Mechanical Mitral Valve Prosthesis Research Articles

Transcatheter Aortic Valve Implantation in Rheumatic Aortic Valve Stenosis Using a Top-down Deployment Supra-annular Leaflets Transcatheter Aortic Valve: Technical Considerations

Aortic valve stenosis due to chronic rheumatic heart disease remains prevalent in the Asia-Pacific region. Because of the lack of substantial calcification that can anchor a transcatheter aortic valve, there are several technical considerations during transcatheter aortic valve implantation (TAVI) when treating this subset of patients. We report a case of successful TAVI using a novel top-down deployment supra-annular leaflets valve in a patient with rheumatic aortic valve stenosis and mechanical mitral valve prosthesis.

Non-Obstructive Thrombosis of Mechanical Mitral Prosthesis: About a Case Report and Literature Review

Introduction: Mechanical mitral valve prostheses are vital for patients with mitral valve disease. While obstruction is a well-recognized complication, non-obstructive dysfunction remains less understood. We present a case of non-obstructive mechanical mitral prosthesis to highlight its clinical importance and management challenges. Case Presentation: A 45-year-old female, who had undergone mechanical mitral valve replacement 9 years prior, presented with dysarthria and facial paralysis. Transthoracic echocardiography revealed preserved prosthesis function with no apparent obstruction. However, transesophageal echocardiography confirmed the non-obstructive thrombosis of the mitral prothesis. We opted for a medical treatment consisting in optimizing anticoagulation with the addition of aspirin. The evolution was favorable with complete regression of the thrombus at the control TEO. Discussion: Non-obstructive mechanical mitral prosthesis is a rare entity, often characterized by atypical symptoms. This case emphasizes the importance of comprehensive assessment beyond prosthetic valve gradients. as well as the importance of combining several imaging methods, including radio cinema and TEO. Surgical intervention wasn’t necessary, as the medical treatment was sufficient. Conclusion: Non-obstructive mechanical mitral prosthesis dysfunction can be challenging to diagnose but is crucial to consider in symptomatic patients with mechanical valves. This case underscores the need for a multidimensional approach, including advanced imaging techniques, to uncover and manage non-obstructive prosthesis dysfunction, ultimately improving patient outcomes and quality of life.

Left Atrial Appendage Closure in Patients With a Mechanical Mitral Valve Prosthesis: A Multicentre Italian Pilot Study

BackgroundIn patients with atrial fibrillation (AF) on vitamin K antagonist (VKA) therapy and therapeutic international normalized ratio (INR) range, the incidence of cardiac thromboembolism is not negligible, and the subgroup of patients who have a mechanical prosthetic mitral valve (PMV) has the highest risk. We aimed to assess the long-term effects of left atrial appendage closure (LAAC) in AF patients with a mechanical PMV who experienced a failure of VKA therapy. MethodsIn this retrospective, multicentre study, patients underwent LAAC because of thrombotic events including transient ischemic attack and/or stroke, systemic embolism, and evidence of left atrial appendage thrombosis and/or sludge, despite VKA therapy, were enrolled. Patients with a mechanical PMV were included and compared with those affected by nonvalvular AF. The primary endpoint was the composite of all-cause death, major cardiovascular events, and major bleedings at follow-up. The feasibility and safety of LAAC also were assessed. ResultsA total of 55 patients (42% female; mean age, 70 ± 9 years), including 12 with a mechanical PMV, were enrolled. The most-frequent indication to LAAC (71%) was LAA thrombosis or sludge. Procedural success was achieved in 96% of overall cases, and in 100% of patients with a PMV. In 35 patients, a cerebral protection device was used. During a median follow-up of 6.1 ± 4.3 years, 4 patients with a PMV, and 20 patients without a PMV, reported adverse events (hazard ratio 0.73 [95% confidence interval 0.25-2.16, P = 0.564]). ConclusionsLAAC seems to be a valuable alternative in patients with AF who have a mechanical PMV, with failure of VKA therapy. This off-label, real-world clinical practice indication deserves validation in further studies.

