Mitral Prosthesis Research Articles

Intra, short and long-term results of mitral VIV for the degenerated surgical mitral prosthesis from italian VIV registry (MIVIV registry)

Abstract Background/Introduction Reoperation of failed bioprosthetic mitral valves is associated with significant morbidity and mortality. Transcatheter mitral valve-in-valve (MViV) replacement was explored early in the development of THVs with transseptal/transfemoral (TS/TF) and transapical (TA) approaches. Purpose This is the first Italian Registry on mitral VIV and it was designed to explore contemporary MViV outcomes with all types of balloon expandable valves. The present study out of the registry aims to asses the >10 years follow-up outcomes in terms of mortality, gender diversity, and perioperative result. Methods Participating centers used standardized definitions to collect clinical information, including patient demographic characteristics, comorbidities, functional status, quality of life indexes, procedural details, and patient outcomes from consecutive MViV cases. Cohort of 265 patients was available for the primary analysis and follow-up too.The patients were grouped by 11 hospitals in Italy performing VIV for degenerated biological mitral prostheses. Results A total of 265 pts underwent mitral VIV due to bioprosthesis degeneration between January 2010 and January 2023. They have been subdivided by transfemoral (TF) with 117 (44%) pts and transapical (TA) with 148 (55,8%) pts. Most of the patients were of female sex (59,2%) and EuroScore II for surgical re-operation was 16.1%. Mixed disease (48%) was more common than mitral regurgitation (29%) and stenosis (22%). 69,8% of the total cohort was in class NYHA III and the mean LVEF was 54%.Otherwise, there were no significant demographic differences between patients undergoing TS and TA. In TF there was more severe PVL (5%)(p-value: 0,001) and much more cases of severe grade of stenosis (54,7%) and regurgitation (57%)(p-value< 0,0001). Considering intraoperative outcomes, technical success has been established in around 97,7% of the total cohort without difference btw groups. Only 3,3% died during hospitalization without difference between groups (P-value=0,735). LVOT obstruction has been seen in 3,4% in the case of TA and 0 for TF. Only 1,5% of the total cohort underwent surgical conversion as well as embolization in only 1,1%. Overall survival from the total cohort was 91,3% at >10 years, Figure 1. Concerning the freedom from cardiac death (CV death) was 96,6% in the total cohort at 13 years. Concerning the difference between access, the general survival is established at 97,4% in TF while 86,3% in TA (p-value =0,050)(Figure 2). Freedom from CV death was 99,1% in TF and 94,5 in TA (p-value=0,209). In gender analysis differentiation, the general survival in females was 98,5% in TF and 85,6% in TA at 13 years (p-value=0,056). Conclusion(s) Transcatheter MViV using a balloon-expandable valve is associated with high technical success, a low complication rate, and a solid long-term benefit in terms of survival. Transseptal access was associated with lower mortality compared with TA access.Figure 1Figure 2

Complex left atrial appendage closure using 3D printing system simulation in a patient with mitral prosthetic valve: a case report

Abstract Background Left atrial appendage (LAA) closure (LAAc) has emerged as a safe and effective alternative to oral anticoagulation (OAC) for stroke prevention in patients with atrial fibrillation (AF) and contraindications to OAC. Case Summary A 61-year-old woman with permanent atrial fibrillation (AF) and a history of mitral surgery replacement with mechanical prosthesis was referred to our cardiology department to undergo left atrial appendage (LAA) closure (LAAc). The preoperative computed tomography (CT) revealed that the ostium of the left atrial appendage was close to the mitral prosthesis ring. As a result of the difficult LAA morphology a CT-image based virtual model was created, then a 3D printing model was prepared in our laboratory and procedure simulation was performed with the two different LAA occlusion devices (plug- vs. pacifier like models) to see which one was more suitable for the patient anatomy. Discussion In this case of complex LAAc in a patient with mechanical prosthetic mitral valve with the use of a 3D-printed model has guided prosthesis selection and device sizing reducing procedure time and complications.

800.49 - Favorable Effects of the AltaValve Mitral Prosthesis on Left Atrium Volume and Strain

800.49 - Favorable Effects of the AltaValve Mitral Prosthesis on Left Atrium Volume and Strain

Case Series of First Microinvasive Fully Endoscopic Use of a New Mitral Prosthesis.

