Mean Mitral Valve Gradient Research Articles

Early and Midterm Outcomes of Rheumatic Mitral Valve Repair.

Rheumatic heart disease (RHD) is the leading cause of mitral valve disease in the developing world. In general, mitral valve repair is preferred over replacement. Although it is very successful in degenerative disease, its results in the rheumatic valve are not as successful as that for degenerative repair. Our approach has been to repair rheumatic mitral valves when the anatomic substrate appears to permit it, and we aimed by this study to present our immediate and midterm follow-ups of our cohort of rheumatic valve repair patients. From February 2011 to March 2013, 52 consecutive patients underwent mitral valve repair for rheumatic disease with different surgical techniques at the National Heart Institute of Egypt. Patients who had concomitant aortic or coronary artery bypass surgery were excluded. Also, patients needing an emergency operation or redo ones were excluded. On the contrary, patients who had concomitant tricuspid valve surgery were included. Demographic, intraoperative, and perioperative outcome data were recorded prospectively. All patients underwent TTE before hospital discharge. During follow-up, patients were contacted by telephone and invited for follow-up TTE yearly after their operations. Fifty-two patients with rheumatic disease underwent mitral repair. Their mean age was 25.92 ± 9.81 years. The study population was 78.8% female. Forty-nine patients were in New York Heart Association functional class III or IV. Repair procedures included implantation of Carpentier-Edwards Classic mitral annuloplasty ring (100% of the whole study group). Mitral commissurotomy and repair of the subvalvular apparatus were generally performed. Thirteen neochordae were implanted. Anterior leaflet extension with an autologous pericardial patch was used in 4 patients; annular decalcification, in 2 patients; tricuspid repair with De Vega technique, in 18 patients (34.5%); and repair with Carpentier-Edwards Classic tricuspid annuloplasty ring, in 9 (17.3%) patients. There was no operative mortality. The mean follow-up time was 59.9 ± 5 postoperative months (range, 49-60 months). Only 2 patients (3.8%) died. Follow-up echocardiography revealed more-than-or-equal-to-moderate (2+) grade of MR in 5 patients. During the follow-up period, the mean LV end-diastolic diameter decreased significantly from 5.57 ± 1.06 cm to 4.93 ± 0.74 cm (<0.001). The mean pulmonary artery pressure decreased from 44.94 ± 17.01 mmHg to 35.69 ± 7.92 mmHg postoperatively (P < .001). The mean mitral valve area increased from 1.2 ± 0.9 cm2 to 2.3 ± 0.2 cm2 postoperatively (P < .001). The mean mitral valve gradient decreased significantly from 12 ± 4.9 mmHg to 4.3 ± 1.9 mmHg postoperatively (P < .001). The mean MR grade decreased from 3.73 ± 0.45 to 0.96 ± 1.08 postoperatively (P < .001). We conclude that repair is possible in patients with rheumatic mitral valve dysfunction. Current techniques with some modifications can be efficient to restore both the anatomy and physiology (better function) of the mitral valve and can lead to favorable early and midterm outcomes. We, therefore, recommend that the number of rheumatic mitral repair procedures should be increased in developing countries to achieve the best results.

Acute Thrombosis of Bioprosthetic Mitral Valve Secondary to Peri-Operative VA-ECMO; The Dangers of Flow Stasis in the Left Atrium

Case report Veno-Arterial (VA) ECMO has been used to help patients recover from cardiogenic shock. VA-ECMO can complicate recovery due to the increase in afterload and decreased flow through the left sided chambers. We present a case of acute bioprosthetic mitral valve (MV) thrombosis in a patient who developed peri-operative cardiogenic shock. A 63 year-old male admitted for acute systolic heart failure found to have coronary artery disease and valvular heart disease underwent MV replacement, tricuspid valve repair and three vessel coronary artery bypass grafting. He developed intraoperative mediastinal bleeding requiring fresh frozen plasma, cryoprecipitate, and factor VII. The patient was unable to be weaned off cardiopulmonary bypass secondary to right ventricular failure. The patient remained centrally cannulated for VA-ECMO and had placement of a femoral intra-aortic balloon pump. The patient was transferred to the ICU in shock and on multiple vasopressors. Due to ongoing mediastinal bleeding, initiation of systemic anticoagulation was delayed by 48 hours. The intraoperative transesophageal echocardiogram (TEE) initially demonstrated a normally functioning bioprosthetic MV. The final intraoperative TEE images following conversion to VA-ECMO showed a poorly opening bioprosthetic MV, Image 1 . A TEE on postoperative day (POD) 2 demonstrated abnormal mobility of the bioprosthetic MV leaflets, left appendage thrombus and smoke-like echogenicity in the left atrium, Image 2 . On POD 5, a TEE demonstrated mean MV gradient of 22 mmHg and worsening of MV mobility secondary to thrombus, Image 3 . Because of concern for MV thrombosis, the patient was taken to the catheterization lab for placement of LV catheter to confirm MV stenosis. A thrombolytic agent was infused via a pulmonary artery (PA) catheter in order to attempt lysis of the MV thrombus. On POD 9, the PA systolic pressures reduced from 50 mmHg to 30 mmHg and the VA-ECMO flow requirements were reduced from 5 to 3.5 Liters per minute. Despite this small improvement in hemodynamics his overall clinical status did not improve. Ultimately the family decided to withdraw care. A post-mortem examination confirmed MV stenosis secondary to thrombosis of the valve extending into the left atrial appendage. Patients in cardiogenic shock who are placed on VA-ECMO are extremely sensitive to the high afterload created by retrograde arterial flow. Our patient developed severe thrombotic MV stenosis secondary to left atrial circulatory stasis when VA-ECMO was initiated. Maintaining adequate left sided flow is crucial to reduce the risk of thrombosis.

