Mean Diastolic Gradient Research Articles

Abstract 11100: Difference in Clinical Characteristics, Left Atrial Reverse Remodeling and Functional Outcomes After Mitral Valve Replacement in Patients With Low-Gradient Very Severe Mitral Stenosis

Introduction: The discrepancy between planimetered mitral valve area (MVA) and mean diastolic pressure gradient (MDPG) has not been studied extensively in patients with mitral stenosis (MS). Hypothesis: The purpose of the current study was to investigate the difference in characteristics and outcomes after mitral valve replacement (MVR) between low and high MDPG groups in very severe MS patients. Methods: This study evaluated 140 patients who received isolated MVR due to very severe MS (planimetered MVA ≤ 1.0 cm2) and performed follow-up echocardiography at least 12 months after MVR. Patients were divided into two groups according to preoperative MDPG (Low-gradient, < 10 mmHg; High-gradient, ≥ 10 mm Hg). Strain and strain rate analysis was performed using speckle tracking echocardiography before MVR in 56 patients. Results: There were 82 patients in low-gradient group and 58 patients in high-gradient group. The low-gradient group was older and demonstrated higher prevalence of female gender, diabetes mellitus, and atrial fibrillation (all p <0.05). When comparing the low-gradient and high-gradient groups, the left atrial volume index was larger (LAVI, 105.1 ± 51.9 ml/m2 vs. 87.8 ± 42.9 ml/m2, p < 0.001) and strain rate during isovolumic relaxation was lower (0.17 ± 0.08 s-1 vs. 0.29 ± 0.09 s-1, p < 0.001) in low-gradient group. After MVR, the percentage in LAVI reduction after MVR was significantly smaller in low-gradient group (-29.9 ± 15.1% vs. -43.5 ± 16.4%, p < 0.001). Persistent symptoms after MVR was more common in the low-gradient group compared to the high-gradient group (p = 0.004), even though preoperative functional class was similar between the groups. Conclusions: Low-gradient very severe MS was common in the population of high prevalence in diastolic dysfunction, such as the elderly, women, diabetes mellitus, and atrial fibrillation, was associated with impaired myocardial isovolumic relaxation, and demonstrated unfavorable left atrial reverse remodeling and a greater risk of persistent symptoms after MVR. These data might suggest the importance of concurrent management of diastolic dysfunction in low-gradient very severe MS.

Echocardiographic Features of Cardiac Angiosarcomas: The Mayo Clinic Experience (1976-2013).

Cardiac angiosarcoma is the most common primary malignant cardiac tumor. The dismal prognosis and nonspecific symptomatology underscore the need for an accurate and cost-effective approach to the identification and characterization of this rare tumor. Mayo Clinic tissue registry archives were queried for all histologically confirmed cases of cardiac angiosarcoma (1976-2013) with available imaging data. Echocardiograms were retrospectively reviewed. Thirty-three cases of cardiac angiosarcoma were identified; of these, 17 had echocardiograms available (mean age, 46 years; six men). Transthoracic echocardiography (TTE) as the initial diagnostic test had 75% sensitivity for visualizing primary cardiac angiosarcoma (9/12 patients). Tumor extension into the pericardium was common and pericardial effusion was present in 15 patients (88%); however, pericardial fluid cytology was negative for malignancy in all tested patients (n = 15). Left ventricular ejection fraction (LVEF) was preserved in 16 patients (94%) (average LVEF, 62%). Right ventricular function was mildly reduced in two patients (12%) at initial presentation. Tricuspid valve obstruction was present in three patients (18%; mean diastolic gradient, 6.3 mmHg [range, 3-11 mmHg]). The sensitivity of TTE as the first diagnostic imaging modality compared favorably with computed tomography. Pericardial effusion was common, but pericardial fluid cytology was negative in all patients who underwent pericardiocentesis. The absence of a stalk was a universal finding that may help distinguish angiosarcoma from benign, primarily pedunculated tumors such as myxoma and papillary fibroelastoma.

Reverse remodeling of left heart following mitral valve repair in case of mesenchimal dysplasia

Objectives. Volume overload in mitral regurgitation leads to compensatory dilation of the left heart chambers. Surgical correction promotes reverse remodeling of the heart. In this study, focus was placed on the changes in the left heart resulted from mitral regurgitation correction by using two different surgical techniques for mitral valve repair. Methods. 94 patients with posterior mitral valve prolapse were randomized in two groups. The first group patients underwent artificial chordal replacement, while a leaflet resection technique was used for the patients of the second group. Preoperative transthoracic and intraoperative transesophageal echocardiography was performed for all patients and data were obtained at 10-12 days after surgery and during long-term follow up. Results. In the early postoperative period, significant reverse remodeling of the left heart chambers was observed (LA 5.4-4.6, p <0.05; LVEDD 5.8-4.9 p <0.05; LVESD 3.6 - 3.1 p <0.05) - LA 5.2 - 4.5 p <0.05; LVEDD 5.8 - 4.8 p <0.05; LVESD 3.5 - 3.2 p <0.05. The mitral valve orifice area in the groups was 3.3 - 3.3 - 3.2 when replacing chords and 3.5 - 3.4 - 3.2 when doing resection, with p being equal to 0.32, 0.36 and 0.51 respectively. The mean diastolic gradient in the first group was 2.0 - 3.0 - 3.0 mm Hg, while in the second one it amounted to 2.3 - 3.2 - 3.3 mmHg, with p <0.05. Conclusion. The authors conclude that significant remodeling of the left heart occurs in the early postoperative period. In the immediate postoperative period, the mitral valve area tends to decrease and the gradient has a tendency to increase in both groups, with no significant changes observed in the late postoperative period.

