secondary mitral regurgitation.

Secondary mitral regurgitation (MR) is present in up to half of patients with dilated cardiomyopathy, and is associated with a poor prognosis. It primarily results from progressive left ventricular remodelling, papillary muscle displacement and tethering of the mitral valve leaflets. Mitral valve repair with an undersized ring annuloplasty is the reparative procedure of choice in the treatment of secondary MR. However, this technique is associated with a 30-60% incidence of recurrent moderate or greater MR at mid-term follow-up, which results in progressive deterioration of left ventricular function and increased morbidity. Combined mitral valve repair and papillary muscle approximation has been applied in order to address both the annular and subvalvular dysfunction that coexist in secondary MR, which include graft and suture-based techniques. Herein, we provide a systematic review of the published literature regarding the technical aspects, clinical application, and outcomes of mitral valve repair with combined ring annuloplasty and papillary muscle approximation for the treatment of secondary MR.

Left-right leaf asymmetry in decussate and distichous phyllotactic systems.

Leaves in plants with spiral phyllotaxy exhibit directional asymmetries, such that all the leaves originating from a meristem of a particular chirality are similarly asymmetric relative to each other. Models of auxin flux capable of recapitulating spiral phyllotaxis predict handed auxin asymmetries in initiating leaf primordia with empirically verifiable effects on superficially bilaterally symmetric leaves. Here, we extend a similar analysis of leaf asymmetry to decussate and distichous phyllotaxy. We found that our simulation models of these two patterns predicted mirrored asymmetries in auxin distribution in leaf primordia pairs. To empirically verify the morphological consequences of asymmetric auxin distribution, we analysed the morphology of a tomato sister-of-pin-formed1a (sopin1a) mutant, entire-2, in which spiral phyllotaxy consistently transitions to a decussate state. Shifts in the displacement of leaflets on the left and right sides of entire-2 leaf pairs mirror each other, corroborating predicted model results. We then analyse the shape of more than 800 common ivy (Hedera helix) and more than 3000 grapevine (Vitis and Ampelopsis spp.) leaf pairs and find statistical enrichment of predicted mirrored asymmetries. Our results demonstrate that left-right auxin asymmetries in models of decussate and distichous phyllotaxy successfully predict mirrored asymmetric leaf morphologies in superficially symmetric leaves.This article is part of the themed issue 'Provocative questions in left-right asymmetry'.

Coexistence of abnormal systolic motion of mitral valve in a consecutive group of 324 adult Tetralogy of Fallot patients assessed with echocardiography

BackgroundThe presence of mitral valve prolapse (MVP) in congenital heart disease (CHD) patients is not well described. Tetralogy of Fallot (TOF) is the most common cyanotic CHD associated with overall...

Abstract 12087: Prevalence and Prognostic Implications of CMR Detected Myocardial Fibrosis in Patients With Mitral Valve Prolapse

Background: Mitral valve prolapse (MVP) is the most common cause of primary mitral regurgitation (MR). Arrhythmia and sudden cardiac death (SCD) have been associated with MVP; however, the mechanism is unclear. Prior studies suggested left ventricular (LV) fibrosis as an arrhythmic substrate. Hypothesis: MVP patients have an increased prevalence of LV fibrosis which associated with adverse outcome. Methods: Patients referred for CMR to assess mitral valve disease were enrolled. Confounding causes of LV fibrosis (CAD, LVEF &lt; 50% etc.) and secondary MR were excluded. Primary MR patients were classified into MVP (&gt;2 mm leaflet displacement) and a non-MVP group. Cine, phase contrast CMR were performed to assess cardiac morphology/function and MR severity. Late gadolinium enhancement (LGE) CMR was performed to identify LV fibrosis. Patients were followed for 1) arrhythmic events comprised of SCD/aborted SCD, or sustained/inducible ventricular arrhythmia requiring ICD and 2) composite outcome that included arrhythmic events or cardiovascular death. Results: 356 primary MR patients (177 MVP, and 179 non-MVP) were enrolled. Baseline characteristics were relatively similar except MVP patients had more severe MR (MR fraction 42.1±14.3% vs. 32.8±12.2%, p&lt;0.03). LGE representing LV fibrosis was more prevalent in MVP group (36.7% vs. 6.7%, p&lt;0.001) and for each MR severity (figure 1A). On multivariate analysis, although lower LVEF, and increasing MR severity were associated with increased LV fibrosis, presence of MVP had the strongest association (OR 6.82, p &lt; 0.001). During the follow up period (median 673 days), MVP patients with LV fibrosis had the highest annualized event rate for arrhythmic events and composite outcome (figure1B). Conclusion: LV fibrosis is more prevalent in MVP than non-MVP patients with primary MR suggesting a unique pathophysiology in MVP. Presence of LV fibrosis in MVP may represent a risk marker of arrhythmic events and adverse clinical outcome.