Approach To Pregnant Women with Mechanical Mitral Valve Prosthesis: A Case Report

Cardiovascular diseases are one of the leading causes of maternal mortality. The management of pregnant women with mechanical valve prosthesis is difficult. Fetal-maternal mortality and morbidity are high. Selection of the most appropriate anticoagulant that will minimize fetal, maternal mortality and avoid embryopathy risk should be tailored according to the needs of each individual patient. 
 In this paper, in the light of the literature, we aimed to discuss our patient, who delivered at 39th gestational week after a pregnancy before which she had not been provided with prepregnancy counseling and during which she did not attend follow-up visits.
 These patients prepregnancy counseling, follow-up visits, anticoagulant management during pregnancy, and prophylaxis and management of complications at the postpartum period are very important and require close follow-up.

Comprehensive Management of Anticoagulants Induced Decompensated Severe Anemia in Postmitral Valve Replacement

Abstract Mechanical prosthetic valve needs consideration for anticoagulation. The objective of this case report was to know how maintenance of oral anticoagulant therapy is very important in patients, especially with mechanical heart valve replacement. It is the holistic management of mitral valve replacement (MVR) patients with high international normalized ratio (INR) (>100), which led bleeding into the peritoneal cavity and causes decompensated severe anemia. Although it is a rare presentation for a patient of MVR with high INR level but which is most commonly presented for cerebrovascular accident. Anemia is a thoughtful worldwide problem that disturbs the quality of life in persons of all ages. A 28-year-old Indian woman with follow-up case of post-MVR came to the hospital with complaints of breathing difficulty, altered sensorium, pulse rate of 150–170 bpm (beats/min) irregularly irregular, blood pressure (80/50 mmHg), palpitation, and abdominal pain. Blood test report revealed her hemoglobin (Hb) was 3.2 g%, suggestive of severe anemia, INR was >100 s. Hence, patient diagnosed as follow-up case of MVR (#27 mm mechanical bileaflet mitral valve prosthesis) with peritoneal bleeding, an oral anticoagulant with decompensated severe anemia managment should be done. Ended the progression of her hospitalization, she received four units of packed red blood cell transfusions; Vitamin K was given intravenous once daily for 2 days and no anticoagulant was given, so far, INR was high with serial monitoring of INR and Hb. Her symptoms of breathing difficulty, pain in abdomen, weakness and giddiness resolute by the finish of her hospital stay, and she recompensed to her oral anticoagulant therapy with improved Hb and hemodynamics. Disapprovingly high INR levels are classically related with bleeding disorders revealed on imperative indicators and hemodynamic variability. To our understanding, one of the lowermost noted Hb is because of bleeding due to very high INR, so monitoring of therapeutic INR level with anticoagulants is very-very important.

Trend in mitral valve prostheses of choice and early outcomes in the United Kingdom

ObjectiveDespite the superiority of mitral valve repair, surgical mitral valve replacement (SMVR) remains an important intervention for patients with valve stenosis, infective endocarditis and complex mitral valve degeneration.There has been an increasing popularity in the worldwide use of biological valves due to the avoidance of long-term anti-coagulation and recent advancements in transcatheter techniques. We aim to evaluate the trend, early clinical outcomes and the choice of prostheses use in isolated SMVR over a 23 years period in the United Kingdom. MethodsAll patients (n = 13,147) who underwent elective or urgent isolated SMVR from March 1996 to April 2019 were identified from the National Adult Cardiac Surgery Audit database.Trends in clinical outcomes, predicted/observed mortality of patients and the utilization of biological prostheses across 5 different age groups: <50, 50–59, 60–69, 70–79 and ≥80 years old were investigated. Early clinical outcomes associated with the use of mechanical and biological mitral valve prostheses in patients between the age of 60–70 years old were analysed. ResultsThe number of isolated SMVR performed has remained stable with approximately 600 cases annually since 2010. The in-hospital/30-day mortality rate has decreased from 7.41% (1996) to 3.92% (2018), despite the EuroScore II increasing from 1.42% in 1996 to 2.43% in 2018.Biological prostheses usage increased across all age group, and particularly in the 60–69 and 70–79 group, from 17.86% and 53.85% in 1996 to 48.85% and 82.38% in 2018, respectively. The use of mechanical prostheses was reduced in patients between the age of 50–59 from 100% in 1996 to 80.65% in 2018. There were no differences in short term outcomes among patients aged 60–70 years who received either a biological or mechanical prostheses. ConclusionThere has been a significant reduction in surgical mitral valve replacement early in-hospital mortality, despite an observed increase in the risk profile of patients over 23 years. A shifting trend in valve replacement choices was observed with a rise in the use of biological prostheses, particularly within the 60–69 and 70–79 age group. Early in hospital outcomes for patients aged 60–70 were not determined by the implanted valve type.

