Mechanical Mitral Valve Research Articles

Evaluation of Safety and Efficacy of Combined Low Dose Aspirin and Warfarin Following Mechanical Heart Valve Replacement for Mitral Valve Disease

Introduction: Warfarin is recommended following mechanical valve replacement to prevent thromboembolic complications. A combination of warfarin and aspirin may further reduce thromboembolic events in these patients. This study was designed to evaluate safety and efficacy of combined low dose aspirin and warfarin therapy following mechanical mitral valve replacement. Materials and Methods: Purposively selected 99 patients who underwent mechanical mitral valve replacement were divided into two groups. Patients of Group A (n=50) received combined low dose aspirin (75mg) and warfarin. Patients of Group B (n=49) received conventional dose of warfarin alone. International normalized ratio (INR) was targeted 1.8-2.4 for group A Patients and 2.5-3.5 for group B Patients. Post-operatively INR, thromboembolic events, anti-coagulation related haemorrhage and other morbidity and mortality were registered in both groups. Result: Patients were followed up postoperatively for 9 months. The mean dose of warfarin in group A and group B was 4.36 ± 0.31 mg and 5.57±0.52 mg respectively (p<0.001). The overall mean INR of two groups of patients were statistically different (P<0.001) with low INR in group A (2.19±0.13) patients compared to group B (3.03±0.31). The thromboembolic events in group A (0.02/patient year) were lower than those in group B (0.08/Patient year). There was no statistically significant (p=0.362) difference in bleeding episodes between two groups but data indicate proportion of minor bleeding manifestations were higher in patients treated with warfarin plus aspirin group. Conclusion: Following mechanical mitral valve replacement, a combination of aspirin (75mg) and low dose warfarin with an aim to maintain INR between 1.8 and 2.4 (lower than recommended 2.5-3.5) may provide satisfactory outcomes in term of thrombosis, embolism and bleeding without increase in mortality. Bangladesh Heart Journal 2021; 36(1): 24-31

Elective Melody valve insertion in mitral position: What have we learnt from our first and successful case?

Melody valve insertion in mitral position is no longer an experimental procedure and is now an acceptable option for severe mitral valve disease in infants and neonates. Although there are more and more publications outlining the outcome, our first and successful case taught us a couple of points that we would like to share. A 20 days-old baby with severe congenital mitral insufficiency underwent Melody valve implantation. The stent was fashioned to avoid left ventricular outflow tract obstruction and expanded with a 14 mm balloon. A small ASD was created to allow further percutaneous balloon dilation. The baby was discharged after 6 weeks and treated with antiplatelet therapy. Postoperative management consisted in close transthoracic echocardiographic follow-up. Two percutaneous balloon dilatations of the stent (14 and 16 mm) were performed, respectively 9 and 16 months after the initial surgery. The patient presented infective endocarditis (Haemophilus influenzae) 26 months after surgery. TTE showed moderate Melody valve regurgitation and stenosis (mean gradient: 11 mmHg) with post-capillary pulmonary hypertension. Mitral valve replacement was performed after 6 weeks of antibiotic therapy. The stent was explanted and a 19 mm mechanical prosthetic valve was inserted. Postoperative course was uneventful. Melody valve in mitral position is now an accepted option but morbidity and mortality remain significant. Post-implantation management is challenging and guidelines are missing. Percutaneous stent dilation, hybrid valve in valve implantation and mechanical mitral valve replacement are 3 possible options in case of valve dysfunction. The per-operative pictures ( Fig. 1 , Fig. 2 ) help to understand why, in our case, the first 2 options would have failed. Fig. 1 shows non-calcified and mobile leaflets. One leaflet had a small 2 mm perforation. The stent itself, in contrast, was so thickened that dilatation or valve in valve procedure would have failed at this stage. Major endothelialization of the stent might significantly limit post-implantation management options. We believe that heart teams have to be aware of this potential evolution of the stent in order to establish the best procedural strategy in these patients.

Left atrial reverse remodeling improves sinus restoration following mitral valve replacement: A case report.