Quality of life after successful percutaneous mitral commissurotomy; 3 years follow up study

BackgroundLimited data are available concerning QoL after PMC in patients with MS. QoL is not easily defined as mere survival; the goal is not only to achieve survival, but also health, well-being and some reasonably good quality of living as well. The content of the Minnesota Living with Heart Failure questionnaire (MLHFQ) was selected to be representative of the ways pulmonary congestion and treatments can affect the key physical, emotional, social and mental dimensions of QoL. We aimed to study the effect of successful PMC on the QoL after 3 years of follow up. Methods50 patients with isolated moderate and severe rheumatic MS who underwent successful PMC. All of the following parameters were measured before PMC and after 3 years of follow up using transthoracic echocardiography: Mitral valve area (MVA), mean diastolic pressure gradient (MDPG), right ventricular systolic pressure (RVSP) and pulmonary vascular resistance (PVR). MLHFQ was applied before PMC and after 3 years of PMC. ResultsAfter 3 years of follow up, QoL was significantly improved in rheumatic MS cases who underwent successful PMC (p<0.001). QoL improvement was significantly correlated with the gain in MVA (r=−0.29, P=0.04). The improvement in QoL is much better in the patients who maintained their MVA≥2cm2 (t=−1.99, p=0.05). ConclusionsIn cases with rheumatic MS; successful PMC improved QoL significantly specially in patients whose MVA stay ≥2cm2 after 3 years of follow up.

Worsening Dyspnea in a 38-Year-Old Woman

A 38-year-old Hispanic woman with longstanding exertional dyspnea sought medical attention because of the recent onset of paroxysmal nocturnal dyspnea. Cardiac physical examination revealed murmurs of mitral stenosis and regurgitation, a prominent a wave in the jugular venous pulse, and a loud pulmonic valvular closure sound. An electrocardiogram showed sinus rhythm, left atrial enlargement, right axis deviation of the QRS complex, and an R/S ratio in lead V1 > 1.0 with a negative T V1, suggesting right ventricular hypertrophy (Figure 1). Figure 1. Electrocardiogram soon after admission showed left atrial enlargement (negative terminal P-wave deflection in lead V1 ≥ 0.1 mV and 0.04 s in duration) (2) and right ventricular enlargement (right axis deviation of the QRS complex and R/S ratio ... At cardiac catheterization, the pressures (mm Hg) were 64/30 in the pulmonary artery, 65/8 in the right ventricle, a mean of 7 in the right atrium with a waves of 10 and v waves of 7, a mean of 26 with a waves of 17 and v waves of 38 in the pulmonary arterial wedge position, and 96/6 in the left ventricle. The cardiac output by thermodilution was 3.4 L/min, which together with a 16 mm Hg mean diastolic pressure gradient between pulmonary arterial wedge and left ventricle gave a calculated mitral valve area of 0.7 cm2 (Figure 2). Angiocardiography revealed mild mitral regurgitation, trivial tricuspid regurgitation, and no aortic regurgitation. Figure 2. Simultaneous pulmonary arterial wedge and left ventricular pressure tracings showing a 16 mm Hg mean diastolic pressure gradient across the mitral valve (MVG). The pressure scale on each side of the tracing is in mm Hg. DFP indicates diastolic filling ... Rheumatic heart disease is the cause of mitral stenosis in most adults. Because of the steady decrease in the incidence of acute rheumatic fever over the past 75 years in the United States, mitral stenosis is now uncommon here and is most often seen in older patients and, as in this patient, in immigrants from less developed countries (1). Clinical evaluation is usually sufficient for making a diagnosis of mitral stenosis (1). The electrocardiogram can be helpful in this regard, but the history, physical exam, chest radiograph, and especially the echocardiogram are usually more helpful. Nevertheless, electrocardiographic evidence of left atrial enlargement and right ventricular hypertrophy in a dyspneic young immigrant woman from an underdeveloped country puts mitral stenosis toward the top of the list of diagnostic possibilities.

