Mild Mitral Stenosis Research Articles

Evaluation of Mean Mitral Gradient in Exercise Doppler Echocardiography in Mitral Stenosis

Background: In mitral stenosis (MS), the international recommendations are favor the mitral dilation if mean transmitral gradient reaches 15 mmHg or greater at the peak exercise Doppler echocardiography (grade C). Objective: Study of the transmitral gradient during exercise Echocardiography in patient with mitral valve area (MVA) of ≤ 2 cm². Results: 300 patients were included. The mean age was 42.7 ± 1.3 years, the sex ratio of 0.23. According to the MVA, three groups were defined. G1 (severe MS): MVA ≤ 1cm² (n =72), G2 (moderate MS): 1cm² < MVA < 1.5cm² (n = 128) and G3 (mild MS): MVA ≥ 1.5 cm² (n = 100). The mean MVA was 0.8 ± 0.1 cm² (G1), 1.3 ± 0.1 cm² (G2) and 1.7 ± 0.1 cm² (G3) (p < 10-6). At rest, from the 1st to the 3rd group, mean heart rate/min was respectively 71.5 ± 2.7, 76.3 ± 1.7 and 73.6 ± 2.1, and means transmitral gradient were respectively to 11.6 ± 0.8 mmHg, 8.8 ± 0.5mmHg and 5.1 ± 0.3mmHg (p < 10-6). At peak exercise, mean heart rate/min was 152.3 ± 2.9 (G1), 150.7 ± 2.2 (G2), 148.7 ± 2.4 (G3) (p = 0.20), and means transmitral gradient 39.2 ± 2.1 mmHg (G1), 31.5 ± 1.3 mm Hg (G2) and 22.8±1.0 mm Hg (G3) (p < 10-6). At maximum of exercise, the mean transmitral gradient was above 15 mm Hg in 95 patients (95%) in group 3 despite MVA ≥ 1.5 cm². All patients of group 1 and group 2 increased their mitral gradient above 15 mm Hg at peak stress. Conclusion: At maximum exercise, most of our patients have increased their transmitral gradient beyond 15 mm Hg, even those who had mild MS (MVA ≥ 1.5 cm²). Therefore, in stress echo-Doppler, the mean mitral gradient at peak exercise justifying percutaneous valvulotomy is probably greater than 15 mm Hg.

Effect of Exercise on Left Atrium Mechanics in Mild Mitral Stenosis.

A significant number of individuals with mild mitral stenosis (MS) experience exertional symptoms that are disproportionate to the hemodynamic severity of their condition. This study aims to determine whether exercise-induced left atrial (LA) dysfunction occurs in these patients and whether it is related to the development of symptoms. In this observational study, we recruited 46 patients with mild MS. Echocardiographic measurements were initially taken at rest, followed by a maximal exercise stress test. Patients were then returned to the echocardiography laboratory for post-exercise measurements. Our study cohort exhibited considerably higher left atrial volume index (LAVI) values (mean: 40.52 ± 18.27) compared to those of a healthy population. Furthermore, the LA reservoir strain (mean: 17.1 ± 8.33) was reduced relative to reference values. Following exercise, there was no change in the LA reservoir strain. However, trans-mitral pressure gradients and systolic pulmonary artery pressures increased. The post-exercise mean trans-mitral gradient was identified as the sole predictor of symptom development in patients with mild MS. The LA reservoir strain is already reduced in individuals with mild MS, and exercise does not lead to further decline in LA reservoir function in these cases. To our knowledge, this study is the first to explore the effects of exercise on LA mechanics in MS.

Sex influence in the etiology and long-term prognosis of significant tricuspid regurgitation