The use of bioprostheses is increasing in younger patients, but it is associated with the risk of later valve deterioration, especially in the mitral position. A new bioprosthesis for mitral valve replacement offers possible longer-term durability and improved hemodynamics. Objectives: Here, we report the implantation of the novel Edwards MITRIS RESILIA mitral valve (Edwards Lifesciences Inc., Irvine, CA, USA) through microinvasive fully endoscopic access as an innovative surgical approach based on a series of twelve patients. Methods: Contrast-based ECG gated CT was preoperatively performed in all patients to determine the intravascular calcifications and vascular parameters, as well as to assess noticeable problems during the operation. CT software for cardiac interventions (3Mensio Medical Imaging BV) was used to simulate surgical prostheses digitally inside the native annulus. With this, a digital LVOT and neo LVOT was created, and the difference between the valve prostheses was measured. Implantation of the MITRIS RESILIA valve was performed in 12 patients according to the instructions for use through microinvasive access in a fully endoscopic fashion using 3D visualization. Results: The mean patient age was 56.50 years, and 7/12 (58.33%) were redo procedures. All patients survived the first 30 days after the procedure, the mean aortic cross-clamp time was 40.17 ± 13.72 min. and mean postoperative transvalvular gradient was 4.45 ± 1.74 mmHg. The neo LVOT in the CT-based simulation was measured with an average area of 414.98 ± 88.69 mm2. The average difference between the LVOT and neo LVOT area was 65.35 ± 34.99 mm2. There was no case of paravalvular leakage or obstruction of the left ventricular outflow tract. Conclusions: The novel MITRIS RESILIA valve is a promising new bioprosthesis for mitral valve replacement that offers improved features as compared to other prostheses. The ease of implantation is increased by this prosthesis by the improved pliability of the sewing cuff and the inward folding of the struts, which was confirmed by short operative times in our series.

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

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

Complete thrombosis of a bioprosthetic mitral valve and left atrium in a patient on venoarterial extracorporeal membrane oxygenation with favorable outcome

Intra-cardiac thrombosis is a potentially devastating complication of extracorporeal membrane oxygenation (ECMO) mechanical circulatory support. We present here a patient who suffered complete thrombosis of a fresh mitral prosthesis and left atrium in the setting of ECMO with aortic insufficiency who was treated with repeat valve replacement and thrombectomy. To our knowledge, she is the only patient in the reported literature to have survived this complication.

Refractory Anemia and Pigment Nephropathy in a Case with Mitral Prosthesis

We present a case of refractory microangiopathic hemolytic anemia with pigment nephropathy in a case of paravalvular leak, emphasizing an early detailed evaluation of anemia in a patient with a prosthetic valve despite having an alternative etiology, which is completely reversible if treated adequately.

Late Outcomes of Porcine and Pericardial Bioprostheses After Mitral Valve Replacement in 1162 Patients

BackgroundDebate continues regarding the superiority of porcine vs pericardial bioprostheses, and data relevant to this comparison are scant. This study compared late survival and structural valve deterioration of porcine and pericardial mitral valve prostheses. MethodsAdults undergoing mitral valve replacement with 1 first-generation porcine valve model and 1 pericardial valve line were reviewed from a prospectively maintained institutional database between 1976 and 2020. Multivariable regression and Cox proportional hazards analysis were used to compare late outcomes. ResultsOf 1162 consecutive patients, 612 (53%) received porcine valves and 550 (47%) received pericardial valves. At 10 years, patient survival (porcine, 36% ± 2%; pericardial, 38% ± 3%; P = .5) and cumulative incidence of mitral valve structural deterioration (porcine, 18% ± 2%; pericardial, 19% ± 3%; P = .3) were similar. The structural failure mode was more likely severe mitral stenosis in pericardial valves (35 of 50 [70%] vs 38 of 106 [36%]; P < .001), and it was more likely severe mitral regurgitation in porcine valves (80 of 106 [75%] vs 19 of 50 [38%]; P < .0001). After adjustment, structural deterioration was associated with younger patient age (P < .001) but not valve type. At 10 years, porcine valves demonstrated a higher cumulative incidence of mitral reoperation (19% ± 2% vs 9% ± 2%; P < .001) and reoperation for structural deterioration (15% ± 1% vs 6% ± 2%; P = .007). ConclusionsThis study demonstrated similar rates of 10-year survival and structural deterioration with porcine and pericardial bioprostheses in mitral valve replacement. The study suggests a lack of major improvement in durability of mitral bioprosthetic valves over time. The failure mode may have a greater influence on surgeon decision making regarding valve choice.