HYDROACOUSTICS OF THE MECHANICAL BILEAFLET HEART VALVE

The results of experimental researches of hydrodynamic noise generated by a jet flow through the mechanical bileaflet mitral valve prosthesis of the Italian company Sorin are given. Physical simulation was carried out in laboratory conditions on the model of the left atrial chamber and the left ventricular chamber of the heart. The hydrodynamic noise of the flow through the artificial bileaflet mitral valve increased with increasing water flow. It was found that the greatest intensity of hydrodynamic noise and its spectral components was observed near the central jet of the bileaflet mitral valve. The obtained average pressure values in the near wake of the open mitral valve near the side jet are (10 – 20) % higher than near the central jet. It was determined that the power spectral densities of pressure fluctuations near the central jet are higher than near the side jet, especially in the frequency range (10 – 100) Hz. It was established that the small-scale vortex structures, which broke away from its leaflets and generated pressure fluctuations in the frequency range (20 – 70) Hz, degenerated starting from a distance of 2.5 valve diameters downstream. Increased levels of pressure fluctuations were observed near the central jet by more than (12 – 13) dB relative to hydrodynamic noise inside the atrial chamber and by more than (5 – 7) dB higher relative to pressure fluctuations near the side jet inside the left ventricular chamber in the frequency range (12 – 15) Hz. With an increase in water flow in the near wake of the mitral valve, an increase in the spectral levels of pressure fluctuations in the frequency range (60 – 80) Hz was observed. At a distance of more than below the open mechanical bileaflet mitral valve, the hydrodynamic noises near the central and side jets became approximately equal in the entire frequency range under consideration. The research results showed that hydroacoustic diagnostics of the operation of the mechanical bileaflet heart valve can be an effective means of diagnosing thrombus formation on the artificial valve leaflets.

Monocyte to HDL ratio may predict thrombosis in patients with mechanical mitral and aortic valve prosthesis.

Increased inflammatory biomarkers have been reported in prosthetic heart valve thrombosis (PHVT). Monocyte to HDL ratio (MHR) and albumin to CRP levels (CAR) are two biomarkers used widely for systemic inflammation but there is a lack of data on prosthetic heart valves. This study aimed to find out the potential predictive value of MHR and CAR for PHVT. Patients who had the diagnosis of mechanical mitral/aortic PHVT and normally functioning prosthesis were retrospectively analyzed. Laboratory data including complete blood count and biochemistry were recorded. Transesophageal echocardiography was performed to diagnose PHVT. The study included 118 patients with mechanical PHVT and 120 patients with normally functioning prosthesis. White blood count, monocyte levels, C-reactive protein, MHR and CAR were significantly higher whereas the lymphocyte, HDL and INR levels on admission were lower in patients with PHVT. Multivariate analysis showed that as well as inadequate anticoagulation, MHR, but not CAR, was found to be an independent predictor of thrombosis in patients with PHVT. Receiver operating characteristic curve analysis was performed to detect the best cut-off value of MHR in the prediction of thrombosis in patients with prosthetic valves. MHR level of > 12.8 measured on admission, yielded an AUC value of 0.791 [(CI 95% 0.733-0.848 p < 0.001) sensitivity 71%, specificity 70%]. Inadequate anticoagulation is the primary cause that leads to thrombosis in mechanical prosthetic valves. Increased MHR, but not CAR, was also shown to be an independent predictor of thrombosis in patients with mechanical mitral and aortic prosthetic valves.

Simultaneous pulmonary vein isolation and ablation of the substrate of biatrial flutter in a patient with a mechanical mitral valve prosthesis: a case report

Catheter radiofrequency ablation of the atrial fibrillation substrate may be difficult in patients after open heart surgery. Difficulties may arise in the presence of a mitral valve prosthesis, atrial arrhythmias of several morphologies (more often left atrial atypical flutter), including incisional ones. These cases require a thorough and scrupulous approach to achieve complete isolation of all available arrhythmia substrates. A distinctive feature of this observation is the successful simultaneous pulmonary vein isolation and two atrial arrhythmias in a patient with a mechanical mitral prosthesis.