PP-114 Relationship between the Frequency of Idiopathic Ventricular Premature Beats and Transmural Dispersion of Repolarization Parameters

TS was detected during routine follow-up. TTE and TEE examinations revealed thickened tricuspid valve leaflets and subvalvular apparatus and a mean diastolic gradient of 7 mmHg across the tricuspid valve (Figure 1). There was also mild-to-moderate tricuspid regurgitation. Since patient had no complaints specific to the tricuspid abnormality, no further intervention was planned. Conclusions: Few cases of TS were published in the literature due to cardiac pacemaker leads. In current case we assume that TS occurred after endothelial injury following repetitive trauma of mechanical lead extraction system upon tricuspid valve and subvalvular apparatus during lead extraction procedure.

Patient-prosthesis mismatch after mitral valve-in-valve procedure - at the cost of life or serious consequence?

An 81-year-old man, who had undergone a complex cardiosurgical procedure 8 years previously (aortic valve replacement by Medtronic Hancock II 23 mm and mitral valve replacement by Medtronic Hancock II 31 mm, tricuspid valve repair using the Kay technique, and coronary artery bypass surgery with left internal mammary artery (LIMA) to left anterior descending (LAD)), was admitted to the hospital with symptoms suggestive of acute heart failure (NYHA IV). Echocardiographic examination revealed satisfactory function of the aortic prosthesis, and massive regurgitation of the degenerative mitral prosthesis. Left ventricle ejection fraction was estimated at approximately 30% with left ventricle (LV) thinning, an akinetic and thin apex, and mild tricuspid valve insufficiency. Due to these findings cardiopulmonary bypass was used. An intra-aortic balloon pump (IABP) was not introduced due to limited femoral access. The patient, in spite of a very high operative risk (STS 29.8%), was referred for urgent redo cardiac surgery. With this in mind, the patient was qualified for transcatheter mitral valve-in-valve (VIV) implantation. The procedure was performed on-pump with the cardiopulmonary bypass connected via femoral vessels. A transapical approach for delivering the 29 mm Edwards Sapien valve into the mitral position was chosen. Significant efforts were made to protect the scarred apex (pericardium was not dissected). Intraoperative transesophageal echocardiogram (TEE) and fluoroscopy demonstrated precise landing of the new prosthesis, as well as resolution of prior regurgitation and absence of perivalvular leakage. Unfortunately, the initially high mean gradient through the valve remained elevated. The postoperative course was uneventful. On postoperative day 5 in the Cardiology Department due to left ventricular end-diastolic diameter (LVED) > 70 mm and one incidence of tachyarrhythmia, a cardioverter-defibrillator was implanted prophylactically. The patient was discharged home 2 weeks after the procedure. The patient remains in stable condition in class II/III NYHA after 10 months of follow-up. Control echocardiography showed moderate/severe stenosis (mitral valve area 1.0 cm2, mean diastolic pressure gradient (PG) 9 mm Hg) of the implanted VIV prosthesis with no perivalvular leakage and degenerative changes of the leaflets (Figure 1). Figure 1 A, B – Angio-CT – internal diameter sizing of the bioprosthesis annulus (A – 2.58 cm, B – 2.78 cm). C – Doppler showing no regurgitation, but the orifice area is still not optimal. D – Angiography after ... Though the problem of low mitral valve orifice after transcatheter VIV implantation has been deliberated in the literature, in our opinion it has not been outlined in sufficient detail [1]. It is not entirely clear if the patient-prosthesis mismatch (PPM) in our case was influenced by the anatomy of this particular patient, or is rather caused by the atypical position of the bioprosthesis, which was originally designed for the aortic position [2]. From a technical point of view the procedure was executed correctly with maximum balloon inflation during implantation and precise prosthesis positioning. The range of mean diastolic pressure gradients through the mitral orifice after VIV procedures is expansive in available data. We presume, according to our experience, that the rigidity of the biological tissue of which the leaflets are made does not allow complete opening under the diastolic pressure gradients between the left atrium (LA) and LV, which are physiologically much lower than that of the aortic valve [3]. Although VIV has been performed approximately a few hundred times worldwide, there are still quite limited data regarding follow-up of these patients after this procedure [4].

Mitral prosthetic valve thrombosis and cardiogenic shock in a limited resource setting in sub-Saharan Africa: A tailored treatment approach