Long-Term Outcomes Comparing Minimally Invasive Mitral Valve Repair versus Conventional Mitral Valve Surgery

Objectives: To compare the long term outcomes between minimally invasive mitral valve repair (MiMVR) and conventional surgery. Current retrospective comparisons between the techniques frequently report echocardiographical (echo) outcomes early after surgery and rarely report them later. Methods: Patients were selected for MiMVR by the surgical multi-disciplinary meeting from June 2008-March 2013. Patients included had at least two transthoracic post-operative echocardiograms. Echocardiographic parameters including left ventricular size and systolic function, degree of mitral regurgitation (MR) and mean mitral valve gradient were recorded. Clinical outcomes including all-cause mortality, re-operation, recurrence of at least moderate MR and elevated mean mitral valve gradients > 5 mmHg were recorded and compared using Kaplan-Meier survival analysis. Results: 223 patients were screened, 96 (43%) met the criteria and were included. Thirty-seven patients underwent conventional surgery and 59 underwent MiMVR. Mean clinical follow-up was 6.3 years and echo follow up was 3.2 years. There was a significantly higher recurrence of moderate MR in the conventional group (38% (n = 19) versus 17% (n = 10)). The mean LV end-diastolic diameter was 4.8 cm (conventional) versus 5.0 cm (MiMVR). The incidence of elevated PG was 26% (n = 13, conventional) and 23% (n = 14, MiMVR). There was no significant difference in incidence in re-operation (conventional 12% (n = 6), MiMVR 8.3% (n = 5)). Long-term mortality was higher in the conventional group (1.7% vs. 18% p = 0.004) although the logistic Euroscore was significantly higher 6.8% ± 5.4 vs. 3.6% ± 1.6. Conclusions: Minimally invasive mitral valve surgery is safe and feasible in selected patients with good medium and long-term echocardiographic follow-up.

Repeated MitraClip procedure in patients with recurrent MR after a successful first procedure: Limitations and outcome.

The present study aimed to evaluate the outcome and potential limitations of a repeated MitraClip procedure (ReClip). The MitraClip procedure has emerged as a treatment option in high surgical risk patients suffering from severe mitral regurgitation (MR). However, despite successful initial repair a significant number of patients develops severe recurrent MR. Patients undergoing a ReClip procedure in our institution were retrospectively identified. Baseline data and the procedural outcome were assessed to identify potential limitations of such procedures. Fifteen out of 234 patients undergoing a mitral-valve repair with the MitraClip device (Abbott Vascular) underwent a ReClip due to recurrent MR. In 11 patients, a MR reduction of at least one degree without causing mitral valve stenosis (trans-mitral mean gradient ≥5 mmHg) was achieved by performing a ReClip. After 1 year, two patients developed severe recurrent MR again. Pulmonary artery pressures significantly decreased after the procedure in individuals with successful repair (MR reduction of at least one degree and mitral valve mean gradient <5 mmHg). A ReClip procedure may be feasible in patients with recurrent MR but the risk benefit ratio should be carefully balanced against other treatment options.