Intentional Laceration of the Anterior Mitral Valve Leaflet to Prevent Left Ventricular Outflow Tract Obstruction During Transcatheter MitralValve Replacement: Pre-Clinical Findings.

The authors propose a novel transcatheter transection of the anterior mitral leaflet to prevent iatrogenic left ventricular outflow tract (LVOT) obstruction during transcatheter mitral valve replacement (TMVR). LVOT obstruction is a life-threatening complication of TMVR caused by septal displacement of the anterior mitral leaflet. Invivo procedures in swine were guided by biplane x-ray fluoroscopy and intracardiac echocardiography. Retrograde transaortic 6-F guiding catheters straddled the anterior mitral leaflet. A stiff 0.014-inch guidewire with polymer jacket insulation was electrified and advanced from the LVOT, through the A2 leaflet base, into the left atrium. The wire was snared and externalized, forming a loop that was energized and withdrawn to lacerate the anterior mitralleaflet. The anterior mitral leaflet was successfully lacerated in 7 live and 1 post-mortem swine under heparinization. Lacerations extended to 89 ± 19% of leaflet length and were located within 0.5 ± 0.4 mm of leaflet centerline. The chordae were preserved and retracted the leaflet halves away from the LVOT. LVOT narrowing after benchtop TMVR was significantly reduced with intentional laceration of the anterior mitral leaflet to prevent LVOT obstruction than without (65 ± 10% vs. 31 ± 18% of pre-implantation diameter, p< 0.01). The technique caused mean blood pressure to fall (from54 ± 6 mm Hg to 30 ± 4mmHg, p< 0.01), but blood pressure remained steady until planned euthanasia. No collateral tissue injury was identified on necropsy. Using simple catheter techniques, the anterior mitral valve leaflet was transected. Cautiously applied inpatients, this strategy can prevent anterior mitral leaflet displacement and LVOT obstruction caused by TMVR.

66. Clinical profile of adult Ebstein’s anomaly

Adults often present with arrhythmias. In the presence of an interatrial communication, the risk of paradoxical embolization, brain abscess, and sudden death increases. 10% cases WPW syndrome, junctional rhythm with intermittent sinus pauses (20%) and ventricular trigeminy (10%). Overt cardiac failure was the initial presentation in (10% patients), whereas 20% patients presented with NYHA functional class II dyspnoea and easy fatiguability. Rheumatic fever was present coexisting with Ebsteins anomaly in (5%). Two patients presented with congenital rubella syndrome with patent ductus arteriosus with Ebsteins anomaly. 5% patients who presented with inferior wall myocardial infarction on routine echocardiographic evaluation had Ebsteins anomaly. Two patients had cyanosis. Associated defects in these patients included ASD (25%), ASD with VSD (20%), PDA (5%), RVOT aneurysm (5%), pericardial effusion (10%). All patients had low pressure tricuspid regurgitation (TR). Posterior leaflet displacement more than septal leaflet displacement was present in 20% patients. Anterior leaflet was not displaced in any of these patients. Celemajors index in most of the patients was in the range of (0.6–0.97). 3 patients had celemajor index of 1.5. Carpentier type I in 20% patients, in type II in 65% patients, type III in 10% patients, type IV in 5% patients. Cardiothoracic ratio ranged from 0.61 to 0.71 and only one patient had a ratio of 0.85. 10% cases WPW syndrome , junctional rhythm with intermittent sinus pauses (20%) and ventricular trigeminy (10%). Overt cardiac failure was the initial presentation in (10%patients), whereas 20% patients presented with NYHA functional class II dyspnoea and easy fatiguability. Rheumatic fever was present coexisting with Ebsteins anomaly in (5%). Two patients presented with congenital rubella syndrome with patent ductus arteriosus with Ebsteins anomaly. 5% patients who presented with inferior wall myocardial infarction on routine echocardiographic evaluation had Ebsteins anomaly. Two patients had cyanosis. Associated defects in these patients included ASD (25%), ASD with VSD (20%), PDA(5%), RVOT aneurysm (5%), pericardial effusion (10%). All patients had low pressure tricuspid regurgitation (TR). Posterior leaflet displacement more than septal leaflet displacement was present in 20% patients. Anterior leaflet was not displaced in any of these patients. Celemajors index in most of the patients was in the range of (0.6–0.97). 3 patients had celemajor index of 1.5. Carpentier type I in 20% patients, in type II in 65% patients, type III in 10% patients, type IV in 5% patients. Cardiothoracic ratio ranged from 0.61 to 0.71 and only one patient had a ratio of 0.85. Ebsteins anomaly in adults can have diverse presentations. Symptoms due to Electrophysiological events were more prevalent than due to hemodynamic disturbances.