Open mitral valve replacement with a balloon-expandable prosthesis using the valve-in-valve technique: a case report

Mitral defects are the most common acquired heart disturbances. The only radical treatment for severe valve stenosis or its insufficiency is surgical correction of the defects. The main challenge of implanting a mechanical mitral prosthesis is associated to its thrombosis complication that demands repeated surgical intervention on re-replacement of the mitral prosthesis. Herein, a clinical case of patient P. (58 years old) is presented, who was admitted to the Federal Center for Cardiovascular Surgery (Penza, Russia) with thrombosis of the mitral valve prosthesis and its dysfunction. The patient has already been undergone repeated surgery to replace the mitral valve. The purpose of the clinical case description is to demonstrate the using of open mitral valve replacement method based on the valve-in-valve technique with a transcatheter balloon-expandable prosthesis, its efficacy and safety.The considered method of treatment can simplify the main stage of the surgical intervention; reduce the time of artificial circulation and aortic clamping as well as the number of intraoperative complications. This type of surgical treatment can be considered as an option for re-prosthesis in patients at high surgical risk who are indicated for re-intervention due to impaired function of previously implanted heart valve prosthesis. A clinical case attests the possibility, efficacy and safety of using a balloon-expandable prosthesis for mitral valve replacement with the valve-in-valve technique upon repeated surgical interventions. Received 12 January 2024. Revised 16 February 2024. Accepted 19 February 2024. Informed consent: The patient’s informed consent to use the records for medical purposes is obtained. Funding: The study did not have sponsorship. Conflict of interest: The authors declare no conflict of interest. Contribution of the authorsLiterature review: M.A. DenisovDrafting the article: I.Ya. SenzhapovCritical revision of the article: A.I. MikulyakSurgical treatment: V.V. Bazylev, M.G. ShmatkovFinal approval of the version to be published: V.V. Bazylev, A.I. Mikulyak, M.G. Shmatkov, I.Ya. Senzhapov, M.A. Denisov

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

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

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

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

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

Cardiovascular diseases are one of the leading causes of maternal mortality. The management of pregnant women with mechanical valve prosthesis is difficult. Fetal-maternal mortality and morbidity are high. Selection of the most appropriate anticoagulant that will minimize fetal, maternal mortality and avoid embryopathy risk should be tailored according to the needs of each individual patient. &#x0D; In this paper, in the light of the literature, we aimed to discuss our patient, who delivered at 39th gestational week after a pregnancy before which she had not been provided with prepregnancy counseling and during which she did not attend follow-up visits.&#x0D; These patients prepregnancy counseling, follow-up visits, anticoagulant management during pregnancy, and prophylaxis and management of complications at the postpartum period are very important and require close follow-up.

Transcatheter Aortic Valve Implantation to Treat Degenerated Aortic, Mitral and Tricuspid Bioprosthesis.

Transcatheter aortic valve implantation (TAVI) is now well established as the treatment of choice for patients with native aortic valve stenosis who are high or intermediate risk for surgical aortic valve replacement. Recent data has also supported the use of TAVI in patients at low surgical risk and also in anatomical subsets that were previously felt to be contra-indicated including bicuspid aortic valves and aortic regurgitation. With advancements and refinements in procedural techniques, the application of this technology has now been further expanded to include the management of degenerated bioprosthesis. After the demonstration of feasibility and safety in the management of degenerated aortic bioprosthetic valves, mitral and tricuspid bioprosthetic valve treatment is now also well-established and provides an attractive alternative to performing redo surgery. In this review, we appraise the latest clinical evidence and highlight procedural considerations when utilising TAVI technology in the management of degenerated aortic, mitral or tricuspid prosthesis.

Early and Mid-Term Outcomes of Using the Chimney Technique in Redo Mitral Valve Replacement in Patients with a Small Mitral Annulus.

The outcomes of redo mitral valve replacement (Re-MVR) in a small mitral annulus with the use of the chimney technique are not well documented. The purpose of this study is to present our early experience with this group of patients, illustrating the periop-erative complications and mortality outcomes. From 2019 to 2020, 77 consecutive patients underwent Re-MVR with the use of the chimney technique because of a small mitral annulus. To evaluate heart structural integrity and clinical outcomes, postoperative clinical data and echocardiograms were examined. The mean age was 56.7 ± 15.98 years. All patients underwent mitral valve surgery, of which 62 were mitral valve replacements, 7 mitral valve repairs, and 8 double valve replacements. The preoperative mitral valve mean gradient was 18.07 ± 9.40 mmHg, and the postoperative mitral prosthesis size was 28.51 ± 1.22 mm. The median increment of mitral size enlargement was 4 (0, 6) valve sizes. The mean mitral gradient coming out of the operating room was 10.34 ± 2.12 mmHg, and at the follow-up echocardiogram performed at 3 years after the procedure, it was 10.36 ± 1.70 mmHg. One-year survival was 93.3%, while the 4-year survival rate was 89.3%, with no reoperation. The use of the chimney technique in small mitral valve re-mitral valve replacement results in larger valve sizes. Moreover, the mean gradients over the mitral valve are acceptable both intraoperatively and over time.

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

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

Current Usefulness of Transesophageal Echocardiography in Patients Undergoing Transcatheter Aortic Valve Replacement.