Abstract 23079: Clinical Outcomes of Transcatheter Mitral Valve Replacement for Degenerated Mitral Bioprostheses (Mitral Valve-in-Valve) and Surgical Rings (Mitral Valve-in-Ring) in the United States: Data From the STS/ACC/TVT Registry

Introduction: Transcatheter mitral valve replacement (TMVR) using aortic transcatheter heart valves (THV) is developing as an alternative to surgery for patients with severe mitral valve disease due to degenerated mitral bioprostheses or failed surgical rings who are poor surgical candidates. Outcomes of off-label procedures in the United States are being collected in the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy (STS/ACC TVT) Registry. A comprehensive analysis of mitral Valve-in-Valve (VIV) versus Valve-in-Ring (VIR) outcomes has not previously been performed. Objectives: To evaluate in-hospital and 30-day clinical outcomes of mitral VIV and VIR procedures in the United States. Methods: Retrospective analysis of data from the STS/ACC TVT Registry on patients who underwent mitral VIV or VIR procedures. Results: 587 patients underwent TMVR VIV (n=494) or VIR (n=93) procedures between January 2013 and December 2016 at 144 hospitals. Median age was 76 (VIV) and 73 (VIR) years, (p=0.024), 60.9% (VIV) and 44.1% (VIR) were female (p=0.003), median left ventricular ejection fraction was 55% in VIV and 50% in VIR (p &lt;0.001), and median STS score was 10.5% (VIV) and 9.2% (VIR), p=0.131. Transseptal access was utilized in 35% VIV and 46.2% VIR procedures, p=0.081. Procedural success was achieved in 74.4% of VIV and 57.8%VIR (p=0.239). Left ventricular outflow tract (LVOT) obstruction was more common in VIR (5.4%) vs VIV (0.06%), p=0.003. Post-procedure median mean mitral valve gradient was 4mmHg in both groups. 95.7% of VIV and 86% of VIR patients had post-procedure mitral regurgitation ≤1(+), p&lt;0.001. In-hospital mortality was 6.9% for VIV and 9.7% for VIR (p=0.343). 30-day mortality was 9% for VIV and 12% for VIR (p=0.387). At 30-day follow up, 85.6% of VIV and 77.7% of VIR patients were in New York Heart Association class I or II (p=0.398). Conclusions: TMVR VIV and VIR using aortic transcatheter heart valves in high surgical risk patients are associated with similar in-hospital and 30-day mortality and symptom benefit. LVOT obstruction post-TMVR and residual mitral regurgitation ≥2 (+) were more frequent in VIR procedures. The long-term effect of these procedures is not known and requires further evaluation.

Pulmonary arterial pressure detects functional mitral stenosis after annuloplasty for primary mitral regurgitation: An exercise stress echocardiographic study.

The restrictive mitral valve annuloplasty (RMA) is the treatment of choice for degenerative mitral regurgitation (MR), but postoperative functional mitral stenosis remains a matter of debate. In this study, we sought to determine the impact of mitral stenosis on the functional capacity of patients. In a cross-sectional study, 32 patients with degenerative MR who underwent RMA using a complete ring were evaluated. All participants performed treadmill exercise test and underwent echocardiographic examinations before and after exercise. The patients' mean age was 50.1±12.5years. After a mean follow-up of 14.1±5.9months (6-32months), the number of patients with a mitral valve peak gradient >7.5mmHg, a mitral valve mean gradient >3mmHg, and a pulmonary arterial pressure (PAP) ≥25mmHg at rest were 50%, 40.6%, and 62.5%, respectively. 13 patients (40.6%) had incomplete treadmill exercise test. All hemodynamic parameters were higher at peak exercise compared with at rest levels (all P<.05). The PAP at rest and at peak exercise as well as peak transmitral gradient at peak exercise were higher in patients with incomplete exercise compared with complete exercise test (all P<.05). The PAP at rest (a sensitivity and a specificity of 84.6% and 52.6%, respectively; area under the curve [AUC]=.755) and at peak exercise (a sensitivity and a specificity of 100% and 47.4%, respectively; AUC=.755) discriminated incomplete exercise test. The RMA for degenerative MR was associated with a functional stenosis and the PAP at rest and at peak exercise discriminated low exercise capacity.

Transcatheter Mitral Valve Replacement for Degenerated Bioprosthetic Valves and Failed Annuloplasty Rings

