Mild Mitral Valve Regurgitation Research Articles

Initial single-center experience with transapical beating heart mitral valve chordal repair of primary mitral regurgitation

Abstract Introduction Ten patients underwent off-pump transapical mitral valve repair with chordal implantation for the treatment of primary mitral valve regurgitation (MR) between 01.2023 and 03.2024 in our tertiary referral center. Purpose Our aim was to examine the safety, feasibility and effectivity of the surgical method. Methods We fulfilled the retrospective analysis of the patients’ preoperative, operative and postoperative data. Results Median age was 75.5 years [IQR: 74; 80], Euroscore II 2.8 [IQR: 2; 3], and STS Score 3.8 [IQR: 2; 4]. Three patients were in NYHA II, four patients in NYHA III and three patients in NYHA IV functional stage. The patients had severe co-morbidities as congestive heart failure (n=9), pulmonary hypertension (n=10), chronic renal failure (n=4), more than mild coronary artery disease (n=4), peripheral arterial disease (n=4), previous pulmonary embolism (n=4), atrial fibrillation (n=3), chronic obstructive pulmonary disease (n=2), previous stroke (n=1). All the patients had posterior mitral leaflet prolapse ± chordal rupture, causing severe mitral regurgitation. Six patients had isolated P2 disease and four had more complex pathology. Median MR PISA radius was 14 mm [12-15.8], 3-dimension vena contracta area 0.56 cm2 [IQR: 0.56-0.57], effective regurgitant orifice 0.61 cm2 [IQR: 0.5-0.84], regurgitant volume 83 ml [IQR: 65-111], leaflet-to-annulus index 1.23 [IQR: 1.2-1.3] and coaptation index 5 mm [IQR: 4.5-5]. All the surgeries were successful, with median 90 minutes [IQR: 75; 100] surgery time, 2-5 chordal implantations. The intra-operative echocardiography showed trace or mild MR in seven cases, and mild-to-moderate MR in three cases. There was no operative/early postoperative mortality, or early valvular/chordal failure. One case of postoperative bleeding occurred with successful surgical revision. There was one case of 30-days-mortality in a critically ill patient with severe heart failure. Mild left-sided pleural effusions and postoperative atrial arrhythmias were detected in five and three patients, respectively. Median ICU stay was 27 hours [IQR: 23.5; 27.8], and postoperative in-hospital stay was 8 days [IQR: 7; 9]. Predischarge transthoracic echocardiography showed trace-to-mild MR in eight patients, and mild-to-moderate MR in two patients, while three months postoperatively we detected four cases of mild, four cases of mild-moderate or moderate and one case of moderate-to-severe MR. In comparison to the baseline values, five patients were in NYHA I, two in NYHA II and two in NYHA III functional stage three months after surgery. Conclusion In summary, transapical beating heart mitral valve chordal repair seems a relatively safe and effective option for high-risk patients, however, we emphasize the significance of judicious preoperative risk and echocardiographic eligibility assessment and the need for further studies to examine the durability and long-time efficacy of the method.

Clinical experience of transapical off-pump mitral valve repair with NeoChord implantation

Abstract Introduction Transapical off-pump mitral valve repair with NeoChord implantation is a novel minimally invasive surgical procedure to treat degenerative mitral valve regurgitation (MR). has gained widespread application for patients presenting with severe mitral regurgitation caused by leaflet prolapse or flail. However, there is a scarcity of data concerning the clinical experience with this device. Purpose This prospective study aims to assess 1-year clinical results of the Neochord Procedure in a consecutive cohort of patients. Methods Between March 2018 and December 2023, 38 patients with severe symptomatic degenerative MR were enrolled in the study. All patients presented with severe MR due to flail of 1 or both leaflets and they all completed postoperative echocardiographic assessment up to 1 year. We identified the primary endpoint as composed of procedural success , freedom from mortality, reintervention, recurrence of severe MR , and decrease of at least 1 New York Heart Association (NYHA) functional class at 1-year follow- up. Results Median age was 59 years (21% female). Acute procedure success (defined as successful placement of at least 3 neochords with reduction of residual MR to less than 2+) was achieved in all patients. The intraoperative and in-hospital mortality rate was 0%. At 1-year overall survival was 97% with the one reported death attributed to other causes. Following the procedure, almost all patients (94%) reported a decrease in NYHA functional class at 1-year follow-up along with a reduction in diuretic usage (18% of patients presented with NYHA Class I, while 76% of them presented with NYHA Class II). Moreover, 18% of patients exhibited mild MR, while 63% presented with moderate MR, and 10% had no detectable mitral leakage. Conclusion Transapical off-pump mitral valve repair with NeoChord implantation seem to be a safe procedure for patients. However, further investigations with a larger sample size and longer follow-up periods are warranted.