Evolution of Mitral Valve Prolapse: Insights From the Framingham Heart Study.

Longitudinal studies of mitral valve prolapse (MVP) progression among unselected individuals in the community, including those with nondiagnostic MVP morphologies (NDMs), are lacking. We measured longitudinal changes in annular diameter, leaflet displacement, thickness, anterior/posterior leaflet projections onto the annulus, coaptation height, and mitral regurgitation jet height in 261 Framingham Offspring participants at examination 5 who had available follow-up imaging 3 to 16 years later. Study participants included MVP (n=63); NDMs, minimal systolic displacement (n=50) and the abnormal anterior coaptation phenotype (n=10, with coaptation height >40% of the annulus similar to posterior MVP); plus 138 healthy referents without MVP or NDMs. At follow-up, individuals with MVP (52% women, 57±11 years) had greater increases of leaflet displacement, thickness, and jet height than referents (all P<0.05). Eleven participants with MVP (17%) had moderate or more severe mitral regurgitation (jet height ≥5 mm) and 5 others (8%) underwent mitral valve repair. Of the individuals with NDM, 8 (80%) participants with abnormal anterior coaptation progressed to posterior MVP; 17 (34%) subjects with minimal systolic displacement were reclassified as either posterior MVP (12) or abnormal anterior coaptation (5). In comparison with the 33 participants with minimal systolic displacement who did not progress, the 17 who progressed had greater leaflet displacement, thickness, coaptation height, and mitral regurgitation jet height (all P<0.05). NDM may evolve into MVP, highlighting the clinical significance of mild MVP expression. MVP progresses to significant mitral regurgitation over a period of 3 to 16 years in one-fourth of individuals in the community. Changes in mitral leaflet morphology are associated with both NDM and MVP progression.

0117: Left ventricular mechanics in mitral valve prolapse: a longitudinal strain study

Valve apparatus alterations may influence left ventricular (LV) mechanics in mitral valve prolapse (MVP). To assess LV mechanics and ventriculo-valvular interaction in MVP. A comprehensive echocardiography including 2D speckle tracking myocardial longitudinal strain assessment was carried out in 194 adult patients with MVP (leaflet displacement >2mm above the annulus) and 30 matched controls. In MVP group mitral regurgitation (MR) was not significant in 76 (39%) patients (NoMR-MVP, effective regurgitant orifice <10mm 2 ), mild to moderate in 53 (27%) and severe in 65 (34%) patients. Posterior (PML) and/or anterior (AML) mitral leaflet prolapse were present in 188 (93%) and 85 (42%) patients, respectively. PML and AML positions averaged –6.0±3.4mm and –1.6±3.5mm, respectively. Ventriculo-atrial disjunction was found in 82 (41%) patients and averaged 5.7±1.6mm. Posterior wall thickening was clearly increased in MVP groups with frank wall bulging in 82 patients (41%). Despite the third left chamber (between mitral annulus and prolapsed leaflets) forward stroke volume was preserved in MVP groups, and even increased in NoMR-MVP (44±9mL/m 2 vs 39±9mL/m 2 in Controls, p<0.001). In addition LV EF was improved in NoMR-MVP. Global Longitudinal Strain (GLS) was also improved in NoMR-MVP (–21.5±2.8%) and in the overall MVP group (–21.7±3.0%) compared with Controls (–19.7±1.7%, both P<0.001). In multivariate analysis GLS improvement was associated with the magnitude of PML prolapse (β=0.14, P=0.04), posterior wall thickening (β=–0.16, P=0.004), posterior papillary muscle displacement in systole (β=–0.21, P=0.002) and posterior wall bulging (β=–0.23, P<0.001). MVP and associated abnormalities have a significant impact on LV mechanics. LV systolic function is improved in MVP as assessed by EF and GLS and preserves forward stroke volume. These changes might have significant effect at long-term on LV myocardium.