BackgroundLimited data exist regarding transcatheter mitral valve replacement (TMVR) for patients with failed mitral valve replacement and repair. ObjectivesThis study sought to evaluate the outcomes of TMVR in patients with failed mitral bioprosthetic valves (valve-in-valve [ViV]) and annuloplasty rings (valve-in-ring [ViR]). MethodsFrom the TMVR multicenter registry, procedural and clinical outcomes of mitral ViV and ViR were compared according to Mitral Valve Academic Research Consortium criteria. ResultsA total of 248 patients with mean Society of Thoracic Surgeons score of 8.9 ± 6.8% underwent TMVR. Transseptal access and the balloon-expandable valve were used in 33.1% and 89.9%, respectively. Compared with 176 patients undergoing ViV, 72 patients undergoing ViR had lower left ventricular ejection fraction (45.6 ± 17.4% vs. 55.3 ± 11.1%; p < 0.001). Overall technical and device success rates were acceptable, at 92.3% and 85.5%, respectively. However, compared with the ViV group, the ViR group had lower technical success (83.3% vs. 96.0%; p = 0.001) due to more frequent second valve implantation (11.1% vs. 2.8%; p = 0.008), and lower device success (76.4% vs. 89.2%; p = 0.009) due to more frequent reintervention (16.7% vs. 7.4%; p = 0.03). Mean mitral valve gradients were similar between groups (6.4 ± 2.3 mm Hg vs. 5.8 ± 2.7 mm Hg; p = 0.17), whereas the ViR group had more frequent post-procedural mitral regurgitation moderate or higher (19.4% vs. 6.8%; p = 0.003). Furthermore, the ViR group had more frequent life-threatening bleeding (8.3% vs. 2.3%; p = 0.03), acute kidney injury (11.1% vs. 4.0%; p = 0.03), and subsequent lower procedural success (58.3% vs. 79.5%; p = 0.001). The 1-year all-cause mortality rate was significantly higher in the ViR group compared with the ViV group (28.7% vs. 12.6%; log-rank test, p = 0.01). On multivariable analysis, failed annuloplasty ring was independently associated with all-cause mortality (hazard ratio: 2.70; 95% confidence interval: 1.34 to 5.43; p = 0.005). ConclusionsThe TMVR procedure provided acceptable outcomes in high-risk patients with degenerated bioprostheses or failed annuloplasty rings, but mitral ViR was associated with higher rates of procedural complications and mid-term mortality compared with mitral ViV.

Randomised trial of mitral valve repair with leaflet resection versus leaflet preservation on functional mitral stenosis (The CAMRA CardioLink-2 Trial)

BackgroundThe gold-standard treatment of severe mitral regurgitation (MR) due to degenerative disease is valve repair, which is surgically performed with either a leaflet resection or leaflet preservation approach. Recent data...

Assessment of Mitral Valve Repair With Exercise Echocardiography: Artificial Chordae vs Leaflet Resection

Mitral valve (MV) repair with artificial chordae (AC) or leaflet resection (LR) is associated with good hemodynamics at rest. The aim of this study was to compare these techniques in terms of exercise capacity and echocardiographic parameters of hemodynamics at rest and peak exercise. We conducted a study in 2015 of 56 patients, who had undergone surgery for degenerative posterior mitral leaflet prolapse between 2005 and 2014 using either AC (n = 24) or LR (n = 32). Clinical data were collected, exercise capacity was measured, and resting echocardiography and peak exercise echocardiography were performed. No significant differences were detected among groups regarding exercise duration or peak exercise workload measured in Watts (W) (AC: 136 ± 43 W and LR: 131 ± 40 W; P = 0.65). The mean mitral gradient at rest was 3.0 ± 1.3 mm Hg in the AC group and 3.0 ± 1.0 mm Hg in the LR group (P = 0.90). The mean MV gradients at peak exercise did not differ significantly between groups (AC: 8.3 ± 3.4 and LR: 11.3 ± 8.7; P = 0.19). Four patients (17%) in the AC group and 1 (3%) in the LR group had systolic anterior motion, P = 0.15. We conclude that both methods of posterior MV leaflet repair were associated with good hemodynamics at rest and peak exercise. The groups had comparable exercise capacity. MV pressure gradients at rest and peak exercise were similar in both groups.

Regression of right ventricular systolic pressure after successful percutaneous mitral commissurotomy in patients with isolated severe mitral stenosis.