Abstract Introduction It is widely recognized that significant tricuspid regurgitation is more frequent in women, but there is practically no information on the prognostic differences according to sex in the different etiological groups. Our objective was to analyze the impact of sex on the frequency and prognosis according to the etiological group. Methods Retrospective multicenter study that included consecutive patients with significant tricuspid regurgitation (moderate-severe degree or greater) diagnosed between 2002 and 2017 in 3 referral hospitals. We retrospectively classified the patients according to sex and type of tricuspid regurgitation based on clinical and echocardiographic data. The type of tricuspid regurgitation was defined in the first step that met the established criteria, differentiating between congenital and organic etiology (structural tricuspid disease), left valve disease (mild mitral stenosis or another at least moderate valve disease), ventricular dysfunction, associated with pulmonary hypertension, or atrial (by not fulfilling any of the above and presenting atrial dilatation). Subsequently, we compared prevalence and mortality from all causes according to sex for each etiology. Results A total of 778 patients were included, 71% women. The median follow-up was 40.2 months (interquartile range 11.2-80.9). When comparing the frequency of each etiological group according to sex, we only found significant differences in tricuspid regurgitation associated with ventricular dysfunction (9.7% men vs 3.1% women, p <0.001). In terms of survival, we found significant differences with higher survival in women with organic etiologies (92.4 months in women vs 54.1 in men, p=0.021), secondary to valve disease (79.6 months in women vs 54.1 in men, p<0.001) or pulmonary hypertension (58.9 months in women vs 28.7 in men, p=0.01). In the rest of the etiological groups, differences were not statistically significant. Figure shows Kaplan-Meier survival curves based on each etiology for each gender. Conclusions Significant tricuspid regurgitation was observed in a higher percentage of women (71%). Regarding the frequency for each type of tricuspid regurgitation, only significant differences were found in the etiology secondary to ventricular dysfunction, being more frequent in men. Regarding the survival curves, significant differences were found with greater survival in the group of women in organic tricuspid regurgitation, secondary to valve disease and secondary to pulmonary hypertension.Kaplan Meier survival curves

Decoding calcific mitral valve disease: a novel deep learning model uncovers the role of calcium burden

Abstract Background Mitral annular calcification (MAC) is a common degenerative disease that affects older adults and causes calcium deposition in the mitral annulus, increasing the risk of mitral valve (MV) dysfunction, cardiovascular events, conduction abnormalities, and mortality. While the primary imaging modality recommended for the clinical evaluation of MAC is echocardiography, it has been reported to be found incidentally in approximately 8% of routine thoracic computed tomography (CT) scans. CT scan is a sensitive imaging modality for assessing MAC, providing the resolution necessary to understand the anatomical involvement of calcification. Research has shown that the MAC burden is associated with disease activity and progression. Still, the exact correlation between the quantitative calcium burden and the degree of severity of mitral valve disease is unclear. Purpose Our study aimed to determine the association between MAC, as assessed on CT, and significant mitral stenosis (MS) or mitral regurgitation (MR), as visualised on echocardiography. In addition, we sought to determine the quantitative MAC cutoffs that would optimally predict significant MS or MR on echocardiography. Methods A retrospective cohort study was conducted at our academic centre. Inclusion criteria were: age≥60 years, resting transthoracic echocardiogram performed between 2013-2022, non-gated chest CT performed within one year before echocardiography, and any degree of MAC documented on the echocardiography report. CT scans were requested for clinical indications unrelated to mitral valve disease. Exclusion criteria were: prior mitral valve intervention, endocarditis, and congenital mitral valve disease. Significant calcific mitral valve disease was defined as ≥moderate MR and ≥mild MS on the echocardiography report, ascertained by expert readers based on multiparametric ASE criteria. MAC volume was quantified on the multi-slice CT DICOM images using a 3D U-Net deep neural network previously trained by our group on an independent cohort. Results The cohort consisted of 1,560 unique patients with a mean age of 79 years and 61% females. The echocardiographic prevalence of significant MR and MS was 10% and 4%, respectively, for 211 affected patients. The CT-based mean MAC volume was 949 mm³ in patients with significant MR or MS, as opposed to 334 mm³ in those without (P<0.001). MAC volume >1000 mm³ was the optimal cutoff to predict significant MS (specificity 90%, sensitivity 51%, area under ROC curve 0.79) and significant MR (specificity 89%, sensitivity 21%, area under ROC curve 0.60). Adjusting for age, sex, and comorbid conditions did not affect the observed association between MAC volume and mitral valvulopathy. Conclusion A novel deep learning model for quantifying MAC volume from non-cardiac clinical CT scans was efficient in screening for calcific mitral valve disease, particularly MS, and identifying patients who may benefit from further evaluation.