5128 Role of Plasmapharesis- A Tale of Two Thyroid Storms

Abstract Disclosure: Z. Zhang: None. S. Joseph: None. A.M. Kodali: None. D. Eagerton: None. Background: Thyroid storm is an acute life threatening endocrinological emergency. The standard treatment for a thyroid storm is antithyroid medication, iodine, beta blockers and corticosteroids. However, when patients are refractory to standard treatment, plasmapheresis may be an effective and safe intervention. Case 1: A 49-year-old male with typical symptoms of hyperthyroidism, presented with a Ventricular tachycardia arrest. After the return of spontaneous circulation, he was febrile, and developed new onset atrial fibrillation (AF) and Amiodarone drip was started. Physical exam showed a thin gentleman with an enlarged thyroid. ECHO showed LVEF 50% with moderate to severe dilatation of left atrium and mild mitral and tricuspid valve regurgitation. CT abdomen/pelvis and CTA chest did not show any pathology. Labs showed TSH of 0.02 (reference range: 0.465-4.68); Free T 4 >6.99 (reference range: 0.78- 2.19). He was started on Propylthiouracil (PTU), Hydrocortisone, Potassium Iodide, and Cholestyramine. His blood pressure was too low to tolerate a beta blocker. He developed increased liver enzymes thought to be due to shocked liver. PTU was switched to Methimazole due to less risk of hepatotoxicity. A Thyroid Stimulating immunoglobulin was 13.40 (reference range 0.00-0.55), confirming Graves’ disease. He developed multiorgan failure and plasmapheresis was initiated. His Free T4 level prior to his first apheresis was still >6.99 but improved to 6.20 after two days. After the second session, free T4 level drastically improved to 2.65. He sustained a level of 2.09 until his hospital discharge. Case 2: A 59-year-old male with untreated hyperthyroidism and AF, who presented with shortness of breath. He was tachycardic, febrile and developed AF with rapid ventricular response. A TSH and free T4 level showed <0.02 (reference range: 0.465-4.68); and >6.99 (reference range: 0.78- 2.19), respectively. Physical exam shows a cachectic man with an enlarged thyroid. ECHO showed reduced ejection fraction of 35% with biventricular failure. He was initially started on PTU, Potassium Iodide, hydrocortisone and esmolol drip and eventually Cholestyramine. Patient developed multisystem organ failure and PTU was switched to methimazole due to continued deterioration of his liver enzymes. Plasmapheresis started with a total of 3 sessions. His free T4 improved from 4.32 to 3.59 by the second session. Round three was performed when his Free T4 increased back to 4.56. Unfortunately, he had a sudden decline in mentation and CT head showed an acute/subacute left anterior parietal stroke and after family discussion, was palliatively extubated and expired. Discussion: This case series shows two cases of thyroid storm treated with plasmapheresis and had two stark contrasts. Further studies should be done to elucidate the usefulness of plasmapheresis for thyroid storm when refractory to standard of treatment. Presentation: 6/2/2024

Mid-term outcomes of minimally invasive surgery for partial atrioventricular septal defect in children