We thankDrDoganandColleaguesfor their commentonourprevi-ously described case [1] and for their contribution on the therapy ofprosthetic valve thrombosis (PVT) during pregnancy [2–4].Wetreatedwiththrombolysisa21year-oldUgandanfemalepatientwith known rheumatic heart disease for highly suspected acute PVT,who had undergone mitral valve replacement with a bileaflet mechan-icalprosthesis(St.Judeno.29)aboutthreemonthsbefore[1].Diagnosiswas based on clinical evaluation and transthoracic echocardiography(TTE).The occurrence of acute PVT was likely due to poor internationalnormalized ratio (INR) control and limited patient's compliance toanticoagulation therapy (warfarin).ItmustbeunderlinedthattheyoungpatientwasnotpregnantatthetimeofacutePVT.Pregnancyoccurredsubsequently,asdescribedinourcase report [1]. The fact that the patient was not pregnant made PVTmanagement easier, particularly the choice to initiate thrombolysis.Furthermore, at that time (May 2011) no urgent prosthetic valve re-placementcouldbeperformedinUganda[5].Thus,theonlymedicalop-tion was thrombolysis. Of further relevance, the patient with highlysuspected PVT was in cardiogenic shock, with evidence of multi-organfailure as demonstrated by anuria and high INR value (INR 9) likely relat-ed to acute liver failure [6]. For this reason, vitamin K was administeredand emergent thrombolysis was performed (standard intravenous bolusof tenecteplase) [7]. With regard to echocardiographic diagnosis, notransesophageal probe was available in the hospital where the patientwastreatedatthetimeoftheevent.Accordingtothe2014AHA/ACCVal-vularHeartDiseaseGuidelinebothTTEandtransesophagealechocardiog-raphy (TEE) are recommended for the evaluation of a suspected PVT(classI, levelofevidence Bforbothapproaches) [7]. However,webelievethat in the setting of hemodynamic instability TEE is not always essentialand should beused with caution. For instance, this is the case of hemo-dynamicallyunstablepatientswithatrialfibrillation(AF)andhighven-tricular response rate [8], where the benefit of immediate electricalcardioversion overwhelms the thromboembolic risk in the absence ofpreliminary TEE screening. Invasive mechanical ventilation and man-agement of cardiogenic shock with inotropic agents and/or mechanicalcirculatory support could potentially allow hemodynamic stabilizationof the patient, thus permitting further investigations such as TEE orfluoroscopy. It is worth underlining how Biteker and Ozkan were ableto manage a hemodynamically unstable patient (blood pressure atpresentation 65/35 mm Hg) and perform TEE, which allowed the iden-tificationofalargeprostheticthrombus(1.6×1cm)[9].Intheirreport-ed case a 40 mm Hg mean diastolic mitral transvalvular gradient andclinical history were highly suggestive of PVT [9]. Referring to ourcase, at less than three months after valve replacement pannus forma-tion seemed less likely than acute thrombosis; on the other hand, nosystemicsignssuggestiveofendocarditiswerepresent,makingthisdif-ferential diagnosis unlikely too. Micro-emboli can cause distal cerebralischemiceventsafteracutethrombolysis,anditispossiblethataslowerinfusion of thrombolytic treatment can reduce this risk as comparedwith a standard administration protocol, although no evidence canfully support a strategy over the other. Particularly in patients in AF(like our patient was), TEE demonstration of thrombus in the left atrialappendage would add information about a potential risk of embolicevents; nevertheless, thrombus identification in the appendage in thereportedoccasionwould havenot substantiallymodi fiedourtherapeu-tic strategy.Finally, TEE-guided low-dose, slow infusion of tissue-type plas-minogen activator with repeateddoses have been demonstrated asasafeandsuccessfulstrategybyOzkanetal.[2,3]. We personallyhave no direct experience on thrombolysis in PVT in pregnancy. Itappears reasonable that thefinal decision on the best approach–surgery versus thrombolysis– be related to the experience of the

Transcatheter tricuspid valve implantation: A multicentre French study

Transcatheter valve-in-valve (VIV) implantation in failing bioprosthesis is an emerging field in cardiology. To report on a French multicentre experience and a literature review of tricuspid VIV implantation. We approached different institutions and collected 10 unpublished cases; a literature review identified 71 patients, including our 10 cases. Clinical aspects and haemodynamic data are discussed. Among our 10 unpublished cases, the reason for implantation was significant tricuspid stenosis (n = 4), significant tricuspid regurgitation (n = 1) or mixed lesion (n = 5). Implantation was performed under general anaesthesia at mean age 28 ± 17 years. The 22 mm Melody valve was implanted in seven patients; the Edwards SAPIEN valve was implanted in three patients. The procedure succeeded in all cases, despite two embolizations in the right cardiac chambers; in both cases, the valve was stabilized close to the tricuspid annulus using a self-expandable stent, before implantation of a second Edwards SAPIEN valve. Functional class improved in all but one case. Mean diastolic gradient decreased from 9 ± 2.45 mmHg to 3.65 ± 0.7 mmHg (p = 0.007); no more than trivial regurgitation was noticed. Among the published cases, the Melody valve was implanted in 41 patients, the Edwards SAPIEN valve in 29 patients and the Braile valve in one patient. Short-term results were similar for our 10 cases, but mid-term results are not yet available. Tricuspid VIV implantation using the Melody or Edwards SAPIEN valves is a feasible and effective procedure for selected patients with failing bioprosthesis.