Perioperative and Anesthetic Considerations in Ebstein's Anomaly.

Ebstein's anomaly is a complex and heterogeneous form of congenital heart disease characterized by malformation and apical displacement of the tricuspid valve leaflets. Patients may present at any time from the neonatal period to adulthood with symptoms ranging from cardiac failure and cyanosis to paroxysmal arrhythmias. Depending on the timing of presentation, various surgical options are available for the management of symptomatic patients. This review will discuss the perioperative and anesthetic management of patients with Ebstein's anomaly with reference to the more common surgical approaches.

Reversible severe mitral regurgitation caused by systolic anterior motion of the mitral valve in the absence of left ventricular hypertrophy: A case report

A 67-year-old woman with exertional dyspnea was referred to our hospital. Transthoracic echocardiography revealed severe mitral regurgitation and significant left ventricular (LV) outflow tract obstruction due to prominent systolic anterior motion (SAM) of the mitral valve without LV hypertrophy. Oral bisoprolol remarkably attenuated SAM. Two- or three-dimensional echocardiographic analysis demonstrated the elongation of anterior and posterior mitral leaflets and interventricular septum (IVS) bulging due to narrow aorto-mitral angle. In the present case, elongation of mitral leaflet and hyperkinetic motion of left ventricle, and IVS bulging due to narrow aorto-mitral angle possibly play important roles in the development of SAM.<Learning objective: Mitral regurgitation due to systolic anterior motion (SAM) can be dramatically improved by beta-blocker therapy. Although the precise mechanism of SAM has not been fully elucidated, structural changes of mitral apparatus (elongation of mitral leaflet and papillary muscle displacement), and structural or functional features of left ventricle (hyperkinetic motion, small ventricle, interventricular septum bulging, narrow aorto-mitral angle) possibly play important roles in the development of SAM.>

Acute coronary obstruction following transcatheter aortic valve implantation: Small vessels, big problems

Transcatheter aortic valve implantation (TAVI) has become in this last decade an alternative treatment to surgery in patients with severe symptomatic aortic stenosis (AS), with a high or prohibitive surgical risk [1]. Despite advances in the development of new devices and the growing experience of centers performing the procedure, the implant is not exempt of risks. Among the potential complications, acute coronary obstruction (CO) represents a rare complication (b1%), but with a high morbidity and mortality [2]. In the majority of the reported cases, the main mechanism of the obstruction is a displacement of the calcified native valve leaflets over the main coronary ostia. The left coronary artery ostium is more frequently affected (~88%) due to its anatomical arrangement [2–3]. Given the significant quantity of ischemic myocardium caused by a left main occlusion, the clinical manifestations are substantial, presented as maintained severe arterial hypotension, electrocardiographic changes (mainly alterations of the ST segment) and/or malignant ventricular arrhythmias [2–4]. However, we are reporting two cases of acute CO following TAVI that, despite occurring

Ebstein malformation associated with left atrium myxoma

A 62 year old lady, diagnosed with Ebstein malformation 12 years ago, presented to clinic with severe fatigue, breathlessness, chest pain, palpitations, and loss of weight. She had clear evidence for irregular rhythm, rales at the basal lung fields and clinical signs of severe right sided failure. A 12 lead ECG showed atrial fibrillation with wide QRS complex (130 ms) and right bundle-branch block. Echocardiography showed septal tricuspid valve leaflet displacement of 1.6 cm into the right ventricle (Figure 1&2). The right atrium was enlarged, 70 x 110 cm in diameter, with moderate tricuspid regurgitation and estimated pulmonary hypertension of 90 mmHg. In addition, there was an echo dense mass (26 x 30 mm) attached to the left atrial side of the interatrial septum, with morphologic appearance consistent with atrial myxoma. According to our knowledge, this case of such combination seems the first reported in the literature.