Objective: This study aims to describe the mid-term outcomes of minimally invasive surgery for partial atrioventricular septal defect in children. Summary: Partial atrioventricular septal defect is one of the three types of atrioventricular septal defect, accounting for about 3.5% of congenital heart disease. Traditionally, complete repair has been performed via sternotomy. However, with the advancement of minimally invasive surgical techniques in treating congenital heart conditions, we conducted this study to assess the feasibility and mid-term outcomes of this approach. Subjects and methods: This descriptive study spanned from January 2018 to December 2023, involving 30 patients diagnosed with partial atrioventricular septal defect who underwent minimally invasive complete repair. The cohort comprised 12 males and 18 females, with an average age of 18 months and average weight of 10.3 kg. The mean diameter of the primary atrial septal defect was 15 mm. Eight patients (26.7%) exhibited moderate to severe mitral regurgitation, and the average pulmonary artery pressure was 37 mmHg. Results: The average durations of cardiopulmonary bypass and aortic cross-clamp were 82 minutes and 58 minutes, respectively. None of the patients required sternotomy. The average time of artificial ventilator post-surgery was 6.9 hours, with a mean hospital stay of 7.6 days. Postoperative echocardiography showed promising results: complete closure of atrial septal defect, with 90% of patients having absent or mild mitral valve regurgitation, only 10% experienced moderate mitral valve regurgitation. The average follow-up period was 38 months, during which there were no postoperative fatalities. One patient required reoperation due to severe mitral regurgitation from an anterior cleft. Conclusion: Minimally invasive surgery for partial atrioventricular septal defect in children can be safely performed, yielding favorable mid-term outcomes during follow-up.

ANOTHER BRICK IN THE WALL: A STRANGE CASE OF A BIG HUG

Abstract Background Left ventricular pseudoaneurysm (LVP) is a rare complication of myocardial infarction MI (less than 0,1% of all patients with MI) and develops when cardiac rupture is contained by adherent pericardium or scar tissue, thus contains no endocardium or myocardium, unlike a true left ventricular aneurysm (LVA). Clinical Case A 41–year–old man without remote cardiac history was admitted to the Emergency Department with chest pain that had started 7 days before after a referred ‘big hug’ from a friend. Results of the physical examination were unremarkable. Electrocardiogram: T waves negative in the inferior and lateral leads. Blood exams: normal troponins, C–reactive protein and D–dimer values. Chest computed tomography: no sign of pulmonary embolism. Transthoracic echocardiography (TE): ejection fraction 45%, voluminous aneurismal chamber communicating with the infero–posterior wall of the LV, stratified thrombus and mild mitral valve regurgitation. Coronary angiography: three vessel coronary artery disease. The last diagnosis was established by cardiac magnetic resonance imaging (MRI) which revealed a voluminous pseudoaneurysm of the inferior wall (56 mm x 50 mm with a 51 mm neck) and transmural late gadolinium enhancement (LGE) of the wall adjacent to the pseudoaneurysm with fibroadipose replacement and calcific metaplasia. The patient was transferred to the Cardiac Surgery Department. Intraoperatively the LVP was resected and the defect of the LV was repaired with a patch in bovine pericardium. In addition, coronary artery bypass grafting and mitral valve repair were performed. Discussion LVP develops when pericardium, in combination with thrombus and inflammation, surrounds a cardiac rupture. Inferior and posterolateral myocardial infarction (MI), due to occlusion of the Circumflex artery, are responsible for 82% of the LVP. LVP can be also found in the apical region due to anterior MI. In conclusion symptoms, signs, electrocardiographic abnormalities and radiographic findings seen in patients with LVP can be indistinguishable from those in patients with coronary disease alone. TE is the first non–invasive method for early diagnosis of LVA, but MRI is the gold standard for differential diagnosis between true aneurysm vs pseudoaneurysm. LGE of the pericardium is a new specific marker of pseudoaneurysm as opposed to true aneurysm.

Bacterial endocarditis caused by contact lens usage

A 17-year-old female was transferred to our hospital due to high fever, general fatigue, and dim eyesight. Three weeks before, she had used cosmetic colored contact lenses and then suffered from bloodshot eyes associated with dim eyesight. Intermittent fever and general fatigue were followed by eye symptoms. Echocardiography revealed moving vegetation on the posterior leaflet of the mitral valve associated with mild mitral valve regurgitation. There were no infectious sites in systemic examinations; thus, the cause of infective endocarditis was considered the infection due to contact lens usage. The patient initially received mitral valve plasty associated with the removal of infective sites. However, redo surgery was necessary 19 days later due to the relapse of infection, and the mitral valve was replaced by bioprosthesis. Traumatic injury of vessels due to inappropriate contact lens usage seemed to lead to systemic hematogenous infection and subsequent endocarditis. We report a rare case of infective endocarditis which was caused by contact lens usage.