Evaluation of the effect of mitral stenosis severity on the left ventricular systolic function using isovolumic myocardial acceleration

Isovolumic acceleration (IVA) is a new tissue Doppler parameter in the assessment of systolic function of both left and right ventricles. It remains unaffected with the changes in pre- and after-load within the physiological range. The aim of our study was to assess the effect of mitral stenosis degree, which is determined by echocardiography, on the left ventricular (LV) function using IVA. A total number of 62 patients with mitral stenosis (MS) and 32 healthy controls were examined. The severity of MS (mild, moderate, and severe) was determined on the basis of mitral valve area (MVA) and the mean diastolic mitral gradient findings. The peak myocardial velocities during isovolumic contraction, systole, early diastole and late diastole were measured by using tissue Doppler imaging (TDI). All TDI-derived global LV basal wall systolic (peak myocardial isovolumic contraction velocity, peak myocardial systolic velocity and IVA), and diastolic velocities (peak early and late diastolic velocities) were significantly decreased in the patients with MS, compared to the healthy patients (p < 0.001, for all). However, IVA was not different when the degree of MS was evaluated (p = 0.114). In addition, IVA was not correlated with the MVA (r = 0.185, p = 0.150). Left ventricular function is impaired in patients with MS regardless of the severity of the disease.

Electrocardiogram in a 28-Year-Old Woman with Dyspnea on Exertion

A28-year-old HIV-infected woman with dyspnea on exertion for 6 months had no history of acute rheumatic fever or opportunistic infections and no family history of heart disease. Her CD4 count 3 months earlier was 473/μL, and she was adherent with her antiretroviral therapy. On physical examination her neck veins were normal, as were her carotid pulses. The chest was clear to auscultation. A 1+/4+ left parasternal (right ventricular) lift was felt, and the left ventricular impulse was normal. The first heart sound was loud and split. The second heart sound was loud and palpable in the second left intercostal space. Heard at the cardiac apex were a soft pansystolic murmur of mitral regurgitation and an early low-medium pitched third heart sound immediately followed by a typical diastolic murmur of mitral stenosis. An electrocardiogram was normal except for signs of left atrial enlargement: a negative terminal portion of the P wave in lead V1 ≥ 0.1 mV in amplitude and ≥ 0.04 seconds in duration (2); P waves in leads II, III, aVF, V3, and V4 ≥ 0.12 seconds in duration (3); and bifid with >0.04 seconds between the 2 peaks (4) in leads III and V3 (Figure). Figure. Electrocardiogram in a 28-year-old woman with exertional dyspnea for 6 months. See text for explication. An echocardiogram explained how a patient with a third heart sound could have a typical murmur of mitral stenosis by demonstrating a large left atrial myxoma that fell into the mitral orifice early in each diastole causing a “tumor plop” followed by a mitral stenosis murmur because the orifice of the valve was almost completely occluded. The mean diastolic pressure gradient across the mitral valve was 18 mm Hg as measured by echo-Doppler. Because the hemodynamics of left atrial myxoma and mitral stenosis are so similar, it is not surprising that both the physical exam and the electrocardiogram would be similar in the two conditions, with P waves suggesting left atrial enlargement being early electrocardiographic findings in both. The patient underwent uneventful operative removal of a 5 × 4 × 8.5 cm left atrial myxoma.

Balloon Valvuloplasty for Bioprosthetic Tricuspid Valve Stenosis

A 73-year-old woman was admitted to our hospital for a scheduled percutaneous transcatheter balloon valvuloplasty of a stenotic tricuspid bioprosthesis. The patient had a history consistent with exertional dyspnea, abdominal distension, and edema of the lower extremities resistant to diuretic treatment over the previous few months. Forty-three years prior, she underwent aortic valve replacement with a Starr-Edwards mechanical prosthetic valve, with a mean pressure gradient of 25 mm Hg, for aortic stenosis of rheumatic etiology (Fig. 1, white arrow). Furthermore, three years after aortic valve replacement the patient underwent mitral valve replacement with a bileaflet mechanical valve for mitral stenosis which had a stenotic portion (mean pressure gradient 10 mm Hg) (Fig. 1, black arrow), and tricuspid valve replacement with a Carpentier-Edwards bioprosthesis for tricuspid stenosis (Fig. 1, yellow arrow). On admission, the patient was on atrial fibrillation and physical examination was compatible with right heart failure. Echocardiography demonstrated severe tricuspid stenosis and a mild regurgitation. The mean diastolic gradient across the tricuspid valve was 15.4 mm Hg (Fig. 2A and B). Therefore, we proceeded to percutaneous valvuloplasty of the tricuspid valve using fluoroscopy, under regional anesthesia and sedation, inflating a 15×40-mm Inoue balloon up to a pressure of 15 atm (Fig. 1B).1),2) According to hemodynamic measurements, the gradient across the bioprosthetic tricuspid valve dropped from 13.0 mm Hg before to 6.0 mm Hg after dilation (Fig. 3), and on repeat echocardiography the mean diastolic gradient was decreased to 7.2 mm Hg without worsening of the regurgitation (Fig. 2C and D). The patient's symptoms soon improved; however, two months later she experienced a massive pulmonary hemorrhage while on heparin and acenocoumarol within therapeutic range, and died after a long hospitalization in the intensive care unit. Fig. 1 Fig. 2 Fig. 3

Electrocardiographic P-wave Indices as a Useful Tool to Predict Successful Percutaneous Balloon Mitral Valvotomy in Patients with Mitral Stenosis.