Objective:To know the regression of right ventricular pressure after successful percutaneous transluminalmitral commissurotomy (PTMC) in patients with severe isolated mitral stenosis.Methods:This descriptive study was performed in inpatient and outpatient department of National Institute of Cardiovascular Disease from 1st February 2016 to 31st August 2016. Echocardiography of all patients with successful PTMC were recorded 24 hours and 06 months following PTMC to see for Regression of right ventricular pressure along with other baseline echocardiographic parameters.Results:A total of 99 patients with severe isolated mitral stenosis who had undergone successful PTMC were studied. Females were 65(65.7%) and males 34(34.3%). Mean age was 27.44±6.26 years. TTE performed before and after PTMC showed significant difference in mean mitral valve area (0.89cm ±0.089cm2 vs. 1.68±0.128 cm2, p valve <0.001) and mean left atrial diameter (4.66± .82cm vs. 4.46± 0.65cm). Mean mitral valve gradient pre PTMC was significantly higher (16.38±2.51 mm of Hg) than that of post PTMC 24 hours (4.75±1.31 mm of Hg) and Post PTMC 06 months (5.22±1.21 mm of Hg), p valve <0.001. Mean right ventricular systolic pressure (RVSP) pre PTMC was significantly higher 62.3±10.91 mm of Hg than that of post PTMC 24 hour’s 57.51±9.67 mm of Hg and post PTMC 06 moths 46.49±7.8mm of Hg, p value 0.001. Mean LVEF 50.14± 5.82.Conclusion:There was a significant regression of right ventricular pressure following successful PTMC in mid-term (06 months) follow up of severe isolated mitral stenosis patients.

Percutaneous Trans-Mitral Commissurotomy in the Contemporary Era, Real Time Experience and a Retrospective Analysis

Rheumatic mitral stenosis is a rare disease nowadays. In the Kingdom of Saudi Arabia and at King Abdulaziz University Hospital, we still see annually a few cases of advanced cases of rheumatic mitral stenosis among adult patients requiring hospital admission and urgent interventional treatment. We opt to study retrospectively the clinical presentation, techniques, outcomes, complications, and predictors of mortality related to percutaneous balloon intervention in patients with symptomatic mitral stenosis who were treated at King Abdulaziz University Hospital between 2009 and 2015. Among 6536 adult admissions over a 6-year time period, there were 21 new cases of symptomatic, echo-confirmed mitral stenosis (3/1000); only 6 cases (28.6%) were eligible for intervention. In the intervention group the mean age was 38; 83% were female; 50% Non-Saudi. In five (83%) out of six cases balloon valvuloplasty had increased mitral valve area by 0.596 ± 0.312 and reduced the mean mitral valve gradient by 6 ± 3.847 (p = 0.05 and 0.012, respectively). The most important predictor of successful dilation to valve area above 1.5 was Wilkin's score. Two indirect deaths occurred in a 6-month follow-up period and were correlated to age of 45 and above with initial presentation of either stroke, or pulmonary hypertension (mean pulmonary artery pressure &gt; 45) and refractory heart failure.

Echocardiographic parameters for assessing successful balloon mitral valvuloplasty in juvenile age groups.

Different echocardiographic parameters have been studied and validated for assessing the severity of mitral stenosis; however, scant data are available for these markers in the context of balloon mitral valvuloplasty in juvenile age groups (ages ⩽20 years). The aim of the present study was to find out the utility of echocardiographic parameters such as mitral valve separation index, left atrial volume, right ventricular systolic pressure, tricuspid annular plane systolic excursion, tricuspid annular systolic velocity, and right ventricular Tei index in predicting success of balloon mitral valvuloplasty and their relation to mitral valve area in juvenile mitral stenosis. We carried out a prospective single-centre study involving 52 juvenile mitral stenosis patients undergoing elective valvuloplasty. Success was defined as an increase in mitral valve area ⩾50% or ⩾1.5 cm2. Echocardiographic measurements were taken before and 24 hours after the procedure and statistical analyses were carried out. The mean age of the study population was 14.3 years (SD ±4.55), ranging from 7 to 20 years. Valvuloplasty was successful in 49 out of 52 patients. The mean valve area improved from 0.89 (SD ±0.16) to 1.73 (SD ±0.22) cm2/m2 (p<0.01), and the mean mitral valve gradient decreased from 19.87 (SD ±7.89) to 7.45 (SD ±2.07) (p=0.021). All the surrogate parameters improved favourably after valvuloplasty (p<0.01). The decrease in right ventricular systolic pressure was a better indicator of the success followed by the increase in valve separation index (area under the curve 0.81 and 0.76, respectively). All the surrogate markers studied showed favourable improvement, and right ventricular systolic pressure reduction and improved mitral valve separation index were better indicators of successful valvuloplasty.