Prognostic value of mitral valve regurgitation in patients with heart failure with mildly reduced ejection fraction

BackgroundAlthough mitral valve regurgitation (MR) is a common valvular heart disease in patients with heart failure (HF), there is a paucity of data on the characterization and outcomes of patients with HF with mildly reduced ejection fraction (HFmrEF) and concomitant MR. MethodsFrom 2016 to 2022, consecutive patients hospitalized with HFmrEF (i.e., left ventricular ejection fraction from 41% to 49% and signs and/or symptoms of HF) were retrospectively included at one institution. Patients with MR were compared with patients without MR. Further risk stratification was performed according to MR severity and etiology (i.e., primary vs. secondary MR). The primary end point was all-cause mortality at 30 months (median follow-up), and the key secondary end point was hospitalization for worsening HF. ResultsOf 2181 patients hospitalized with HFmrEF, 59% presented with mild, 10% with moderate, and 2% with severe MR. MR was associated with increased all-cause mortality at 30 months (HR = 1.756; 95% CI 1.458–2.114; p = 0.001), with higher risk in more advanced stages. Furthermore, MR patients had higher risk of HF-related re-hospitalization at 30 months (HR = 1.560; 95% CI 1.172–2.076; p = 0.002). Even after multivariable adjustment, mild, moderate, and severe MR were still associated with all-cause mortality. Finally, the risk of all-cause mortality was lower in patients with secondary MR compared with patients with primary MR (HR = 0.592; 95% CI 0.366–0.956; p = 0.032). ConclusionMR is common in HFmrEF and independently associated with higher risk of all-cause mortality and HF hospitalization.

Predictor of mitral valve regurgitation severity and left ventricular dilatation using amino-terminal pro-brain natriuretic peptide marker in pediatric rheumatic heart disease.

Early rheumatic heart disease (RHD) is characterized by valve regurgitation, leading to ventricular distention and possible elaboration of amino-terminal pro-brain natriuretic peptide (NT-proBNP). Thirty-one children with RHD were entered in the study. Transthoracic echocardiography was performed in all patients to assess the severity of the valve disease and cardiac function, thus will be classified into three groups: mild, moderate, and severe mitral valve regurgitation (MR), with and without left ventricular (LV) dilatation. At the time of echo, venous blood samples were drawn; thus, NT-proBNP levels were measured using sandwich immunoassay. The median NT-proBNP levels in mild, moderate, and severe MR were 32.34, 120.75, and 7094 pg/ml, respectively. The median NT-proBNP levels in patients with and without LV dilatation were 3045 and 30.82 pg/ml. There was a significant correlation between the severity of MR and NT-proBNP levels (P < 0.001), thus a significant correlation between LV dilatation and NT-proBNP levels (P = 0.013). A cutoff value of 2598.50 pg/ml was obtained with a sensitivity value of 90% and a specificity of 90.5% for NT-proBNP levels against severe MR. A cutoff value of 199.35 pg/ml was obtained with a sensitivity value of 73.3% and a specificity of 75% for NT-proBNP levels on LV dilatation. A cutoff value of 2598.50 pg/ml was obtained with a sensitivity value of 85.7% and a specificity of 79.2% for NT-proBNP levels against severe MR with LV dilatation. There was a significant relationship between NT-proBNP levels and the severity of MR and LV dilatation in children with RHD.