Introduction: Patients with hemodynamically significant mitral stenosis (MS) have prolonged P-wave duration and increased P-wave dispersion (PWD) that decrease after successful percutaneous balloon mitral valvotomy (PBMV). The purpose of this study was to investigate if the changes in these indices may predict a successful procedure. Methods: Fifty two patients with MS in sinus rhythm underwent PBMV (90.4% female; mean age 38±10 years). Mitral valve area (MVA), valve score, mean diastolic mitral gradient (mMVG), mitral regurgitation severity, and systolic pulmonary artery pressure (sPAP) were evaluated by echocardiography before PBMV and repeated after one month. P-wave duration (Pmax /Pmin) and PWD were measured before and immediately after PBMV, at discharge, and at the end of the first month after discharge. Results: Among all procedures, 38 (73.1%) were defined as successful. Mean age, valve score, mMVG, and MVA before PBMV were similar for both groups. MVA was significantly greater in the successful PBMV group (1.65±0.27 vs. 1.41±0.22; P= 0.003). sPAP was reduced after PBMV in all patients and there were no significant differences in the mean sPAP before and after PBMV in both successful and unsuccessful groups. Pmax and PWD were significantly decreased immediately after the procedure (P= 0.035), the next day (P= 0.005) and at one month (P= 0.002) only in patients with successful PBMV. Pmin did not change significantly in either group. Conclusion: Only is successful PBMV associated with a decrease in Pmax and PWD. These simple electrocardiographic indices may predict the success of the procedure immediately after PBMV.

Acute thrombosis of bioprosthetic mitral valve

We report a case of acute thrombosis of bioprosthetic mitral valve in a 59 year–old Korean female, who underwent a mitral valve replacement with a 25 mm Carpentier - Edwards PERIMOUNT Plus bioprosthesis (Edwards Lifesciences, Inc.; Irvine, CA, USA) and a mini-Maze procedure for correction of mitral stenosis (MS) and atrial fibrillation (AF). On the 10th postoperative day, the patient began to complain of increasing dyspnea and general malaise. Her symptoms worsened and developed into pulmonary edema. Echocardiography revealed a mean diastolic pressure gradient (MDPG) of 10 mmHg across the mitral valve and pressure-half time (PHT) of 166 msec. Due to progressive decompensated heart failure, the patient underwent a repeat sternotomy to replace the bioprosthetic mitral valve. Intraoperatively, we found a thrombosis around the bioprosthetic mitral valve. We excised the bioprosthetic mitral valve and replaced it with a 27 mm ATS mechanical valve (ATS medical, Inc.; Minneapolis, MN, USA). We experienced a rare case that required an early reoperation for a thrombosis of the bioprosthetic valve.

Transvenous, Antegrade Melody Valve-in-Valve Implantation for Bioprosthetic Mitral and Tricuspid Valve Dysfunction: A Case Series in Children and Adults

The purpose of this study was to report the results of percutaneous valve-in-valve therapy using the Melody valve (Medtronic, Minneapolis, Minnesota) for patients with degenerated mitral and tricuspid bioprosthetic valves. Open surgery for replacement of degenerated bioprosthetic valves is associated with morbidity and mortality. Nineteen patients (median age 65 years, range 10 to 88 years; 7 males) with degenerated mitral (n= 9) or tricuspid (n= 10) bioprosthetic valves underwent transvenous valve-in-valve implantation of the Melody valve. In the mitral patients, the mean Society of Thoracic Surgeons mortality score was 13.3 ± 5.6%. All patients had a prosthetic valve mean diastolic inflow gradient ≥5 mm Hg. Moderate or worse regurgitation was present in 7 of 9 mitral and 7 of 10 tricuspid patients. Implantation of a Melody valvewas successful in all. Among the mitral patients, mean diastolic gradient decreased from 12.3 ± 4.6 mm Hg to 5.2 ± 2 mm Hg (p < 0.01). Residual regurgitation was trivial to mild in 6, mild to moderate in 2, and moderate in 1 patient. Among the tricuspid patients, mean diastolic gradient decreased from 10.0 ± 4.3 mm Hg to 5.6 ± 2.5 mm Hg (p < 0.01). Residual regurgitation was trivial to mild in 9and mild to moderate in 1 patient. New York Heart Association functional class improved in 17 of 19patients (p < 0.01). No periprocedural deaths, myocardial infarctions, strokes, or valve embolizations occurred. Vascular access site complications occurred in 4 patients. Percutaneous valve-in-valve implantation of the Melody valve in the mitral or tricuspid position for treatment of bioprosthetic valve dysfunction is feasible and can lead to significant symptomatic improvement in carefully selected high-risk patients.