Functional tricuspid regurgitation associated with left-side valvulopathy: clinical profile and long term evolution based on pulmonary pressure

Abstract Introduction Tricuspid regurgitation (TR) is an entity with multiple etiologies, with functional TR associated with left-sided valvulopathy being the most frequent group in clinical practice, accounting for approximately 50%. This group has traditionally been considered a consequence of pulmonary hypertension (PH) secondary to left-sided valvulopathy, although this dogma has hardly been evaluated despite new clinical and pathophysiological knowledge of TR. In this study we aimed to evaluate the clinical profile and evolution of a large series of patients with significant TR based on pulmonary pressure. Methods Multicenter and retrospective study that included a series of consecutive patients with significant TR (moderate to severe or greater) diagnosed between 2002 and 2017. After excluding patients with organic TR (congenital or acquired), those with TR associated with left-sided valvular disease were included, defined by the presence of mild mitral stenosis, previous left-sided surgery, left-sided valvular prosthesis or other left-sided valvular disease of at least moderate grade. Patients were classified according to the absence or presence of PH which was estimated by echocardiography, defining a systolic pulmonary arterial pressure (PASP) ≥ 50 mmHg. Subsequently, the baseline clinical characteristics of the sample were compared and a follow-up was carried out to evaluate long-term mortality and hospitalization events due to heart failure (HF). Results A total of 422 patients were were included (160 with PASP <50 and 262 with PASP ≥50). The attached table shows the baseline characteristics of both groups. Patients with PASP <50 were younger, had a higher percentage of previous valvular surgery, AF, HTN, and DM, along with a lower percentage of pulmonary disease and right HF. After follow-up (median 42.6 months), significant differences were observed between the two groups (Figures 1 and 2) with higher overall long-term survival (p<0.001) and higher freedom from HF hospitalization (p 0.013) in the group without PH. Cox regression analysis showed that female sex was a predictor of higher survival (p<0.001) while age and previous diagnosis of RHF were predictors of mortality (p<0.001). Similarly, the presence of previous RHF and previous hospitalizations for HF were predictors of the HF hospitalization event (p<0.001). Conclusions In a large series of patients with left-sided valvular heart disease and TR, cases with estimated absence of significant PH were frequent (37.9%). Furthermore, it was observed that pulmonary disease (a possible concomitant cause of PH) was more frequent in the group with significant PH. The group without PH had a different clinical profile and a better long-term prognosis. All of this suggests that there are different factors that determine the development of significant TR associated with left-sided valvular heart disease, beyond secondary PH itself. These factors could influence the patient's prognosis.Baseline clinical characteristics.Kaplan Meier survival curves.

Abstract 19066: God Fixed It! A Case of Mitral Valve Prolapse

Background Mitral Valve prolapse (MVP) occurs in 1.2 to 3% of the population. Myxomatous degeneration is the most common cause of MVP in the United States. Clinical features range from asymptomatic to serious complications such as heart failure, endocarditis, arrhythmias, and sudden cardiac death. Patients with MVP may develop severe mitral regurgitation (MR) requiring surgery. We present a unique case of severe MR in a patient with MVP. Case A 67-year-old male with a history of Dysautonomia and Parkinson’s disease presented to the cardiology clinic with complaints of exertional dyspnea, lightheadedness, and palpitation. Transthoracic echo was obtained as part of the workup revealing ejection fraction>55%, Myxomatous Mitral Valve with significant prolapse of the posterior leaflet which was partially flail causing severe MR, regurgitant volume of 149 cc, and percentage of 69%. Cardiac catheterization showed normal coronaries. A transesophageal echo to evaluate the MR and surgical repair of the mitral valve was offered, but the patient refused surgery. He was later lost to follow-up. After 4 years, he presented to the clinic with some exertional dyspnea. Repeat echo revealed moderately calcified posterior leaflet with less mobility causing only moderate MR. His MR continued to improve, an echo after 5 years revealed increasing calcific changes involving posterior leaflet and chordal attachment, causing mild MR and mitral stenosis. Discussion Isolated MVP can develop degenerative MR in up to 25%, and 0.4 to 1.9% can suffer sudden cardiac death. Surgery is recommended for severe symptomatic MVP with MR and it is considered fatal if left unrepaired. In this case, the patient refused surgery and had an unusual natural history of valve calcification leading to decreased mobility, reduced prolapse, and converting severe MR into mild. To our knowledge, this is the first case in literature where there is a self-correction of MVP due to the calcification of the valve leaflet.