The Case Files

The Case Files

P104 LASER BALLOON APPROACH FOR PULMONARY VEIN ISOLATION IN MARFAN SYNDROME

Abstract Background Marfan syndrome (MFS) is an autosomal dominant disorder of the connective tissue and it’s associated with an increased incidence of atrial fibrillation (AF), due to scar–mediated processes and sites of atrial ectopy. Limited data exist regarding ablation techniques in these patients. The frailty of atrial walls correlated to connective disease makes the ablation challenging with an increased risk of complications. Laser–balloon (LB) approach for pulmonary vein isolation (PVI) could be a promising strategy due to the possibility to ablate a large volume of tissue with a single application of energy, short procedure times, and real–time monitoring of balloon–tissue contact. We present a case in which LB technology was applied for PVI in an MFS patient Clinical case A 44–year–old woman with MFS and paroxysmal AF underwent PVI. The echocardiographic examination showed mild aortic and mitral valve regurgitation, the first due to a slight dilation of the aortic root, the latter associated with mitral valve prolapse. Atrial volume was normal. No other comorbidities were present. The procedure was executed in general anesthesia. A decapolar catheter was inserted in the coronary sinus and used later to stimulate the phrenic nerve during the ablation of the right pulmonary veins (Fig.1C). Left atria (LA) was reached after an ultrasound–guided transeptal puncture. High–density mapping of the LA was performed to assess the number and geometry of PVs (Fig.1A). A LB catheter was used to perform laser ablation at the level of PV antrum, delivering 13 W in automatic rapid mode in regions with optimal contact and 5.5 W in areas with more represented blood–tissue interface. LA mapping after ablation assessed the effective isolation of pulmonary veins (Fig.1B). No complications occurred during the procedure. Conclusion a laser–balloon approach for PVI in MFS patients seems feasible and safe. To our knowledge, this is the first application of this technology on MFS patients. Larger data are needed to confirm our findings.

Blood Pressure Management Undergoing Surgery Through Invasive Arterial Blood Pressure Measurement in a Dog with Concomitant Aortic Stenosis and Left Ventricular Outflow Tract Obstruction

A 12-year-old mix-breed dog was presented with anal sac tumor and scheduled for left anal sacculectomy. Pre-operative echocardiography revealed that the dog had moderate aortic regurgitation (AR), mild mitral valve regurgitation, and dynamic left ventricular outflow tract obstruction. A hypotension of invasive arterial blood pressure (IABP) following low mean and diastolic blood pressure during surgery was suspected to be related to AR and treated by heart rate titration with atropine and dopamine infusion. Accurate blood pressure assessment with IABP and extrapolation treatment strategy of hypotension related to AR by human medicine are useful for anesthetic management in dogs with AR.

68 The confounder in time of confusion: a case report on Multisystem Inflammatory Syndrome in Children (MIS-C)

68 The confounder in time of confusion: a case report on Multisystem Inflammatory Syndrome in Children (MIS-C)

Left atrial function may mitigate the effect of mitral regurgitation on right chambers in patients with severe aortic valve stenosis

Abstract Introduction Left atrial (LA) function has been associated to right chambers hemodynamics in the context of mitral valve regurgitation (MR). However, this physiological interplay between left atrial function, mitral regurgitation and right ventricular (RV) parameters has not yet been clarified in patients with aortic valve stenosis (AS). Aim of the study To assess the combination of LA function and different MR grades with right chambers performance and pulmonary non-invasive hemodynamics status in patients with severe AS using an advanced automated echocardiographic approach. Methods Consecutive patients with severe AS referred to our institution were analyzed. Mitral regurgitation was classified according to integrative guideline-based criteria. 2D advanced speckle tracking echocardiography analysis was conducted to measure the LA peak atrial longitudinal strain (PALS) and right ventricular free wall strain, (RVFWS) using Tomtec Arena, version TTA2 41.00, with dedicated LV/LA/RV analysis option (Tomtec, Unterschlei heim, Germany). All conventional right chambers performance indexes were also measured: TAPSE, S'- TDI, fractional area change, systolic pulmonary artery pressure (sPAP). We featured 3 patients groups based on MR grade and LA function: (a) no/mild MR and preserved PALS (above the median); (c) &amp;gt;mild MR and reduced PALS; (b) the remaining patients with &amp;gt;mild MR and low PALS or &amp;gt;mild MR and high PALS. Results A total of 102 patients with severe aortic stenosis formed the study cohort: age was 82±9, 47% were female, mean left-ventricular-ejection-fraction 56%±12, more than mild MR was present in 24% of patients, mean PALS was 19±10%, sPAP 38±12 mmHg, RVFW strain 21±6%, and RVFW/sPAP 0.62±0.25. The 3 subgroups presented similar age and sex distribution. Right ventricular function significantly worsened moving from group (a) to (c); RVFW strain decreased from 25±5 (a) to 19±7 (b) and 17±5% (c), p&amp;lt;0.001; sPAP increased from 34±9 (a) to 39±12 (b) and 47±13 mmhg (c), p&amp;lt;0.001; and RVFW/sPAP decreased from 0.76±0.21 (a) to 0.54±0.23 (b) and 0.39±0.11 (c), p&amp;lt;0.001. Patients in the group (c) were more symptomatic (NYHA class III/IV increase from 40% in group a and 63% in group (b) to 80% in group c, p=0.006). When added to MR grade, in a logistic regression analysis, PALS provided incremental prediction of all right ventricular parameters (p&amp;lt;0.01). Conclusion This study highlights that the combination of MR and reduced LA function is associated with symptoms and RV impairment in patients with severe AS. These preliminary results suggest that preserved LA function may modulate the adverse effects of the AS-MR combination by preventing/delaying the development of pulmonary hypertension and right ventricular dysfunction. Funding Acknowledgement Type of funding sources: None.