ARRHYTHMOGENESIS IN MITRAL VALVE PROLAPSE

Mitral valve prolapse is generally considered a benign condition, however, asubset of patients remains at high risk of arrhythmogenesis which may lead to sudden cardiacdeath. Objective: To stratify risk of arrhythmogenesis in patients with mitral valve prolapseon the basis of high resolution ECG, Holter monitoring, resting heart rate and mitral leafletgeometry. Study Design: Cross sectional comparative study. Place of study: Armed ForcesInstitute of Cardiology (AFIC)/National Institute of Heart Diseases, Rawalpindi and Army MedicalCollege, Rawalpindi, Pakistan Methodology: Mitral leaflet displacement and thickness weremeasured on echocardiography in 37 patients with mitral valve prolapse. Resting heart rateand time domain indices of heart rate variability of each patient were recorded from 24 hoursHolter monitoring. High resolution ECG of all the patients was carried out to record ventricularlate potentials. Statistical analysis was performed using SPSS and the alpha value was set at&lt;0.05 for significance. Results: The mean values for resting heart rate, leaflet displacement andleaflet thickness were 77.19±6.29 per minute, 3.64±0.92 mm and 4.96±0.79 mm respectively.Ventricular late potentials were present in 8 (21.62%) whereas heart rate variability was reducedin 5 (13.51%) patients. Leaflet thickness was significantly greater in patients with ventricularlate potentials as compared to those without (p-value 0.004). Patients with reduced heart ratevariability had significantly higher resting heart rate as compared to those with normal variability(p-value 0.02). One patient (2.7%) had ventricular late potentials, reduced heart rate variability,resting heat rate of 88 beats per minute and leaflet thickness over 5 mm. Conclusions:Combined effects of high resolution ECG, holter monitoring and leaflet geometry identified thehigh risk subset, comprising of 2.7% of the study population.

Predicting atrial tachycardia and major cardiovascular events in adults with unrepaired Ebstein's anomaly of the tricuspid valve

Heart Association class >2 (Hazard ration (HR 7.66[95% CI 1.535-38.204],p=0.013), left ventricular (LV) ejection fraction (HR) 0.43[95%CI 0.245-0.742],p=0.003/5%), LV stroke volume (HR 0.69[95%CI 0.515-0.923],p=0.013/ 5mL) and right ventricular (RV) ejection fraction (HR 0.49[95%CI 0.276-0.856],p=0.012/5%); all remained significant even when tested solely for mortality. In all but one patient VT/death was preceded by AT and AT was predictive of major adverse cardiovascular events (HR 11.16[95%CI 1.299-95.813],p=0.028), emphasizing its role as an early marker of long-term adverse events. Freedom from first-onset AT (n=17 patients, 21.5%) declined during the follow-up. Univariate predictors for first-onset AT included RV ejection fraction (HR 0.65 [95%CI 0.463-0.907],p=0.011/5%)], RV/LV end diastolic volume ratio (HR 1.65[95%CI 1.207-2.258],p=0.002) and apical tricuspid septal leaflet displacement indexed to LV length (HR 1.03[95%CI 1.002-1.068],p=0.040); when used together as a score, risk prediction was further enhanced (HR 4.84[95%CI 1.615-14.522],p=0.005). Conclusions

The challenge of valve-in-valve procedures in degenerated Mitroflow bioprostheses and the advantage of using the JenaValve transcatheter heart valve

Recently, the feasibility of valve-in-valve procedures using current first-generation transcatheter heart valves (THV) in cases of structural valve degeneration has been reported as an alternative to conventional open repeat valve replacement. By design, certain biological valve xenografts carry a high risk of coronary ostia occlusion due to lateral displacement of leaflets after valve-in-valve procedures. In the present report we aimed to prove feasibility and safety of transapical valve-in-valve implantation of the JenaValve THV in two cases of degenerated Mitroflow bioprostheses. We herein report two cases of successful transapical valve-in-valve procedures using a JenaValve THV implanted in Sorin Mitroflow bioprostheses for structural valve degeneration. Both patients were alive and in good clinical condition at 30 days from the procedure. However, increased transvalvular gradients were noted in both cases. Transcatheter valve-in-valve implantation of a JenaValve THV is a valid alternative for patients with degenerated Mitroflow bioprostheses of sufficient size and in the presence of short distances to the coronary ostia who are too ill for conventional repeat open heart surgery. Increased pressure gradients have to be expected and weighed against the disadvantages of other treatment options when planning such a procedure.

Familial clustering of mitral valve prolapse in the community.