The prognostic impact of P wave dispersion in prediction of clinical outcome after percutaneous balloon mitarl valvuloplasty in patients with mitral stenosis and sinus rhythm

Objective: The aim of the study was to investigate the impact of P-maximum and P-wave dispersion on the long term clinical outcome after successful percutaneous balloon mitral valvuloplasty (PBMV) in patients with mitral stenosis (MS) and sinus rhythm. Also to test the correlation between P-variables and right ventricular function and pulmonary artery pressure before and after PMBV. Methods: Eighty-five patients undergoing PMBV were enrolled in this study. We evaluated P-maximum, P-minimum and P-wave dispersion before and one month after PBMV. We studied the changes in pulmonary arterial pressure (PAP), left atrial (LA) dimension, mitral diastolic gradient, and mitral valve area, in addition to the changes in right ventricular function utilizing tissue Doppler assessment both before and after PMBV, in addition the role of the P-wave dispersion in predicttion of late cardiac events. Results: There were significant decreases in mean diastolic gradient, PAP, and LA size and significant improvement in right ventricular tissue Doppler indices after PMBV. Ac- company these hemodynamic changes after PMBV. P-maximum and P-wave dispersion were found to be decreased (P off values of ≥62.8 msec for P-wave dispersion and 118 mes for P-maximum.ROC curve showed AUC of 0.919 for P-wave dispersion and 0.913 for P-maximum (P

P wave dispersion as a valuable marker in prediction of outcome of tricuspid regurgitation and improved right ventricular function after percutaneous balloon mitarl valvuloplasty in patients with mitral stenosis

To investigate the impact of P-wave dispersion (PWD) outcome of tricuspid regurgitation (TR) and right ventricular (RV) function after successful percutaneous mitral balloon valvuloplasty (PMBV) in patients with mitral stenosis (MS) and sinus rhythm. Seventy-eight consecutive patients undergoing PMBV were enrolled in this study. We evaluated PWD before and 1 month after PBMV. We studied the TR severity and RV function, in addition to the changes in pulmonary artery pressure (PAP), left atrial (LA) dimension, mitral diastolic gradient, and mitral valve area, the changes before and after PMBV. Patients with TR regression and improved RV function were classified as group A and those without regression of TR were classified as group B. There were significant decreases in mean diastolic gradient, PAP, and LA size, significant regression of TR from moderate-severe TR to mild TR and improvement in RV function after PMBV. PWD significantly decreased (P < 0.001). Group B patients during follow-up had a higher PWD than those in group A (P < 0.001). It was revealed with linear regression and correlation analysis that the degree of changes in PWD were correlated with development of regression of TR and improved RV funcion after PMBV. P-wave maximum and dispersion are significantly increased in patients with MS. They decreased significantly after PMBV. They were significantly correlated with TR severity and impairment of right ventricular function and the degree of PAP. P maximum and dispersion could be considered as independent predictors of TR regression and improved RV functionin patients with MS after PMBV.

Lost and Found : Catastrophic en Block Embolism of a Mechanical Prosthetic Valve Thrombus after Thrombolytic Therapy

A 45-year-old woman presented with refractory pulmonary oedema secondary to a massive thrombosis of a St. Jude mechanical mitral prosthetic valve. She was noncompliant with warfarin and had suffered embolic stroke 3 years earlier, from which she had recovered. She was in sinus rhythm with absent valve clicks on auscultation. A transthoracic echocardiogram revealed a high transmitral peak gradient of 34 mmHg and a mean gradient of 27 mmHg with an ejection fraction of 55% [Figure 1A]. The international normalised ratio (INR) was 1.29. An urgent transesophageal echocardiogram (TEE) demonstrated a large (6 cm2) left atrial thrombus attached to the mechanical valve at the discs which were stuck in a closed position [Figures 1B and ​and1C1C]. Figure 1: (A) Transthoracic echocardiography showing mean diastolic mechanical mitral valve transvalvular gradient of 27 mmHg and a peak gradient of 34 mmHg in a patient with prosthetic valve thrombosis. (B) Transesophageal echocardiography demonstrating stuck ... The patient was advised to have emergency surgery, but she and the family refused. In spite of explaining the risks involved in thrombolysing a large clot, the patient and the family preferred thrombolytic therapy. As a life-saving measure, patient was thrombolysed with 10 units of reteplase intravenously over 2 minutes with a repeat dose of 10 units administered 30 minutes later. After an hour of thrombolysis a repeat TEE showed complete disappearance of the thrombus from the left atrium with one of the discs stuck in closed position [Figures 2 A and B]. The peak transmitral gradient was 7 mmHg and the mean gradient was 4 mmHg [Figure 2C]. Immediately, the patient started to complain of severe pain in the left leg with cold periphery and absent femoral pulse on both sides. An urgent computed tomography angiogram of the abdomen, pelvis and legs demonstrated complete occlusion of left common iliac artery and right common femoral artery with reformation of distal arteries [Figures 3A, B and C]. An emergency open bilateral ilio-femoral embolectomy was performed and a large thrombus removed from the left common iliac artery [Figure 4 A and B]. Unfortunately, the patient developed refractory sepsis with acute renal shut down and died after 10 days of admission. Figure 2: (A) Transesophageal echocardiography demonstrating disappearance of a large left atrial thrombus attached to a stuck mechanical valve after thrombolysis with reteplase. Note the bileaflet mechanical valve in closed position. (B) Transesophageal echocardiography ... Figure 3: Contrast-enhanced computed tomography (CT) scan in axial (A) view showing presence of contrast in the right common iliac artery (arrowheads) with absence of opacification of left common iliac artery in a patient with prosthetic valve thrombosis treated ... Figure 4: (A) Intra-operative image of a large thrombus protruding from left common iliac artery in a patient with prosthetic valve thrombosis treated with thrombolysis. (B) Image of a large thrombus explanted en bloc from left common iliac artery in the patient ... The incidence of left-sided prosthetic valve thrombosis (PVT) ranges from 0.5% to 0.8% per patient-year.1,2 The mortality of obstructive PVT is about 10% irrespective of the treatment strategy.1 The American College of Cardiology/American Heart Association (ACC/AHA) and American College of Chest Physicians guidelines recommend fibrinolytic therapy as first-line treatment for patients in good functional class with low thrombus burden ( 0.8cm2).3,4 Furthermore, in the following groups of patients surgery is advised, namely: 1) patients with large left atrial thrombus; 2) patients with any active bleeding or a history of intracranial bleeding; 3) patients with evidence of ischaemic stroke from 4 hours to six weeks, and 4) post-valve replacement within 4 days.1 The major complication of thrombolytic treatment for PVT is the risk of embolisation which occurs in 12–15% of the cases.3 A registry study demonstrated that thrombus size on TEE and a past history of stroke were independent predictors of complications as seen in this patient.2 Left atrial thrombi are also known to embolise at the time of, or shortly after a change in atrial rhythm.5 In this case, there was not only obstructive PVT, but it was associated with a large left atrial thrombus and hence surgery was the initial choice of treatment. However, the patient refused surgery and was thrombolysed with catastrophic embolism.