IntroductionMitral stenosis is one of the most common abnormalities in rheumatic heart disease (RHD). These patients often experience atrial fibrillation, due to left atrial dilatation, causing a high risk of thromboembolic events; rhythm or heart rate control are thus important treatment strategies. In patients undergoing surgery, sinus rhythm restoration is not fully understood, and not all surgical patients return to sinus rhythm. We report an adult woman with mitral regurgitation who experienced sinus restoration after mitral valve replacement (MVR) surgery.Case presentationA 44-year-old woman presented with chief complaints of orthopnea and shortness of breath during activity for 2 months. Electrocardiography (ECG) revealed atrial fibrillation with normal ventricular response, and echocardiography showed severe mitral stenosis with Wilkins score of 10 (3-2-3-2), moderate mitral and aortic regurgitation due to RHD, moderate tricuspid regurgitation with probable pulmonary hypertension, normal left ventricular systolic function, ejection fraction of 60.5% (biplane). MVR surgery was performed using a mechanical mitral valve. Postoperative ECG found sinus rhythm and first-degree AV block. Postoperative echocardiography found a decreased left Atrial volume index of 70.8 mL/m2, indicating further remodeling of the patient's heart.ConclusionSinus restoration sometimes occurs in patients after MVR. The correction procedure causes minimal anatomical changes, particularly the loss of non-conductive and pathological tissue, followed by hemodynamic changes that eventually lead to the left atrial reverse remodeling mechanism.

B-PO05-100 SAFETY AND EFFICACY OF CRYOBALLOON ABLATION OF ATRIAL FIBRILLATION IN PATIENTS WITH MECHANICAL MITRAL VALVE

Mitral valve disease as well as its surgical replacement with mechanical valve (MMV) are associated with increased risk of atrial fibrillation (AF). Isolation of the pulmonary veins (PVI) in presence of MMP can be challenging. To evaluate the safety, feasibility, and efficacy of cryoballoon (CB) PVI in patients with MMV. All patients with MMV, who underwent CB-PVI between 2017 and 2019 in four high-volume electrophysiological centers were studied. Clinical data were collected before ablation and during subsequent follow-up visits. All PVs were isolated intra-procedurally (Table). The mean time of follow-up was 29.9±12.9 months (range 16-55). Six (75%) patients were monitored with ILR. Two (22%) patients had clinical recurrences during follow-up period (1-AF and 1-atypical flutter). No major complications noted. Cryoballoon ablation of Atrial fibrillation in patients with Mechanical Mitral Valve appears to be feasible, safe, and effective in our small sample.

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.

Mechanical Mitral Valve Thrombosis Treated With Fibrinolysis

A 27-year-old lady presented to the emergency department with a 3-week history of worsening shortness of breath. Her past history was significant for mechanical mitral valve replacement 6 months prior for rheumatic mitral stenosis. She had recently been non-compliant with international normalised ratio checks for warfarin dosing in the setting of local lockdown for the COVID-19 pandemic. On examination, there was loss of mitral valve click with associated elevated jugular venous pressure, right ventricular heave, loud P2, and bi-basal crepitations.

Isolated congenital cleft mitral valve leaflet: a rare cause of refractory cardiogenic shock complicating acute myocardial infarction

We report a unique presentation of isolated congenital cleft mitral valve complicating cardiogenic shock from acute myocardial infarction. Isolated cleft mitral valve is an uncommon diagnosis that can have significant clinical implications, especially if not recognized in patients presenting to the catheterization lab with acute myocardial infarction and cardiogenic shock. A review of this rare diagnosis including the options and timing of therapeutic interventions, which can include MitraClip, is important for publication.The case is of a patient who presented with an anterior acute ST elevation myocardial infarction. Despite early coronary revascularization and conventional support, refractory cardiogenic shock ensued requiring mechanical circulatory support escalation to Veno-arterial extracorporeal membrane oxygenation. Subsequently, left ventriculography revealed a massively dilated left atrium and severe mitral regurgitation raising concerns for a mechanical mitral valve complication. The patient was taken to the operating room for possible mitral valve surgery, but a preoperative transesophageal echocardiogram revealed an isolated posterior cleft mitral valve. Since the patient had stabilized on mechanical circulatory support, emergent surgery was deferred. The patient successfully recovered during index hospitalization with mechanical circulatory support and discharged on guideline directed medical therapy.In conclusion, isolated cleft mitral valve is a rare diagnosis that can often be underrecognized without comprehensive 3-dimensional transesophageal echocardiography evaluation. If diagnosed early with significant regurgitation, surgical treatment results in good outcomes and preservation of LV systolic function. Percutaneous correction of a CMVL with MitraClip has been described and may offer an alternative approach for high risk surgical patients.