Knowledge of mitral valve prolapse (MVP) inheritance is based on pedigree observation and M-mode echocardiography. The extent of familial clustering of MVP among unselected individuals in the community using current, more specific echocardiographic criteria is unknown. In addition, the importance of nondiagnostic MVP morphologies (NDMs; first described in large pedigrees) has not been investigated in the general population. We hypothesized that parental MVP and NDMs increase the risk of offspring MVP. Study participants were 3679 Generation 3 individuals with available parental data in the Offspring or the New Offspring Spouse cohorts. MVP and NDMs were distinguished by leaflet displacement >2 versus ≤2 mm beyond the mitral annulus, respectively. We compared MVP prevalence in Generation 3 participants with at least 1 parent with MVP (n=186) with that in individuals without parental MVP (n=3493). Among 3679 participants (53% women; mean age, 40±9 years), 49 (1%) had MVP. Parental MVP was associated with a higher prevalence of MVP in Generation 3 participants (10 of 186, 5.4%) compared with no parental MVP (39 of 3493, 1.1%; adjusted odds ratio, 4.51; 95% confidence interval, 2.13-9.54; P<0.0001). When parental NDMs were examined alone, the prevalence of Generation 3 MVP remained higher (12 of 484, 2.5%) compared with those without parental MVP or NDMs (27 of 3009, 0.9%; adjusted odds ratio, 2.52; 95% confidence interval, 1.25-5.10; P=0.01). Parental MVP and NDMs are associated with increased prevalence of offspring MVP, highlighting the genetic substrate of MVP and the potential clinical significance of NDMs in the community.

Role of myocardial viability in functional ischaemic MR

Functional ischaemic mitral Regurgitation myocardial viability as a predictor of postoperative outcome after isolated coronary artery bypass grafting. Ischaemic cardiomyopathy is the most common cause of heart failure in the United States. 1This advanced form of coronary artery disease is marked by diffuse myocardial damage, left ventricular remodeling, and often functional ischemic mitral regurgitation (IMR). Aim Patients with Moderate functional ischaemic MR in ischaemic cardiomyopathy will benefit from mitral valve repair at the time of CABG or will benefit from CABG alone without mitral valve repair. Methods The study population consisted of 135 consecutive patients (age, 65 ± 9 years; 81% male) with ischaemic heart disease and moderate IMR referred electively for isolated CABG who met the following criteria: stable left ventricular (LV) dysfunction with an LV ejection fraction 45 % for at least 3 months and stable moderate IMR (vena contracta width, 0.3–0.7 cm; ratio of jet area to left atria [LA] area, 20–40%) on 2 different examinations performed at least 1 month apart during stable conditions. In the presence of qualifying LV dysfunction, an additional 2 criteria were required to diagnose IMR: the presence of apical displacement of mitral leaflets and the absence of organic leaflet lesions. Assessment of myocardial viability was not used for patient selection. All patients included in the study had CABG as the sole procedure. Dyssynchrony between the papillary muscles was determined by tissue Doppler imaging. Myocardial viability was assessed by single-photon emission computed tomography. Results The absence of preoperative papillary muscle dyssynchrony and presence of viability in myocardial segments adjacent to papillary muscles were associated with improvement in postoperative functional ischaemic MR in > 90% of patients. In contrast, the absence of myocardial viability and presence of significant papillary muscle dyssynchrony (e.g. scar in the region of posterior papillary muscle) were associated with no improvement or worsening postoperative IMR. This study shifts the focus from the mitra l valve to myocardial viability and function as the primary determinants of recovery from moderate functional ischaemic MR after isolated CABG. The results of this study will have a strong impact on the 3 key elements in the care of patients with ischaemic cardiomyopaihy and functional ischemic MR: Diagnostic workup, therapeutic approaches, and interpretation of outcomes. Myocardial viability can be determined by dobutamine stress echocardiography, single-photon emission compuled tomography, positron emission tomography, or magnetic resonance imaging. Conclusions The authors recommend isolated CABG for patients with functional ischemic MR if there is: 1 – Viable myocardium. 2 – And No ventricular dyssynchrony. The absence of viability or presence of ventricular dyssynchrony is indicative of advanced-stage ischaemic cardiomyopathy in which recovery from functional ischemic MR with isolated CABG is unlikely; in these patients, concomitant mitral valve repair should be considered.