Surgical correction of total anomalous pulmonary venous return in an adult patient

BackgroundTotal anomalous pulmonary venous return (TAPVR) is rare congenital heart disease. Most TAPVRs require surgical corrections in the neonatal period and survival to adulthood without surgical correction is extremely rare. Most untreated patients with large atrial septal defects and no pulmonary venous obstruction have pulmonary vascular damage from pulmonary over circulation.Case presentation44-year-old TAPVR patient admitted to our medical center. A snowman-shaped heart, including cardiomegaly and an increase in pulmonary blood flow, was seen in the chest X-ray. A large-sized (around 3 cm) atrial septal defect with dilated right atrium, right ventricle, and pulmonary artery was detected on echocardiography. Heart computed tomography was performed for further evaluation, and supra-cardiac type TAPVR without any obstructive lesion was identified.ConclusionsTAPVR in an adult patient is extremely rare, and this patient was treated successfully with surgical correction and is doing well. A sinus rhythm and mild mitral valve regurgitation have remained during 2.5 years of outpatient follow-up.

Health-Related Quality of Life Analysis Supports the Recommendation for HeartMate3 Implantation without Concomitant Mitral Valve Surgery

<h3>Purpose</h3> Functional mitral valve regurgitation (MR) is common in patients with end-stage heart failure awaiting left ventricular assist device (LVAD) implantation. The resolution of functional MR in LVAD patients has been detected for different LVAD types and across all grades of MR severity. However, it should be proven if the health-related quality of life (HRQoL) after LVAD implantation is comparable in patients with different preoperative MR grades. <h3>Methods</h3> We performed a single-center HRQoL analysis including 34 patients with HeartMate 3 (HM3) implantation using the SF12 Health Survey and the Hospital Anxiety and Depression Score (HADS) at least 1 year after LVAD implantation. The study groups were classified according to echocardiographically defined grade of MR. The group without severe MR (none, mild or moderate MR) comprised 24 patients; the group with severe MR comprised 10 patients. Clinical characteristics including the six-minute walk test (6MWT) were documented. <h3>Results</h3> Age, gender, history of prior heart valve surgery as well as the rate of heart transplantation, ECMO and RVAD implantation, right heart failure, ventricular arrhythmias, stroke, suction events, LVAD thrombosis, and bleeding events were comparable between LVAD patients with severe and not severe MR (p < 0.05). The 6MWT was comparable in the postoperative period (p = 0.13) and one year after LVAD implantation (p = 0.57). No significant differences were apparent in the SF-12-determined physical health (severe MR: 36.6 ± 8.4; not severe MR: 40.1 ± 9.3; p = 0.32) and mental health (severe MR: 49.5 ± 9.7; not severe MR: 54.3 ± 10.5; p = 0.22) as well as in the HADS-determined anxiety (severe MR: 5.6 ± 3.6; not severe MR: 4.9 ± 3.3; p = 0.58) and depression grade (severe MR: 6.3 ± 3.7; not severe MR: 4.6 ± 4.1; p = 0.28). <h3>Conclusion</h3> Physical and mental health as well as anxiety and the depression grade that were measured with standardized questionnaires are comparable in LVAD patients with preoperative severe and not severe MR. The results of this HRQoL pilot study support the recommendation of the International Society for Heart and Lung Transplantation for a HM3 implantation without concomitant MV repair and replacement.