Low-dose slow infusion thrombolysis in the treatment of prosthetic heart valve thrombosis: a clinical case

Agnė Kraujelytė1, Indrė Justina Ignatavičiūtė1, Vilius Janušauskas2, Aleksėjus Zorinas2, Jurij Šabliauskas3, Donata Ringaitienė3 1Vilnius University, Faculty of medicine, Vilnius, Lithuania. 2Heart and Chest Surgery Center, Cardiac Surgery department – Vilnius University Hospital Santaros Clinics 3Institute of Clinical Medicine- Vilnius University- Faculty of Medicine, Clinic of Anesthesiology and Reanimatology- Vilnius University Hospital Santaros Clinics – Centre of Anaesthesiology- Intensive Therapy and Pain Management, Vilnius, Lithuania. Background and Aims. Describe and present a clinical case of a patient treated with low-dose slow infusion thrombolysis after prosthetic valve thrombosis. Methods. The patient is a 75 year old women treated with low–dose slow infusion thrombolysis in the Resuscitation and Intensive Care Unit II of Vilnius University Hospital. Data was monitored since 2017 till 2020. A detailed analysis of the patient’s life and medical history was made. The course and dynamics of examinations and treatment procedures / medications prescribed to the patient were analyzed in a structured way. The literature on the selected topic is examined in detail in order to compare the efficacy and outcome of low-dose slow infusion thrombolysis with the results of previous studies and in the case we presented. Permission to use patient data has been obtained with the consent of the personal data protection specialist. Patient confidentiality was guaranteed – name, surname, address and other personal data were not collected. The results of the study are published only in a summary form. Results. A 75-year-old patient had a prosthetic mitral mechanical valve in 2009 St. Jude 29 MJ. In 2015, the valve was replaced due to high thrombosis. Since 2016 the woman was hospitalized 4 times (once a year) in December for recurrent mitral valve thrombosis for a low-dose slow infusion thrombolysis procedure. Overall of 12 thrombolysis were performed. Actilyse 25 mg / 6 h was infused with heparin after each thrombolysis for aPTT 50-80 sec. The efficacy of thrombolysis was evaluated by repeated transesophageal ultrasound examinations. The mean pressure gradient dynamics was decreasing (24mmHg 4.3mmHg). A geneticist and hematologist were consulted for suspected thrombophilia that had not been diagnosed, but hyperhomocysteinemia had been identified. 2020 she was hospitalized in July for suspected recurrent MV prosthetic thrombosis, but there were insufficient data on thrombosis, so the patient was admitted to outpatient treatment, recommending a Level III cardiologist consultation twice a year. Conclusions. Low-dose, slow-infusion thrombolytic therapy is currently increasingly being used in patients with prosthetic valve thrombosis. This is because it has safety, efficacy, and a lower incidence of complications. However, this clinical case demonstrates that such treatment does not always prevent recurrence of thrombosis. Keywords: Actilyse, low – dose, slow infusion thrombolysis, prosthetic valve thrombosis. https://doi.org/10.53453/ms.2021.06.20

Catastrophic Candida prosthetic valve endocarditis and COVID-19 comorbidity: A rare case.