Thrombotic mechanisms in low-thrombogenicity mechanical mitral valve prostheses.

Thrombotic mechanisms in low-thrombogenicity mechanical mitral valve prostheses.

Cost-Effectiveness of the Pharmacist-Managed Warfarin Therapy vs. Standard Care for Patients With Mechanical Mitral Valve Prostheses: An Egyptian Healthcare Perspective.

BackgroundDespite warfarin therapy had been used for decades for patients with mechanical mitral valve prostheses (MMVPs), serious and life-threatening complications are still reported worldwide with a significant economic burden. This study is aimed at assessing the clinical and the cost-effectiveness of adopting pharmacist-managed warfarin therapy (PMWT) services for optimizing warfarin treatment in Egypt.MethodsA prospective randomized trial in which 59 patients with MMVPs were randomly assigned to receive the PMWT services or the standard care and followed up for 1 year. The primary outcome was percentage time in the therapeutic range (TTR). For the cost-effectiveness analysis, a Markov cohort process model with nine mutually exclusive health states was developed from a medical provider’s perspective. A lifetime horizon was applied. All costs and outcomes were discounted at 3.5% annually.ResultsThe study results revealed a significantly higher median TTR in the intervention group as compared to the control group; 96.8% [interquartile range (IQR) 77.9–100%] vs. 73.1% (52.7–95.1%), respectively, p = 0.008. A significant association between standard care and poor anticoagulation control (p = 0.021) was demonstrated by the multivariate regression analysis. For the cost-effectiveness analysis, the total cumulative quality-adjusted life-years (QALYs) and total costs per patient were 21.53 and 10.43; 436.38 and 1,242.25 United States dollar (USD) in the intervention and the control groups, respectively, with an incremental cost-effectiveness ratio (ICER) of −72.5796 for the intervention group.ConclusionThe PMWT strategy was proven to provide a significantly better anticoagulation control and to be a cost-saving approach in Egyptian patients with MMVPs. Nevertheless, the dominance of this strategy is sustained by maintaining the therapeutic International Normalized Ratio (INR) control within the recommended range. Our findings will benefit Egyptian policy-makers who may seek novel health strategies for better resource allocation.Clinical Trial Registration[ClinicalTrials.gov], identifier [NCT04409613].

Long-term outcomes of mechanical versus biological valve prosthesis in native mitral valve infective endocarditis

Objectives. To study the long-term outcomes of mitral valve replacement with mechanical or biological valve prostheses in native mitral valve infective endocarditis patients. Desing. We conducted a retrospective, nationwide, multicenter cohort study with patients aged ≤70 years who were treated with mitral valve replacement for native mitral valve infective endocarditis in Finland between 2004 and 2017. Results. The endpoints were all-cause mortality, ischemic stroke, major bleeding, and mitral valve reoperations. The results were adjusted for baseline features (age, gender, comorbidities, history of drug abuse, concomitant surgeries, operational urgency, and surgical center). The median follow-up time was 6.1 years. The 12-year cumulative mortality rates were 36% for mechanical prostheses and 74% for biological prostheses (adj. HR 0.40; CI: 0.17–0.91; p = 0.03). At follow-up, the ischemic stroke had occurred in 19% of patients with mechanical prosthesis and 33% of those with a biological prosthesis (adj. p = 0.52). The major bleeding rates within the 12-year follow-up period were 30% for mechanical prosthesis and 13% for a biological prosthesis (adj. p = 0.29). The mitral valve reoperation rates were 13% for mechanical prosthesis and 12% for a biological prosthesis (adj. p = 0.50). Drug abuse history did not have a significant modifying impact on the results (interaction p = 0.51 for mortality and ≥0.13 for secondary outcomes). Conclusion. The use of mechanical mitral valve prosthesis is associated with lower long-term mortality compared to the biological prosthesis in non-elder native mitral valve infective endocarditis patients. The routine choice of biological mitral valve prostheses for this patient group is not supported by the results.