Surgical management of diastolic heart failure after septal myectomy for obstructive hypertrophic cardiomyopathy.

ObjectiveSome patients with obstructive hypertrophic cardiomyopathy may remain limited after surgical relief of the subaortic obstruction. In this report, we describe experience in surgical management of patients with advanced diastolic heart failure symptoms after adequate transaortic septal myectomy for obstructive hypertrophic cardiomyopathy.MethodsWe identified adult patients who presented with heart failure symptoms after previous transaortic septal myectomy for obstructive hypertrophic cardiomyopathy and underwent repeat sternotomy for transapical myectomy to enlarge a small left ventricular cavity. Functional recovery after hospital dismissal was assessed through a questionnaire-based survey.ResultsSix patients with previous septal myectomy presented with New York Heart Association functional class III symptoms. Preoperative transthoracic Doppler echocardiography confirmed adequate relief of subaortic outflow tract obstruction with only trivial or mild mitral valve regurgitation; left atrial volume index was increased at 46 mL/m2 (range, 44-47 mL/m2). Following transapical myectomy, the left ventricular diameter was enlarged from 23 mm (range, 21-27 mm) to 29 mm (range, 27-31 mm) at end-systole and from 40 mm (range, 38-42 mm) to 43 mm (range, 42-50 mm) at end-diastole. All the patients were alive after a median follow-up of 0.6 years (range, 0.4-3.5 years), and 5 patients responded to a postoperative survey and indicated improvement in their heart condition compared with functional status before the repeat myectomy.ConclusionsPatients with diastolic heart failure after septal myectomy for obstructive hypertrophic cardiomyopathy may present with systolic cavity obliteration due to excessive myocardial hypertrophy. Repeat transapical myectomy can enlarge the left ventricular chamber and augment the diastolic volume, which results in improved physical capacity and patient-perceived functional status.

Validation of mitral regurgitation reversibility in patients with HeartMate 3 LVAD implantation.

The resolution of functional mitral valve regurgitation (MR) in patients awaiting left ventricular assist device (LVAD) implantation is discussed controversially. The present study analyzed MR and echocardiographic parameters of the third-generation LVAD HeartMate 3 (HM3) over 3years. Of 135 LVAD patients (with severe MR, n=33; with none, mild, or moderate MR, n=102), data of transthoracic echocardiography were included preoperatively to LVAD implantation, up to 1month postoperatively, and at 1, 2, and 3years after LVAD implantation. Demographic data and clinical characteristics were collected. Severe MR was reduced immediately after LVAD implantation in all patients. The echocardiographic parameters left ventricular end-diastolic diameter (P<.001), right ventricular end-diastolic diameter (P<.001), tricuspid annular plane systolic excursion (P<.001), and estimated pulmonary artery pressure (P<.001) decreased after HM3 implantation independently from the grade of MR prior to implantation and remained low during the 2years follow-up period. Following LVAD implantation, right heart failure, ventricular arrhythmias, ischemic stroke as well as pump thrombosis and bleeding events were comparable between the groups. The incidences of death and cardiac death did not differ between the patient groups. Furthermore, the Kaplan-Meier analysis showed that survival was comparable between the groups (P=.073). HM3 implantation decreases preoperative severe MR immediately after LVAD implantation. This effect is long-lasting in most patients and reinforces the LVAD implantation without MR surgery. The complication rates and survival were comparable between patients with and without severe MR.