Reproducibility of transthoracic 3D echocardiography in the assessment of mitral valve area in patients with rheumatic mitral stenosis: real time versus ECG-gated 3D echocardiography.

To assess reproducibility of Real time 3D echocardiography (RT3D) and ECG-gated 3D echocardiography (EG3D) when measuring the mitral valve area (MVA) in rheumatic mitral stenosis (MS). MVA was assessed by three operators in 68 MS patients using RT3D and EG3D. Reproducibility of each technique was determined by calculating the standard error of measurements (SEM). SEM was similar between RT3D and EG3D. MVA variability was of 0.4cm² or 30% of any RT3D or EG3D measured MVA. The minimal change in MVA above which two measurements should be considered to differ significantly for the same operator was of 0.4cm² for RT3D and 0.5cm² for EG3D. For two different operators making successive measurements, the minimum significant change was of 0.5cm² for RT3D and 0.6cm² for EG3D. The minimum significant difference when switching from RT3D to EG3D or vice versa is of 0.6cm². Low temporal resolution of 6Hz has the least variability when using RT3D (0.19cm² vs. 0.26cm², p = 0.009) but significantly underestimated MVA (1.3 ± 0.4cm² vs. 1.4 ± 0.4cm², p < 10- 3) when compared to EG3D. MVA variability was significantly higher in mild MS when compared to severe MS whether it is RT3D (0.23cm² vs. 0.18cm², p = 0.02) or EG3D (0.27cm² vs. 0.16cm², p < 0.001). RT3D and EG3D are equally reproducible in the assessment of MVA in patients with MS. Further measurements standardization is required to have a clinically acceptable estimations of the true 3D MVA and minimal detectable differences.

Un cas rare de complexe de Shone incomplet chez un homme de 35 ans avec un morphotype marfanoïde et revue de la littérature

Shone syndrome is a rare and complex congenital heart disease. It is characterized in its complete form, by a constellation of the four potentially obstructive lesions of the left heart side. Incomplete Shone's complex includes 2 or 3 of the characteristic lesions which, include a supravalvular mitral membrane, valvular mitral stenosis (MS) by a parachute mitral valve (PMV), subaortic stenosis and aortic coarctation (Coa). We describe here, the case of a 35-year-old man, hospitalized for chronic dyspnea and in whom, the diagnosis of incomplete Shone's complex is retained by echocardiographic analysis. Observed lesions include a parachute mitral valve responsible for mild regurgitation and moderate mitral stenosis, bicuspid aortic valve, and pseudo interruption of the aorta with dilatation of the ascending aorta and a patent ductus arteriosus. This case is the 2nd on 3942 patients in Drighil congenital heart disease registry.

Evaluation of Pregnancy Outcome in Women with Rheumatic Mitral Valve Stenosis

Background and Aims: Rheumatic heart disease is still one of the most common heart lesion in developing countries. The maternal and fetal hazards increase with the severity of Mitral stenosis. This study was aimed to determine the fetomaternal outcome in women with mitral stenosis during pregnancy. Methods: This was descriptive cross-sectional study which included all pregnant patients with isolated rheumatic mitral valve stenosis. Major adverse outcomes studied were cardiac failure, thromboembolic event, admission in cardiac care or intensive care unit, atrial fibrillation, endocarditis, pulmonary hypertension and cardiac death. Results: Out of 3194 pregnant women, 31 had mitral stenosis. Their mean age was 27 years, mean mitral valve area 1.43cm2 and majority were primigravida (61.29%). Among them, symptomatic cardiac failure was present in 6.66%, 30% and 66.66% of mild, moderate and severe mitral stenosis respectively. The chances of cardiac failure, atrial fibrillation, preterm delivery and small for gestational age babies was high in all patients without having percutaneous trans-luminal mitral commissurotomy than those who underwent the procedure for moderate to severe mitral stenosis during pregnancy. Conclusion: There were high chances of adverse fetomaternal outcome in pregnant women with mitral stenosis. Cardiac failure was found to be increased with the severity of mitral stenosis. PTMC during pregnancy resulted in decreased cardiac failure, atrial fibrillation, preterm delivery and small for gestational age babies.

Assessment of Right Ventricular Systolic Function with 3-Dimensional Speckle Tracking Echocardiography in Isolated Mild Mitral Stenosis.