Adherence to Anticoagulation Ambulatory during the Beginning of Coronavirus Pandemic

INTRODUCTION: Treatment with Vitamin K Antagonists is already proven to be significant in reducing thromboembolic events in patients with indications for systemic anticoagulation. In the context of ambulatory adherence, the SARS-CoV2 coronavirus pandemic emerged as a challenge for managing patients undergoing anticoagulation. &#x0D; &#x0D; METHODS: To avoid crowding and follow the recommended measures of social distancing, the Anticoagulation Ambulatory of the Hospital Universit&amp;aacute;rio de Santa Maria started to adopt a differentiated model of care, with a collection of hospital prothrombin time and immediate home return, followed by teleconsultation, with medication adjustment, as necessary. The present study aimed to assess adherence to the new care model, as well as the profile of patients seen. A retrospective cohort study was conducted, analyzing consultations between March and May 2020. &#x0D; &#x0D; RESULTS: The results demonstrate a low-educated population (76% had completed elementary school at most). The most common indications for the use of oral anticoagulation were atrial fibrillation (33.6%), followed by mechanical aortic valve prosthesis (31.3%) and mechanical mitral valve prosthesis (17.2%). Regarding adherence, especially to blood collection in the scheduled period, there was low adherence in the initial weeks of the pandemic declaration, with substantial improvement in adherence in the last two weeks of analysis. &#x0D; &#x0D; CONCLUSION: Determining the clinical characteristics and profile of patients helps to determine the local needs of this population and implement active search strategies to improve adherence rates, which may reduce unfavorable outcomes.

Клінічний випадок лікування підгострого ендокардиту в пацієнта після закриття оклюдером відкритого овального вікна

The role of transcatheter closure of the patent foramen ovale in the occurrence of various complications remains a controversial issue. Atrial arrhythmias and bleeding are common complications, while infectious complications are extremely rare. In this clinical case we would like to report a patient who underwent transcatheter closure of a patent foramen ovale complicated by subacute endocarditis of a fully endothelized device 5 years after surgery. A 49-year-old patient was admitted to the surgical department with diffuse chest pain, sweating and fever. Three weeks earlier the patient had a fever associated with a cold. The data of the general and biochemical blood analysis indicated the presence of an inflammatory reaction of the body. After transthoracic and transesophageal echocardiography, infective endocarditis was diagnosed. The patient underwent surgery as planned. After removal of the occluder and excision of the mitral valve cusps, implantation of a mechanical mitral valve prosthesis was performed. At the site of the removed occluder, the atrial septal defect was repaired with an autologous pericardial patch. Transesophageal echocardiography showed no residual blood flow through the interatrial septum. The postoperative period was uneventful. The patient was discharged in satisfactory condition 10 days after surgery. The total duration of the antibiotic therapy was 5 weeks. Key words: open oval window, infectious endocarditis, transcatheter closure of the defect.

Severe dysfunction of a mechanical mitral valve prosthesis coexisting with non-ST-segment elevation myocardial infarction.

Severe dysfunction of a mechanical mitral valve prosthesis coexisting with non-ST-segment elevation myocardial infarction.

BEATING HEART MITRAL VALVE REPLACEMENT. EXPERIENCE AT A TERTIARY CARE HOSPITAL

Objective: To study the early outcomes of mitral valve surgery performed with a beating heart and cardiopulmonary bypass.&#x0D; Study Design: Prospective descriptive study.&#x0D; Place and Duration of Study: Cardiac Surgery department, Rawalpindi Institute of Cardiology, Rawalpindi, from Aug 2017 to Aug 2019.&#x0D; Methodology: Consecutive patients requiring mitral valve surgery were included in the study. Those requiring multiple procedures, redo procedures and emergency procedures were excluded from the study. Data was collected on preformed proformas and perioperative variables were recorded. Patients were followed till discharge or 30 days after the surgery. Statistical Package for Social Sciences version 23.0 was used to analyse the data.&#x0D; Results: A total of 27 patients were included in the study, 21 (77.78%) female and 6 (22.2%) male patients. The mean age of the patients was 30.89 ± 10.8 years. Of the cohort, 4 (14.8%) had mitral stenosis, 16 (59.3%) had mitral regurgitation and mixed disease (both mitral stenosis and mitral regurgitation) was present in 7 (25.9%). The median pulmonary artery pressure (mPAP) was 34 mmHg. All the patients received mechanical mitral valve prosthesis, 27 (100%). A modified Devaga’s procedure for tricuspid valve repair was done in 4 (14.8%) patients. Most of the patients required only mild inotropic support, 22 (81.4%). Median intensive care unit stay was 24 hours with a mean of 33 ± 16 hours. All the patients were alive at the end of the early follow up.&#x0D; Conclusion: Beating heart mitral valve surgery on cardiopulmonary bypass is a feasible technique. It has acceptable early outcome in terms of mortality and major morbidity indicators.