Abstract 13739: Progression of Mitral Stenosis in Patients With Severe Mitral Annular Calcification and Chronic Kidney Disease

Background: Severe mitral annular calcification (MAC) is recognized as a rare cause of mitral stenosis. However, little is known regarding its relationship with chronic kidney’s disease (CKD). We evaluated progression of mean mitral valve (MV) gradients and the right ventricular systolic pressures (RVSP) over time in patients with CKD. Methods: Database for the years 1996 through 2013 was searched for patients with severe MAC. MAC was graded in a semi-quantitative manner. Patients were included if they had severe MAC at their index study, had ≥ 2 studies in the period of ≥ 2 years, and had glomerular filtration rate estimated ≤ 3 months from the index study. Patients with prior MV surgery, rheumatic heart disease, or other MV disease were excluded. CKD was classified by 5 conventional stages. The slope of regression line using all studies of a given patient was used to determine the progression rate. Results: 924 patients (7002 studies) were included. Data are expressed as mean ± standard deviation. Study population age was 72 ± 11 years. Follow up time was 4.8 ± 2.8 years. Number of echocardiograms performed per patient was 8 ± 5. Index MV gradient was 3.9 ± 3.2 mmHg with progression rate 0.13 ± 0.86 mmHg / year (p = 0.0001). Index RVSP was 39 ± 15 mmHg with progression rate 0.97 ± 4.49 mmHg / year (p = 0.0001). Progression appeared slower in younger (&lt;65, n=189) than older (≥65, n = 735) patients (MV gradient p=0.07, RVSP p= 0.10). 66 patients had MV surgery with MV gradient at the time of surgery being 13.76 ± 4.15 mmHg. There were no significant differences in the progression rate among CKD stages (MV gradient p = 0.11, RVSP p = 0.87) or with dialysis status (n=41, MV gradient p= 0.50, RVSP p= 0.13). Conclusion: While there tended to be faster rate of progression of mitral stenosis in older patients with severe MAC, CKD class was not a differentiating factor. It appears that mitral stenosis in patients with severe MAC progress more in older patients but not necessarily in patients with poor kidney function.

Mitral valve gradient after valve repair of degenerative regurgitation with restrictive annuloplasty

BackgroundsOutcomes of mitral valve repair have been well described for patients with degenerative regurgitation. The hemodynamic effects of repair have not been as well studied, however. We report hemodynamic outcomes in these patients. MethodsWe reviewed 1147 patients who underwent isolated mitral valve repair for degenerative mitral valve regurgitation between January 2004 and December 2013. Baseline characteristics included mean age 58.6 ± 13.4 years, male sex in 792 patients (69.1%), mean ejection fraction of 0.64 ± 0.07, and New York Heart Association class III/IV dyspnea in 215 patients (18.8%). ResultsMitral valve repair involved the posterior leaflet in 764 patients (66.6%), anterior leaflet in 57 patients (5.0%), both leaflets in 260 patients (22.7%), and annuloplasty alone in 66 patients (5.8%). Among the patients who underwent posterior leaflet repair, 713 (93.3%) were treated with our standard technique of triangular leaflet resection/plication and repair with partial posterior band annuloplasty using an unmeasured 63-mm flexible band. Follow-up echocardiography data were obtained in 1138 survivors (99.4%) at 600 ± 880 days. Mild or less valve regurgitation was present at last follow-up in 1030 patients (90.5%). The mean mitral valve gradient was 3.1 ± 1.4 mm Hg in the operating room and 3.5 ± 1.6 mm Hg at the last follow-up (P < .001). The mean mitral valve gradient decreased from the first to the second median time periods (124.5 days) of follow-up (3.7 ± 1.6 mm Hg to 3.3 ± 1.8 mm Hg; P < .001). ConclusionsMitral valve repair for degenerative regurgitation results in a small mitral valve gradient that appears to decrease with time after discharge.

Preoperative and predischarge predictors for persistent pulmonary hypertension after mitral valve surgery in patients with chronic organic mitral regurgitation

Objectives. This study sought to evaluate the prevalence of pulmonary hypertension after mitral valve surgery ini patients with chronic organic mitral regurgitation and to determine preoperative and predischarge predictors for persistent pulmonary hypertension after surgeryMethods. This is a cohort retrospective study involving subjects with chronic organic mitral regurgitation with preoperative systolic PA pressure &gt; 50 mmHg undergoing surgery. Demographic and echocardiography datas were collected prior to surgery, predischarge, and follow up datas were evaluated after minimal 6 months duration. Subjects were then devided into groups based on existence of persistent pulmonary hypertension after follow up. Bivariate and multivariate analysis was done to determine contributing factors.Results.There were 92 subjects with dominant mitral regurgitation included in this study with median age 40 (range 17-68) years with slight female predominance (55%). Persistent pulmonary hypertension was observed in 23 subjects (25%) predischarge and in 20 subjects (20.7%) after mean follow up of 11 + 5.5 months. Bivariate analysis revealed preoperative TAPSE, underlying etiology, severity of pulmonary hypertension preoperatively, postoperative atrial fibrilation, mean mitral valve gradient predischarge, and the presence of residual pulmonary hypertension predischarge were related with persistent pulmonary hypertension. From multivariate analysis, post operative atrial fibrillation [OR 7.3 (CI 95% 1.64-33.33, p=0.09)], mean mitral valve gradient predischarge [OR 1.67 (CI 95% 1,3-2.7, p=0.038)], and preoperative TAPSE [OR 0.143 (CI 95% 0.03-0.70, p=0.017)] were independent predictors for persistent pulmonary hypertension after mitral valve surgery.Conclusion. Persistent pulmonary hypertension was observed in 20.7% subjects after mitral valve surgery. Preoperative TAPSE, post operative atrial fibrillation, and predischarge mean mitral valve gradient were independent predictors.