In rheumatic severe mitral stenosis, right ventricular mechanics deteriorate with the increasing severity of mitral stenosis. Therefore, we aimed to investigate right ventricular mechanics in patients with mild mitral stenosis using 3-dimensional speckle tracking echocardiography. In total, 40 patients with mild mitral stenosis and 36 age- and gender-matched healthy controls were included. Conventional echocardiographic examination was performed and 3-dimensional data sets were acquired for strain analysis. Besides conventional echocardiographic parameters, right ventricular volume and function and 3-dimensional speckle tracking echocardiography-derived right ventricular free wall longitudinal strain were compared between patients with mild mitral stenosis and healthy controls. Although 3-dimensional right ventricular volumes and ejection fraction were similar between the groups, 3-dimensional speckle tracking echocardiography-derived right ventricular free wall longitudinal strain was significantly lower in patients with mild mitral stenosis than in controls (25.57 ± 4.39% vs. 27.90 ± 4.71%, P =.028). Significant correlations were observed between right ventricular free wall longitudinal strain and mitral valve area and estimated systolic pulmonary artery pressure (r = 0.597, P <.001; r = -0.508, P =.003, respectively). Another significant positive correlation was observed between planimetric mitral valve area and 3-dimensional speckle tracking echocardiography-derived right ventricular free wall longitudinal strain (r = 0.597, P <.001). The degree of severity of mild mitral stenosis in terms of mitral valve area can help in the early detection of subclinical right ventricular systolic function impairment which can be easily detected by 3-dimensional speckle tracking echocardiography. Right ventricular contractile performance could decrease even in mild mitral stenosis.

PERIOPERATIVE MANAGEMENT OF A CASE OF CHRONIC RHEUMATIC HEART DISEASE POSTED FOR EMERGENCY CAESAREAN SECTION

Rheumatic heart disease(RHD) still remains an endemic in India. It is one of the major causes of mortality and morbidity in parturients in developing countries. We present a 26 year old second gravida with history of chronic rheumatic heart disease with multiple valvular disease. She presented with complaints of palpitations, dyspnoea progressing from New York Heart Association (NYHA) class II to class III. On physical examination, patient was pale, had bilateral pedal edema, tachycardia, dyspnoea, undifferentiated murmur on auscultation. Further evaluation revealed anemia, dilated left atrium, moderate mitral regurgitation, mild mitral stenosis, mild aortic regurgitation and fetal distress. Patient was taken for emergency caesarean section in the view of maternal condition and fetal distress. She developed pulmonary edema during surgery and was kept on ventilator to optimize the patient condition with further management. She was successfully extubated after 3 days of meticulous care in intensive care unit (ICU).

Effect of mitral valve transcatheter edge-to-edge repair on indices of left atrial performance in chronic mitral regurgitation.

Effect of transcatheter edge-to-edge repair (TEER) using MitraClip in patients with mitral regurgitation (MR) on left atrial (LA) kinetic energy (LAKE), an index of LA work, and LA strain, a measure of LA performance, have not been well defined. Patients with chronic primary or secondary 3+ or 4+ MR were analyzed pre- and post-TEER using MitraClip. LAKE was determined by echocardiography using LA stroke volume and A-wave velocity. Peak atrial longitudinal strain (PALS), peak atrial strain in early diastole, and peak atrial contraction strain (PACS) were obtained by speckle tracking echocardiography. Thirty-nine patients undergoing TEER with MitraClip were screened, 12 met criteria for analysis (9 primary and 3 secondary MR). Compared to pre-TEER, there was a significant increase post-TEER in LAKE (71.0±64.1vs. 177.5±167.9 dyne·cm·103 , respectively; p=.008) and Doppler transmitral A-wave velocity (87.8±41.4vs. 138.5±43.7cm/s, respectively; p<.001); LA stroke volume did not change significantly. Mitral valve mean gradient significantly increased post-TEER compared to pre-TEER (5.7±2.1vs. 3.3±2.1mmHg, respectively; p=.01). There was a trend toward decrease in PALS post-TEER compared to pre-TEER (16.2±4.8vs. 20.7±9.9%, respectively; p=.05). Peak atrial strain in early diastole significantly decreased post-TEER compared to pre-TEER (7.2±3.0vs. 14.1±7.2%; respectively, p<.001), while PACS did not significantly change (9.1±3.5vs. 6.7±5.2%, respectively; p=.07). In patients with chronic MR, LAKE increases after TEER with MitraClip driven by an increase in LA emptying velocities. Changes were also seen in LA strain with MitraClip. These procedurally induced changes due to mild mitral stenosis may have clinical implications.