Background and Purpose: Coronavirus disease 2019 (COVID-19) and Candida prostatic valve endocarditis present various clinical manifestations which may overlap; hence, discrimination between them is extremely difficult.Case report: The case was a 66-year-old man with a past medical history of mitral and aortic valves replacement one year before COVID-19 co-infection. He was admitted with fever (for 7 days), shortness of breath, cough, seizure, lethargy, headache, and 85% oxygen saturation. Transesophageal echocardiography revealed multiple large-sized, highly mobile masses on both sides of the mechanical mitral valve highly suggestive of vegetation. Chest computed tomography scanning showed simulating scattered COVID-19 peripheral ground-glass opacities confirmed by reverse-transcription polymerase chain reaction. The set of blood cultures yielded yeast colonies that were identified as Candida tropicalis. The patient died of septic shock shortly after receiving antifungal therapy.Conclusion: This case emphasized the importance of early diagnosis and implementation of antifungal treatment, particularly in patients with prosthetic cardiac valves, to reduce their unfavorable outcomes in COVID-19 patients

Detection of Mechanical Prosthetic Valve Dysfunction

The long-term outcome of mechanical aortic and mitral prosthetic valve (A-PV, M-PV) dysfunction (PVD) remains a serious complication associated with high morbidity and mortality. We sought to evaluate the incremental diagnostic value of combined transthoracic echocardiography (TTE) and fluoroscopy (F) in patients with suspected PVD. A total of 354 patients (178 A-PV, 176 M-PV) were imaged by TTE and F within 5 days of hospital admission. PVD was confirmed by transesophageal echocardiography, computed tomography, effective thrombolysis, or surgical inspection. PVD was confirmed in 101 patients (57%) with M-PV and 99 (55%) with A-PV. Regardless of the mechanism of PVD, TTE shows good sensitivity and specificity, with accuracy of 80% for M-PV and 91% for A-PV. F shows high specificity, but low sensitivity with accuracy of 68% for M-PV and 78% for A-PV. The integration of TTE + F significantly improved accuracy both for M-PV (83%) and A-PV (96%). At ROC analysis, the combined model of TTE + F showed the highest area under the curve for the detection of PVD compared with TTE and F alone (p < 0.001). In conclusion, in patients with a clinical suspicion of PVD, the combined model of TTE + F offers incremental value over TTE or F alone. This multimodality imaging approach overcomes limitations of TTE or F alone and provides prompt identification of patients who may require further imaging assessment and/or closer follow up.

Comparison of automated fastener (Cor-Knot) versus manually tied knots in patients undergoing minimally invasive mitral valve replacement

Introduction: Automated knot fastener has been used in minimally invasive valve surgery to alleviate the longer total operating time and improve outcomes. Their advantages over manual knot tying remain questionable. This study aims to compare automated knot fasteners' efficacy with conventional knot-pushers in minimally invasive mitral valve replacements (MiMVR).&#x0D; Methods: Between 2016 and 2020, 50 patients underwent isolated mechanical mitral valve replacement via right mini-thoracotomy in rheumatic or degenerative mitral valve disease. The patients were grouped into two groups. Group I (n= 25) included patients who had MiMVR using the Cor-knot device, and Group II (n= 25) had MiMVR using the conventional knot-pusher. Primary endpoints were cross-clamp, cardiopulmonary bypass, and total operative times and the secondary outcomes were paravalvular leak and reoperation. There were no significant differences in the demographic data between the two groups.&#x0D; Results: Cross-clamp time (79± 1.11 vs. 98.88± 1.34 min; P&lt;0.001), cardiopulmonary bypass time ( 132 (Q1- Q2: 129- 134) vs. 148 (140- 155) min; P&lt;0.001) and operative times ( 206 (203- 209) vs. 228 (223- 234) min; P&lt;0.001) were significantly shorter in Group I. There was no difference in postoperative complications between groups. The early paravalvular leak occurred in one patient (4%) in Group I and required valve re-exploration. In Group II, four patients (16%) had a paravalvular leak; 3 of them were severe and required valve re-exploration (P= 0.35). Transthoracic echocardiography at discharge revealed no evidence of a paravalvular leak in both groups.&#x0D; Conclusion: Automated fastener device (Cor-knot) could reduce operative times during minimally invasive mitral valve replacement. Operative complications are comparable between both techniques, and follow-up studies are recommended.

Outcomes related to anticoagulation management for mechanical valve replacements.