Early post-operative thrombosis of the prosthetic mitral valve in patient with heparin-induced thrombocytopenia

Heparin-induced thrombocytopenia (HIT) is one of the most common immune-mediated adverse drug reactions, with frequencies as high as 2-3% for certain groups of post-cardiac surgery patients. We report on an 50-year-old woman with early post-operative thrombosis of the prosthetic mitral valve due to heparin-induced thrombocytopenia. Non-invasive imaging (two-dimensional transesophageal echocardiography; 2D-TEE) allowed the exact localisation of thrombotic masses and revealed the increase of the mean diastolic mitral gradient. The HIT diagnosis was proved by the clinical scoring system, and with the identification of heparin platelet factor 4-induced antibodies. After the withdrawal of LMWH therapy and the start of intravenous lepirudin treatment, the patient's medical condition improved continuously. Follow-up echocardiography showed a step-wise decrease in the severity of the mean diastolic mitral valve gradient and a complete resolution of thrombus formations. Perhaps we may remind ourselves that, whilst HIT is one of the most common immune-mediated adverse drug reactions for certain groups of post-cardiac surgery patients, it can be managed successfully. We would also stress the importance of serial 2D-TEE examinations in the early post-operative period.

Valvular heart disease: plasma B-type natriuretic peptide levels in patients with pure rheumatic mitral stenosis

Objective Our study is designed to evaluate the plasma BNP levels in patients with pure MS and its possible correlation with clinical and echocardiography parameters of the disease.Methods and results The study included 29 patients (27 women, 2 men, mean age 43.4 ± 11.8 y) with pure mitral valve stenosis in sinus rhythm and 24 age-and gender-matched healthy voluteers (17 women, 7 men, mean age 42 ± 13 y). Plasma BNP levels were significantly higher in the mitral stenosis group compared to controls (91.1 ± 69.6 pg/ml vs 14.4 ± 9.2 pg/ml, P < 0.0001). In univariate analysis, plasma BNP levels correlated positively with left ventricular end-systolic diameter (r = 0.439, P=0.041), left atrial diameter (r = 0.772, P < 0.001), peak diastolic transmitral gradient (r = 0.621, P=0.003), mean diastolic transmitral gradient (r = 0.751, P < 0.001), peak systolic pulmonary artery pressure (r = 0.467, P=0.044), functional capacity (r = 0.819, P < 0.001) and negatively with left ventricular ejection fraction (r = -0.482, P=0.020) and planimetric mitral valve area (r = -0.494, P=0.006). No significant correlation existed between age, end-diastolic diameter and right ventricular diameter (r=0.185, P = 0.337; r=0.227, P = 0.309; r=0.319, P = 0.092; respectively). A receiver operating characteristic (ROC) curve identified a BNP value of 32 pg/ml as the best cut-off for the identification of patients with mitral stenosis with a positive predictive value of 100% and a negative predictive value of 75%.Conclusions In this study we found elevated plasma BNP levels in patients with pure MS in sinus rhythm. Plasma BNP levels correlated with disease severity and this can have potential clinical implications, for example in patients undergoing percutaneous balloon mitral valvuloplasty or in patients with poor echocardiographic windows.