Severe rheumatic mitral stenosis – analysis of clinical and echocardiographic very long-term outcomes after percutaneous mitral balloon valvuloplasty

Abstract Introduction Mitral balloon valvuloplasty (MBV) is the guideline recommended treatment for symptomatic severe mitral stenosis (MS) with suitable anatomy, but is often deemed transitory. However, data on very-long term echocardiographic follow-up is scarce. The aim of our study was to describe clinical and echocardiographic outcomes in patients previously submitted to MBV for rheumatic MS. Methods We conducted a single-centre retrospective study enrolling patients previously submitted to MBV for rheumatic MS from 1990 until 2021. Follow-up was considered until last registered echocardiographic re-evaluation. Patients without electronic health records available were excluded. The primary endpoint was a composite of all-cause death or need of surgery. Results A total of 193 patients were included (15.5% male, with a mean age of 52±15 years at the time of MBV, 60.6% with permanent atrial fibrillation). During a mean follow-up of 11±8 years, 87 (45.1%) patients implanted a mitral valve prosthesis, 4 (2.1%) were submitted to surgical mitral valvuloplasty and 30 (15.5%) died without being reinterventioned. Moreover, a total of 23 (11.9%) embolic events were registered – 21 strokes, 1 pulmonary embolism and 1 acute lower limb embolism. Overall, 133 patients (68.9%) survived more than 5 years, 95 (49.2%) more than 10 years and 56 (26.9%) more than 15 years since MBV without meeting the primary endpoint. The maximum follow-up without intervention was 32 years. Concerning patients submitted to surgery, the mean time from MBV until operation was 9.4±7.3 years (minimum 8 days; maximum 29.3 years). In regard to echocardiographic long-term outcomes on alive non-operated patients (mean follow-up of 12±9 years), 52.8% remain with mild MS, 91.6% with mild or no mitral regurgitation and 77.6% with mild or no tricuspid regurgitation. Furthermore, only 20.4% have right ventricle dysfunction (defined as a TAPSE &amp;lt;17 mm), 18.3% have pulmonary hypertension (pulmonary artery systolic pressure &amp;gt;45 mmHg), and 6.8% have residual interatrial communication. Conclusion MBV is a minimally invasive procedure that has an important benefit in a very significant proportion of patients with rheumatic mitral stenosis, with potential benefit that may last more than three decades without need for another invasive intervention. Funding Acknowledgement Type of funding sources: None.

S2954 COVID-19 Infection as a Trigger for Seronegative Autoimmune Hepatitis: A Case Report