BackgroundThis study evaluates anticoagulation management and its impact on longitudinal clinical outcomes in patients undergoing mechanical valve replacement.MethodsPatients undergoing mechanical mitral valve replacement (MVR) or aortic valve replacement (AVR) from 2010–2018 at a single center were included. Patients were stratified into therapeutic and non-therapeutic anticoagulation groups based on the median percentage of international normalized ratio (INR) values within the reference range (2.0–3.0 for AVR, 2.5–3.5 for MVR) during the first post-operative year. Using Cox regression analysis, comorbidity-adjusted survival and freedom from adverse events were compared.ResultsSix hundred and fifty-one patients underwent mechanical valve replacement (166 MVR, 485 AVR). Comorbidity-adjusted survival was similar in the MVR and AVR cohorts (P=0.23). There was a median of 27 [interquartile range (IQR): 14–42] INRs drawn per patient in the first post-operative year. The median percentage of INRs within the reference values during the first post-operative year was 42.85% (IQR: 30.77–53.95%), with the majority of non-therapeutic INRs being subtherapeutic (34.51%; n=6,864). There were no significant differences in adjusted survival between the therapeutic and non-therapeutic groups [hazard ratio (HR): 1.12, P=0.73]. Within the first post-operative year, there were no significant differences in stroke, major bleeding, peripheral non-stroke arterial thromboembolism, and readmission for intravenous heparin in the therapeutic and non-therapeutic groups.ConclusionsTaking into account relevant comorbidities and valve type, patients with a larger proportion of non-therapeutic INRs during the first post-operative year demonstrated no difference in longitudinal clinical outcomes. Further research into more standardized INR monitoring and potentially expanded INR target ranges for patients undergoing mechanical valve replacement is warranted.

What Factors Should Be Considered to Improve Outcome of Mechanical Mitral Valve Replacement in Children?

To identify risk factors for pediatric mechanical mitral valve replacement (mMVR) to improve management in this challenging population. From 1993 to 2019, 93 children underwent 119 mMVR operations (median age, 8.8 years [interquartile range [IQR]: 2.1-13.3], 54.6% females) at our institution. Twenty-six (21.8%) patients underwent mMVR at ≤2 years and 93 (78.2%) patients underwent mMVR at >2 years. Median follow-up duration was 7.6 years [IQR: 3.2-12.4]. Early mortality was 9.7%, but decreased with time and was 0% in the most recent era (13.9% from 1993 to 2000, 7.3% from 2001 to 2010, 0% from 2011 to 2019, P = .04). It was higher in patients ≤2 years compared to patients >2 years (26.9% vs 2.2%, P < .01). On multivariable analysis for mitral valve reoperation, valve size <23 mm was significant with a hazard ratio of 5.38 (4.87-19.47, P = .01);. Perioperative stroke occurred in 1% and permanent pacemaker was necessary in 12%. Freedom from mitral valve reoperation was higher in patients >2 years and those with a prosthesis ≥23 mm. Median time to reoperation was 7 years (IQR: 4.5-9.1) in patients >2 years and 3.5 years (IQR: 0.6-7.1) in patients ≤2 years (P = .0511), but was similar between prosthesis sizes (P = .6). During follow-up period (median 7.6 years [IQR: 3.2-12.4], stroke occurred in 10%, prosthetic valve thrombosis requiring reoperation in 4%, endocarditis in 3%, and bleeding in 1%. Early and late outcomes of mMVR in children are improved when performed at age >2 years and with prosthesis size ≥23 mm. These factors should be considered in the timing of mMVR.