0019 : Supravalvular mitral ring: an underestimated form of congenital mitral stenosis

The congenital supravalvular mitral ring is a rare subtype of congenital mitral stenosis. This form is poorly understood and thus underestimated. It has a good prognosis with appropriate management. The identification of this entity remains unrevealed in the literature, only less than 100 cases were reported. The aim of this study was to share the diagnostic and therapeutic experiences of the Casablanca pediatric cardiology unit. Between December 2008 and January 2014, 1927 patients with congenital heart disease were collected retrospectively in the Ibn Rochd cardiology department of Casablanca university hospital. 19 patients had congenital mitral stenosis (0.01% of the entire series), 8 of them were related to a supravalvular mitral ring. The sex ratio M / F was 1: 1. The median age was 10 months [5-168]. For all patients, the diagnosis was made by echocardiography. The average mean mitral valve gradient was 14± .8mmHg. Associated anomalies were: interventricular communication (n=3), coarctation of the aorta alone (n=1), coarctation of the aorta associated with a bicuspid aortic valve (n=2), Double Outlet Right Ventricle (DORV) (n=1) and a complex congenital cardiopathy (n=1). The surgery was indicated to 7 patients; the 8th patient had DORV with Eisenmenger. The supra-mitral ring was surgically resected to 4 patients with a good surgical outcome, 2 patients are awaiting for surgery and one patient was lost to view. No deaths per or postoperative were noted. The supravalvular mitral ring is a rare variety of congenital mitral stenosis. It is often underestimated and potentially serious. The echocardiography is the diagnosis key. Surgical treatment is usually indicated. After resection, the prognosis is good without risk of recurrence and that improves long-term survival.

Left atrial asynchrony and mechanical function in patients with mitral stenosis before and immediately after percutaneous balloon mitral valvuloplasty: a real time three-dimensional echocardiography study.

This study evaluated the feasibility of assessing left atrium (LA) function and asynchrony in patients with rheumatic mitral stenosis (MS) before and immediately after percutaneous balloon mitral valvuloplasty (PBMV) by real time three-dimensional echocardiography (RT3DE). Thirty patients with rheumatic MS who underwent PBMV and 30 controls were enrolled. RT3DE was used to measure LA volume and function, the standard deviation of time to the minimal systolic volume divided into 16 segments, 12 segments, or 6 segments (Tmsv 16-SD, Tmsv 12-SD, Tmsv 6-SD), and the maximum differences (Tmsv 16-Dif, 12-Dif, 6-Dif) in RT3DE derived values in MS patients before and 2 days after PBMV were obtained and compared with those of normal controls. The associations between the LA asynchrony and heart volume, function, mitral valve area (MVA), maximum mitral valve gradient (MVGmax ), mean mitral valve gradient (MVGmean), and mean LA pressure (MLAP) were investigated. Left atrium asynchrony indexes were significantly larger, and LA function parameters were significantly lower in the MS group than in the controls (P < 0.05 for all). Of all the LA asynchrony indexes, LA Tmsv16-SD was most significantly correlated with the LA volume and function parameters, MVGmax , MVGmean , and MLAP (P < 0.05 for all). LA asynchrony indexes and LA volume significantly deceased, and LA function significantly increased post-PBMV (P < 0.05). Real time three-dimensional echocardiography is a reliable and reproducible method to quantify LA function and asynchrony. RT3DE revealed a significant, early improvement in LA function and asynchrony in MS patients after PBMV.