Introduction: Autoimmune hepatitis (AIH) is an immune-mediated liver disease that commonly develops in a genetically predisposed patient after exposure to an environmental trigger. These triggers include viruses, immunization and drugs. Both COVID-19 infection and vaccination have been linked to the development of AIH. Case Description/Methods: A 58-year-old male patient, known to have vitiligo and mild rheumatic mitral stenosis presented to our hospital complaining of flu-like symptoms. The patient denied any history of alcohol intake, substance abuse, over-the-counter or herbal medications, or family history of liver or autoimmune disease. His chronic medications included aspirin and bisoprolol. He tested positive for COVID-19 PCR, so he was admitted for observation. Chest X-ray showed no abnormality, and he was not started on any medication. His laboratory investigations (Table 1) were remarkable for ALT of 271 and AST of 175 U/L. During hospitalization, liver enzymes were trending down but remained elevated. The hepatitis workup (Table 1) was notable for an elevated IgG level of 16.9 g/l (normal range 7-16). His radiological investigations included US abdomen that revealed mildly increased echotexture, MRI liver that was only remarkable for tiny cyst 2 mm, and liver elastography that showed a stiffness average of 5.77 kPa indicating mild stiffness. The patient was offered a liver biopsy, but he was reluctant. During follow-up, his LFTs remained elevated but were fluctuating (Figure 1a). On week 31, he finally agreed for liver biopsy that showed moderate interface and portal tract inflammatory cell infiltrate composed mainly of lymphocytes with occasional eosinophils (Figure 1b,c). The histopathological findings were suggestive of AIH. On week 34, he was started on prednisone 40 mg. LFTs on week 36 were completely normal. The prednisone was tapered over the following two months. Six months later, repeat LFTs were also normal. Discussion: Our patient had an elevation of LFTs after COVID-19 infection that persisted for weeks and promptly responded to steroids therapy. Drug-induced liver injury was less likely as he didn’t receive any hepatotoxic medications prior to or during his hospitalization. In our patient, the Revised Original Score for Autoimmune Hepatitis (AIH) was 17, indicating definite AIH. The proposed mechanism of AIH development after COVID-19 infection is the molecular mimicry between spike protein S1 and multiple human tissue proteins. More studies are needed to examine this association.Figure 1.: a: Trend of LFTs over time. b,c: histopathological images showing interface and portal tract inflammation. Abbreviations alphabetically: Bx: biopsy - d/c: discharge - Dx: diagnosis - f/u: followup - Rx: treatment Table 1. - shows extensive hepatitis workup Laboratory test result Reference ALT 271 0-40 U/L AST 175 0-37 U/L ALP 38.9 40-129 U/L Antinuclear ab Negative Negative Anti Mitochondrial ab Negative Negative Anti Mitochondrial M2 ab Negative Negative Anti Smooth Muscle ab Negative Negative Anti Liver Kidney Microsomes Negative Negative Hepatitis B Core ab Reactive non-reactive Hepatitis B Core Ab IgM non-reactive non-reactive Hepatitis B Surface Antigen Non-reactive Non-reactive Hepatitis B e Ab Non-reactive Non-reactive Hepatitis B e Antigen Non-reactive Non-reactive Hepatitis A Ab IgM Non-reactive Non-reactive Hepatitis C Ab Non-reactive Non-reactive Hepatitis E IgG Reactive Non-reactive Hepatitis E IgM Non-reactive Non-reactive Herpes Simplex virus Ab IgM Non-reactive Non-reactive Parvovirus Ab IgM Non-reactive Non-reactive Alpha-1 anti-trypsin 37 20-53 µmol/L Ceruloplasmin 33 14 to 40 mg/dL CMV PCR Negative Negative EBV PCR Negative Negative HBV PCR Negative Negative

Edge-to-Edge Technique Used as a Bailout for Suboptimal Mitral Repair: Long-term Results

BackgroundFor cases of initial suboptimal mitral valve repair, the edge-to-edge (EE) technique has been used as a bailout procedure. However the long-term durability of those rescued mitral valves is currently unknown. With this study we aim to evaluate the long-term clinical and echocardiographic results of the EE technique used to rescue patients with initial suboptimal conventional mitral valve repair. MethodsA retrospective review of our institutional database was done to query for patients who had undergone mitral valve repair with the EE technique used as a bailout procedure. The cumulative incidence function using death as a competing event was used to estimate cardiac death and redo for mitral valve replacement. To describe the time course of mitral regurgitation, we performed a longitudinal analysis using generalized estimating equations with random intercept for correlated data. ResultsEighty-one patients were selected. The median follow-up was 9.1 years (interquartile range, 6.7-12.1; maximum, 22.6 years). At 15 years the estimated Kaplan-Meier overall survival was 63.2% ± 8.69% (95% confidence interval, 43.76-77.46) and the predicted rate of moderate to severe mitral regurgitation recurrence was 16.67%. At 15 years the cumulative incidence function for redo for mitral valve replacement with death as a competing event was 2.5% (95% confidence interval, 0.48-7.84). No case of more than mild mitral stenosis was detected. ConclusionsThe EE technique can be effectively used as a bailout procedure in patients with suboptimal conventional mitral valve repair with satisfactory long-term results.

Efficacy and Safety of Left Atrial Appendage Occlusion in Mild Mitral Stenosis Patients with High Bleeding Risk.