An Unusual Cause of Concordance in the Setting of Left Bundle Branch Block

A 73-year-old female with a past medical history of atrial fibrillation, mechanical mitral valve replacement on warfarin, hypertension and hypothyroidism presented to the emergency department with a fall. She fell and hit her head upon standing up from a seated position. She reported a constant posteriorly located headache along with episodes of nausea and vomiting. She denied chest pain, shortness of breath, syncope and fever. The initial examination showed blood pressure of 107/64mmHg, respiratory rate of 13/Min, pulse of 76/Min, oxygen saturation of 96% and Glascow Coma Scale (GCS) of 13, verbal response 4, motor response 6 and eye response 3. Pupils were round and reactive to light. No focal weakness or sensory loss were noted. The patient’s mental status and GCS progressively worsened for which she eventually was intubated. The patient had a mild leukocytosis of 14.11×109 (4.0-10.0). Her sodium, calcium, magnesium, phosphorus and potassium were normal. International Normalized Ratio (INR) was 2.9. The troponin upon presentation was 0.69ng/ml and trended down throughout the hospitalization. Her EKG showed normal sinus rhythm with a left bundle branch block with ST segment elevation in leads V3 - V5 and concordant ST elevation &gt;1mm in V5. Sgarbossa criteria for acute myocardial infarction in the presence of LBBB was 5 points. Computed tomography (CT) scan of the head without contrast showed large bilateral cerebellar hemorrhages with mild inferior herniation of the cerebellar tonsils. Echocardiogram showed ejection fraction of 55-60% with no wall motion abnormalities. Immediate supportive treatment, including fluids and reversal of anticoagulation with prothrombin complex concentrate and vitamin K were administered. The patient underwent a successful suboccipital decompressive craniotomy.

Characteristic localization patterns of thrombus on various brands of bileaflet mitral mechanical heart valves as assessed by three-dimensional transesophageal echocardiography and their relationship with thromboembolism.

Three-dimensional transesophageal echocardiography (3D-TEE) provides detailed images of prosthetic valve thrombosis (PVT). However, data regarding PVT localization patterns based on 3D-TEE and their association with clinical findings among various bileaflet mitral prosthetic valve brands is lacking. The locations of thrombi were classified into 4 groups according to hinge and annulus involvement based on 3D-TEE: ring-like PVT involving entire mitral annulus (type-1), PVT involving peri-hinge(s) region and extends through some part of the annulus (type-2), PVT involving mitral annulus without involving hinge(s) region (type-3), and PVT involving only (peri)hinge(s) area (type-4). This study was conducted in 265 patients (male: 71, mean age: 46.3 ± 12.7years) with mitral PVT, including 150 St Jude Medical (SJM), 65 Carbomedics, 29 Medtronic ATS open-pivot, and 21 Sorin bileaflet mechanical valves. There was a significant difference in most common PVT localization patterns between different prosthetic valves (type-1 for Carbomedics and Sorin; type-2 for SJM and type-3 for ATS valves; p < 0.001). Additionally, PVT involving only (peri)hinge region(s) (type-4) was mostly observed in patients with SJM valves (18%). (Peri)hinge(s) area involvement was observed in the majority of study patients (78.1%). In patients who presented with thromboembolism, the most common PVT localization pattern was type-1 (53%). Increased age, low international normalized ratio on admission, PVT with a mobile part > 2mm, type-1 and type-4 PVT were associated with thromboembolic events. In conclusion, thrombus can be displayed in distinct locations in several types of bileaflet mechanical valves due to different design, hinge and pivot mechanisms, which can be complicated with thromboembolic events.

Incorporating the anterior mitral leaflet to the annulus impairs left ventricular function in an ovine model

ObjectivesTranscatheter mitral valve prostheses are designed to capture the anterior leaflet and surgical techniques designed to fully preserve the subvalvular apparatus at prosthetic valve insertion both serve to shorten the anterior mitral leaflet height, thus effectively incorporating it into the anterior annulus. This study quantifies the acute effects of incorporating the anterior mitral leaflet into the annulus on left ventricular function. MethodsFourteen adult sheep (weight, 48.7 ± 6.2 kg) underwent a mechanical mitral valve insertion on normothermic beating-heart cardiopulmonary bypass, with full retention of the native mitral valve but with placement of exteriorized releasable snares around the anterior mitral leaflet. Continuous measurements of left ventricular mechano-energetics were recorded throughout, alternating incorporating and releasing of the anterior mitral leaflet to the mitral annulus. Echocardiography confirmed the incorporation into the annulus and release. ResultsThe independent indices of left ventricular contractility (ie, end systolic pressure volume relationship and preload recruitable stroke work) were both significantly impaired when the anterior mitral leaflet was incorporated to the annulus and restored after release, as were the hemodynamic parameters: cardiac output, stroke volume, stroke work, and left ventricular pressure decreased by 15%, 17%, 23%, and 11%, respectively. Echocardiography demonstrated increased sphericity of the left ventricle during anterior mitral leaflet incorporation. ConclusionsIncorporating the anterior mitral leaflet to the anterior annulus adversely affected left ventricular contractility, caused distortion of the left ventricle in the form of increased sphericity, and impaired hemodynamic parameters in normal ovine hearts.