Is commissural closure associated with mitral annuloplasty a durable technique for the treatment of mitral regurgitation? A long-term (≤15 years) clinical and echocardiographic study

Mitral regurgitation (MR) due to commissural prolapse/flail can be corrected by suturing the margins of the anterior and posterior leaflets in the commissural area (commissural closure). The long-term results of this type of repair are unknown. Our aim was to assess the clinical and echocardiographic outcomes of this technique up to 15 years after surgery. From 1997 to 2007, 125 patients (age, 56.8 ± 15.7 years; left ventricular ejection fraction, 58.1% ± 7.1%) with MR due to pure commissural prolapse/flail of 1 or both leaflets underwent commissural closure combined with annuloplasty. The etiology of the disease was degenerative in 88.8% and endocarditis in 11.2%. The commissural region involved was posteromedial in 96 patients (76.8%) and anterolateral in 29 (23.2%). Hospital mortality was 1.6%. At discharge, MR was absent or mild in 120 patients (97.5%) and moderate (2+/4+) in 3 (2.4%). Clinical and echocardiographic follow-up was 98.4% complete (mean length, 7.1 ± 3.0 years; median, 6.7; longest follow-up, 15). At 11 years, the actuarial survival, freedom from cardiac death, and freedom from reoperation was 78.8% ± 6.2%, 95.2% ± 3.3%, and 97.4% ± 1.4%, respectively. At the last echocardiographic examination, MR 3+ or greater was demonstrated in 4 patients (3.3%). Freedom from MR 3+ or greater at 11 years was 96.3% ± 1.7%. No predictors for recurrence of MR 3+ or greater were identified. The mean mitral valve area and gradient was 2.9 ± 0.4 cm(2) and 3.4 ± 1.1 mm Hg, respectively. New York Heart Association class I to II was documented in all cases. Commissural closure repair combined with annuloplasty provides excellent clinical and echocardiographic long-term results in patients with MR due to commissural lesions.

Calcification of the Mitral Valve and Annulus: Systematic Evaluation of Effects on Valve Anatomy and Function

Mitral annular calcification (MAC) is common in chronic kidney disease. It is associated with cardiovascular events and can cause valvular dysfunction, but it has not been systematically characterized. The aim of this prospective study was to assess the prevalence and distribution of MAC, its effects on leaflet motion, and its association with mitral stenosis and mitral regurgitation (MR) in a hemodialysis population. Echocardiograms were obtained in 75 consecutive hemodialysis outpatients. MAC extent and distribution were graded semiquantitatively using two-dimensional and three-dimensional echocardiography. Associations with the presence and severity of mitral stenosis and MR were explored. The mean age was 60 ± 14 years; 60% were men, and 87% were African American. MAC was present in 64% (moderate to severe in 48%). Calcium extended more than halfway onto the leaflet in 37% and beyond the annulus in 40%. Leaflet motion was restricted in 37%. Mitral stenosis was present in 28%, and the extent of calcification was associated with mean mitral valve gradient (P < .0001). MR was prevalent (present in 81%) but was severe in none. The severity of MAC was greater in patients with moderate MR than in those with no or mild MR (P = .04). Three-dimensional analysis suggested an uneven distribution of annular calcium; the middle and lateral anterior segments were less often calcified than the anterior-medial or posterior segments. Calcification in any annular segment was highly associated with restricted motion of the attached leaflet segment. MAC is common and often extensive in hemodialysis patients. Calcium may be unevenly distributed among the annular segments. When present, annular calcification reduces the angle of leaflet opening and can cause valvular dysfunction.

Percutaneous mitral balloon valvuloplasty beyond 65 years of age

The profile of subjects undergoing percutaneous mitral balloon valvuloplasty (PMBV) in developed countries has shifted toward the elderly. In the group of elderly patients long-term results after PMBV, as well prognostic factors that may improve patient selection for this procedure have not been fully elucidated. Aim of the study was to evaluate the safety and efficacy of PMBV for the treatment of mitral stenosis in patients older than 65. The studied group consists of 132 consecutive patients aged > 65, who underwent PMBV. All PMBV procedures were performed by the antegrade transvenous approach using the Inoue balloon system. Procedural success, defined as mitral valve area ≥ 1.5 cm2 and mitral regurgitation £ 2+, was obtained in 105 (79.5%) patients. Mean follow-up was 6.25 ± 4.33 years. Echo score > 8 and higher mean mitral valve gradient were significant independent predictors of inadequate immediate result. Survival curves showed that for the whole studied group after PMBV the 3-, 5-, and 10-year overall survival rates were significantly better in patients with left atrium diameter £ 5.0 cm before intervention (95.4%, 91.3% and 80.5% vs. 89.6%, 69.5%, and 53.7%, respectively; p = 0.002). Survival free of mitral valve intervention or heart failure ≥ NYHA III was significantly better for patients with good immediate result and mean pulmonary artery pressure after PMBV < 25 mm Hg. PMBV is safe and efficacious in elderly patients with symptomatic mitral stenosis. Long-term results are good and related mainly to the quality of the procedure.