Atrial fibrillation (AF) is highly prevalent in patients with mitral stenosis (MS), but the efficacy of left atrial appendage occlusion (LAAO) in these patients remains unclear.The aim of this study was to evaluate the efficacy and safety of LAAO in patients with MS complicated by AF at high risk of bleeding.We recruited patients from September 2015 to September 2018. We compared the 3-year outcomes of LAAO in 21 patients with AF complicated by MS and 42 sex- and age-matched patients with AF without MS.The MS group had more cases of peripheral arterial embolism (28.6% versus 2.4%, P = 0.004), more spontaneous echo contrast (47.6% versus 9.5%, P = 0.001), a larger LAA orifice diameter (P < 0.01), and a slower LAA flow (P < 0.05) than the Non-MS group. The mean size of the selected occluder device was bigger for patients with MS than for patients with Non-MS (29.2 ± 3.7 versus 26.9 ± 3.1 mm, P = 0.014). In the first 45 follow-up days, 2 (9.5%) patients with MS had device-related thrombi (DRT); one of them had transient ischemic attack 24 hours postoperatively. From 45 days to 6 months, one patient in each group had DRT. After 6 months, two patients in the Non-MS group still had residual leaks; one of them had a stroke, with a small DRT. The proportion of dual antiplatelet therapy was higher in the Non-MS group than in the MS group (33.3% versus 4.8%, P = 0.012), but this population had an increased bleeding risk.LAAO is relatively effective and safe for preventing embolic events in patients with MS complicated by AF, at high risk of bleeding.

ABO Blood Type Is Associated with Thrombotic Risk in Patients with Nonvalvular Atrial Fibrillation.

Blood type is reportedly correlated with the occurrence of cardiovascular diseases, presumably because of its effect on thrombogenicity. However, the relationship between blood type and thrombotic complications in atrial fibrillation (AF) remains unclear. This retrospective study analyzed the blood types of 1170 AF patients (mean age, 70 years; 58% men) who were followed up for up to 4 years. Patients with greater than mild mitral stenosis or prosthetic valves were excluded. The cohort included 305 (26%) type O, 413 (35%) type A, 333 (28%) type B, and 119 (10%) type AB patients. The primary endpoint of major adverse cerebrovascular events (MACE) occurred in 52 (4.4%) patients. When longitudinal outcomes were plotted, AB blood type patients had worse prognosis than non-AB blood type patients (p = 0.039), particularly type O blood patients (p = 0.049). Multivariate Cox regression analysis revealed that AB blood type was associated with higher MACE rates (adjusted hazard ratio, 2.01; 95% confidence interval, 1.01–4.00; p = 0.048) than non-AB blood types independent of anticoagulation therapy duration or CHA2DS2-VASc score. These indicate that AF patients with AB blood type are at an increased risk of MACE compared to those with non-AB blood type independent of the duration of anticoagulation or the CHA2DS2-VASc score.

Staged left ventricular recruitment facilitated by Sano conduit upsizing

Staged left ventricular recruitment facilitated by Sano conduit upsizing

Hemophagocytic Lymphohistiocytosis Associated With Endocarditis: A Case Years in the Making.

Hemophagocytic Lymphohistiocytosis Associated With Endocarditis: A Case Years in the Making.

Commissural closure to treat severe mitral regurgitation: standing the test of time.

Mitral regurgitation (MR) due to commissural prolapse or flail represents a pattern of valve dysfunction that can be treated, among other techniques, by suturing the margins of the anterior and posterior leaflets in the commissural area (commissural closure). The very long-term results of this technique have not been reported so far and represent the objective of this study. A retrospective review of our institutional database was carried on querying for patients who underwent commissural closure and ring annuloplasty within the time frame 1997-2007 to provide a robust long-term assessment. Cumulative incidence function (CIF) using death as a competitive outcome was used to estimate cardiac death and reoperation for mitral valve replacement. To describe the time course of MR, we performed a longitudinal analysis using generalized estimating equations with a random intercept for correlated data. A total of 125 patients were included. At 15 years, the CIF for cardiac death, with non-cardiac death as a competitive event, was 8.0 ± 2.57% (95% confidence interval [3.88-13.93]). At 15 years, the CIF for reintervention for a mitral valve replacement with death as a competitive event was 5.0 ± 1.98%, 95% confidence interval [2.04-9.89]. No significant predictors of reintervention for mitral valve replacement were identified. At 5 years, the predicted rate of MR ≥3+ recurrence was 2.53% while it was 8.22% at 15 years. In no case a more than mild mitral stenosis was detected. Severe MR due to commissural prolapse/flail can be effectively treated with commissural closure and ring annuloplasty. In our series, the rate of reoperation in the very long term was extremely low. Similarly, longitudinal analysis demonstrated a very low rate of MR ≥3+ recurrence.