Rheumatic Heart Disease Down but Not Elimnated - A Case Study for Community Action

Acute rheumatic fever, a multisystem inflammatory disease beginning in childhood with manifestations of episodes of fleeting joint pains, skin, and central nerve system. Such episodes if not treated well or preventive steps not taken will pave way for rheumatic heart disease, after many years. RHD involves immune inflammatory injury to cardiac values. Here I present one such case I witnessed in March 2020. A 40-year-old female with known history of RHD since 2013 sought treatment in KMC super specialty hospital. Patient was under medication for RHD. In the current episode she Reported with the complaints of chest pain, sore throat, fever, and fatigue on 27th March 2020. Based on echocardiogram, cardiologist confirmed that she has Rheumatic heart disease with mild mitral valve and tricuspid valve regurgitation. She was asked to continue Pentids 400 mg and metoclopramide that she was already taking and added Tab. Paracetamol 500 mg, Domperidone, Omeprazole, table B complex 400 mg. She was advised for routine check-up and follow up care. There was an improvement in patient condition within 2 days. Patient is under routine follow and under medications as of 31 May 2021 and doing well. Public Health Professional opine that RHD control program by the national health authorities is the need of the time.

Regurgitant volume to left ventricular end-diastolic volume ratio: another step to risk stratification in patients with secondary mitral regurgitation?

Abstract Funding Acknowledgements Type of funding sources: None. Background Quantitative evaluation of secondary mitral valve regurgitation (MR) remains an important yet challenging step in the evaluation of this entity. Its severity can be underestimated when using the proximal isovelocity surface area (PISA) method, which does not take left ventricular (LV) volume into account. Normalizing mitral regurgitant volume (Rvol) for the LV end-diastolic volume (EDV) might overcome this key limitation. This study aimed to investigate the prognostic implication of Rvol/EDV ratio in patients with secondary MR. Methods Patients with at least mild secondary MR and reduced left ventricular ejection fraction (&amp;lt;50%) under optimal guidelines-directed medical therapy were retrospectively identified at a single-center. The cohort was divided into terciles according to the RVol/EDV ratio. The primary endpoint was all-cause mortality. Results A total of 572 patients (median age 70 years; 76% male) were included. Median LVEF was 35% (IQR 28-40) and LVEDV was 169 ml (IQR 132-215). Median measures of secondary MR were EROA 14 mm2 (IQR 8-22) and RegVol 23 ml (12-34). During a median follow-up of 3.8 years (interquartile range 1.8 to 6.2 years) there were 254 deaths (44%). The unadjusted mortality incidence increases across terciles distribution. Patients at the 2nd and 3rd terciles of the RVol/EDV ratio showed significantly higher mortality when compared to those at the 1st one (baseline reference) (figure 1). After multivariable analysis, terciles of the Rvol/EDV ratio remained independently associated with increased all-cause mortality (considering the 1st tercile as the reference; adjusted HR for the 2nd tercile 1.46 [95% CI 1.05- 2.02] p = 0.023; adjusted HR for 3rd tercile 1.56 [95% CI 1.09 – 2.22], p = 0.015). Conclusion In patients with secondary MR, Rvol/EDV ratio is independently associated with all-cause mortality. However, the appropriate cut-off to determine any kind of clinical decision remains to be determined. Abstract Figure.

Bi-valvular endocarditis occurring 2 months after COVID-19 infection.

A 60-year-old diabetic man was admitted in cardiology department for dyspnea and fever evolving over 3 weeks with urinary symptoms. In his past history there was a COVID-19 infection that required hospitalization with oxygen therapy for a week and he reported repetitive urinary tract infections. The physical exam showed an axillary temperature at 39.5°c crackling sounds on the lung and no right ventricular failure signs. Laboratory tests showed biologic inflammatory markers elevation; cytobacteriological urine test isolated: enterococcus foecalis and several hemocultures isolated the same named bacteria. Transthoracic echocardiography showed a preserved left ventricular function, a vegetation at the expense of the anterior leaflet of mitral valve (7*4mm); mild mitral valve regurgitation and a huge vegetation at the expense of tricuspid valve (15*20mm) with important tricuspid regurgitation and pulmonary arterial hypertension. The transesophageal echocardiography showed the same vegetation at the expense of the mitral and tricuspid valve and no abnormalities in the other valves. After an initial antibiotic therapy, the patient was referred for surgery in front of worsening mitral insufficiency which has become grade 4.