Bioprosthetic versus mechanical mitral valve replacements in patients with rheumatic heart disease.

Rheumatic heart disease (RHD) remains a critical problem in developed countries. Few studies have compared the long-term outcomes of bioprosthetic valves and mechanical valves in patients with RHD who have received mitral valve (MV) replacement. Patients with RHD who received MV replacement with bioprosthetic or mechanical valves were identified between 2000 and 2013 from Taiwan's National Health Insurance Research Database. The primary late outcomes of interest were all-cause mortality and redo MV surgery. Propensity score matching at a 1:1 ratio was performed. We identified 3638 patients with RHD who underwent MV replacement. Among those patients, 1075 (29.5%) and 2563 (70.5%) chose a bioprosthetic valve and mechanical valve, respectively. After matching, 788 patients were assigned to each group. No significant difference in the risk of in-hospital mortality was observed between groups (P=.920). Higher risks of all-cause mortality (10-year actuarial estimates: 50.6% vs 45.5%; hazard ratio, 1.19; 95% confidence interval, 1.01-1.41; P=.040) and MV reoperation (10-year actuarial estimates: 8.9% vs 0.93%; subdistribution hazard ratio, 4.56; 95% confidence interval, 1.71-12.17; P<.01) were observed in the bioprosthetic valve group. Furthermore, the relative mortality benefit associated with mechanical valves was more apparent in younger patients and the beneficial effect persisted until approximately 65years of age. In the patients with RHD who underwent MV replacement, mechanical valves were associated with more favorable long-term outcomes in patients younger than the age of 65years.

Successful retrieval of a broken PentaRay catheter spine in a patient with mechanic mitral valve prosthesis.

Successful retrieval of a broken PentaRay catheter spine in a patient with mechanic mitral valve prosthesis.

Outcomes of Surgical Mitral and Aortic Valve Replacements Among Kidney Transplant Candidates: Implications for Valve Selection.

BackgroundLimited literature exists that evaluated outcomes of kidney transplant–eligible patients who are having dialysis and who are undergoing valve replacement. Our main objective in this study was to compare mortality, reoperation, and bleeding episodes between bioprosthetic and mechanical valve procedures among kidney transplant–eligible patients who are having dialysis.Methods and ResultsWe studied 887 and 1925 dialysis patients from the United States Renal Data System, who underwent mitral valve replacement and aortic valve replacement (AVR) after being waitlisted for a kidney transplant (2000–2015), respectively. Time to death, time to reoperation, and time to bleeding requiring hospitalizations were compared separately for AVR and mitral valve replacement. Kaplan–Meier survival curves, Cox proportional hazards model for time to death, accelerated time to event model for time to reoperation, and counting process model for time to recurrent bleeding were used. There were no differences in mortality (hazard ratio [HR], 0.92; 95% CI, 0.77–1.09) or risk of reoperation or risk of significant bleeding events between bioprosthetic and mechanical mitral valve replacement. However, mechanical AVR was associated with a modestly significant less hazard of death (HR, 0.83; 95% CI, 0.74–0.94) compared with bioprosthetic AVR. There were no differences in time to reoperation, or time to significant bleeding events between bioprosthetic and mechanical AVR.ConclusionsFor kidney transplant waitlisted patients who are on dialysis and who are undergoing surgical valve replacement, bioprosthetic and mechanical valves have comparable survival, reoperation rates, and bleeding episodes requiring hospitalizations at both mitral and aortic locations. These findings emphasize that an individualized informed decision is recommended when choosing the type of valve for this special group of patients having dialysis.

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.