Assessment of the warfarin anticoagulation knowledge of patients with mechanical mitral valve prosthesis and its effect on therapy adherence and relevant complications

Assessment of the warfarin anticoagulation knowledge of patients with mechanical mitral valve prosthesis and its effect on therapy adherence and relevant complications

Thrombosis of Mechanical Mitral Valve Prosthesis Treated With Fibrinolysis

Mechanical prosthetic valve thrombosis is an uncommon but serious complication associated with high mortality and morbidity. Conventionally, prosthetic valve thrombosis is treated with surgical intervention, but recent literature has shown that slow-infusion of low-dose fibrinolytic therapy could be of equal efficacy.

505 Car accident, an unusual cause of acute severe mitral regurgitation due to anterolateral papillary muscle rupture

Abstract A 52-year-old man was admitted to the emergency department of the University Hospital after being involved in a car crash. At first he was alert with stable vital parameters. There was bilateral rales on lung auscultation, without further prominent aberrant findings at the initial clinical examination. Shortly after, he became agitated with respiratory distress, resulting into respiratory insufficiency. Computed tomography (CT) scan of the thorax showed multiple rib fractures, a translated sternal fracture and pulmonary contusion. After intubation and stabilization he was transferred to the Intensive Care Unit (ICU), where his respiratory and cardiovascular parameters progressively worsened, leading to cardiogenic shock. An urgent chest X-ray revealed a tension pneumothorax with mediastinal shift to the right, for which a chest tube was inserted in the left hemithorax. No or little improvement was seen after this intervention. Therefore, an emergency transthoracic echocardiography (TTE) was performed. Subcostal view showed a severe mitral regurgitation with a mass in the left atrium. Because of a limited transthoracic window, we proceeded to a transoesophageal echocardiogram (TEE). A completely ruptured anterolateral papillary muscle of the mitral valve was seen, protruding in the left atrium and resulting in severe mitral regurgitation (Figure). Other echocardiographic findings were a hyperdynamic systolic function of the left ventricle, a hypo-contractile right ventricle with a mild-to-moderate quantity of pericardial effusion. Taking into account the increased cardiovascular risk profile of the patient, a coronary angiography was performed and showed normal coronary anatomy. Consequently, urgent surgical intervention was performed. Perioperative assessment confirmed the earlier described echocardiographic findings. Due to severe laceration of the left ventricular wall at the level of the attachment site of the anterolateral papillary muscle, reconstructive surgery was not possible. The anterolateral papillary muscle head with the attached mitral valve leaflet was fully excised with repair of the concealed myocardial rupture site. A mechanical mitral valve prosthesis and an intra-aortic balloon pump for hemodynamic support were placed. After four days the balloon pump was removed and the tenth day after admission the patient was extubated. Conclusion Acute severe mitral regurgitation due to papillary muscle rupture is a rare but potential fatal complication of a blunt trauma. TOE is essential in early diagnosis. Abstract 505 Figure 1

A case of non-invasive topical diagnostics with successful ablation during persistent atrial fibrillation

Treatment of persistent and long-persistent forms of atrial fibrillation remains a pressing issue. Using a personalized approach can help to more successfully eliminate arrhythmias and reduce the return probability. One of these approaches is the use of radiofrequency ablation in conjunction with modern high-tech research methods. The article describes a clinical case of successful catheter ablation of persistent atrial fibrillation in a patient with a mechanical mitral valve prosthesis, due to the use of non-invasive topical diagnostics prior to surgery.