This review article describes in depth the current usefulness of transesophageal echocardiography in patients who undergo transcatheter aortic valve replacement. Pre-intervention, 3D-transesophageal echocardiography allows us to accurately evaluate the aortic valve morphology and to measure the valve annulus, helping us to choose the appropriate size of the prosthesis, especially useful in cases where the computed tomography is not of adequate quality. Although it is not currently used routinely during the intervention, it remains essential in those cases of greater complexity, such as for patients with greater calcification and bicuspid valve, mechanical mitral prosthesis, and "valve in valve" procedures. Three-dimensional transesophageal echocardiography is the best technique to detect and quantify paravalvular regurgitation, a fundamental aspect to decide whether immediate valve postdilation is needed. It also allows to detect early any immediate complications such as cardiac tamponade, aortic hematoma or dissection, migration of the prosthesis, malfunction of the prosthetic leaflets, or the appearance of segmental contractility disorders due to compromise of the coronary arteries ostium. Transesophageal echocardiography is also very useful in follow-up, to check the proper functioning of the prosthesis and to rule out complications such as thrombosis of the leaflets, endocarditis, or prosthetic degeneration.

Clinical Outcomes After Mitral Valve Replacement With Epic and Mosaic Bioprosthetic Valves

BackgroundComparative studies of outcomes between different biological mitral valve prostheses are scarce. This study compares the late clinical results of valve replacement with the Epic and Mosaic bioprostheses. MethodsPatients undergoing isolated elective mitral valve replacement (MVR) between 2005 and 2019 were eligible for inclusion. Primary outcomes were freedom from mitral valve reintervention and overall survival. Inverse probability of treatment weighting and competing risk analyses were performed. ResultsMVR was performed in 247 (73.7%) patients with the Epic prosthesis and in 88 (26.3%) patients with the Mosaic prosthesis. The median follow-up was 3 (interquartile range, 0.20-5.64) years. At 10 years postoperative, the estimated survival rates were 86.1% (95% CI, 80.5%-91.9%) and 73.5% (95% CI, 60.6%-89.3%) for the Epic and Mosaic groups, respectively (P = .40). On inverse probability of treatment weighted analysis, no significant intergroup difference was found (hazard ratio, 1.20; 95% CI, 0.54-2.66; P = .70]. At 10 years, the cumulative incidence functions of mitral valve reintervention with death as competing risk were 34.4% (95% CI, 32.7%-36.1%) and 17.6% (95% CI, 16.2%-18.9%) for the Epic and Mosaic groups, respectively. On multivariable Fine-Gray analysis, the type of implanted mitral valve prosthesis just failed to reach a statistically significant difference in mitral valve reintervention (hazard ratio, 0.43 for Mosaic valve; 95% CI, 0.18-1.06; P = .067). Structural valve deterioration was an uncommon indication for reintervention in the first 10 years postoperative. ConclusionsClinical results of MVR with the Epic or Mosaic prosthesis are satisfactory. Our results suggest that the Mosaic bioprosthesis might offer better freedom from reintervention.

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

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

Mitral valve replacement using a collar-reinforced mitral prosthesis for severe mitral annular calcification, which secures implantation in both the supra-annular and intra-atrial positions: a case report

BackgroundAppropriate management of mitral annular calcification associated with mitral valve surgery must be determined on a case-by-case basis. However, an established procedure remains uncertain.Case presentationThis report describes a surgical case of severe mitral and aortic valve stenosis associated with severe mitral annular calcification in a 71-year-old woman who underwent mitral valve replacement with a collar-reinforced mitral prosthesis. The patient underwent surgical repair after the treatment for heart failure. As the present patient was deemed to be at high risk for conventional mitral valve replacement, we applied a composite prosthetic valve that was enlarged circumferentially on the ventricular side of the prosthesis with a bovine pericardial patch. First, the solid calcium bar was left untouched and only the friable calcified mass that was easily scattered was removed. Subsequently, the prosthesis was secured by two mattress sutures placed in the intra-atrial position at the region of the extended calcified myocardium. Additionally, ten mattress sutures were placed in the supra-annular position at the other regions capable of passing stitches from the ventricular side to the atrial side. Finally, a 1.5 cm wide trimmed bovine pericardial collar was sutured circumferentially from the annulus to the atrial wall using running 4–0 polypropylene for reinforcement. Although temporary hemodialysis was performed for acute renal failure, the patient remained asymptomatic.ConclusionsThe present case suggests that mitral valve replacement using a collar-reinforced mitral prosthesis may be an effective technique for severe mitral annular calcification. To avoid catastrophic complications associated with treatment for severely calcified annulus, it is crucial to make a prudent preoperative decision regarding the surgical strategy under circumstances where conventional mitral valve replacement is impossible.

Risk of thromboembolic and bleeding events in patients with atrial fibrillation after valvular intervention in either aortic or mitral position

Abstract Background The optimal oral anticoagulant treatment (OAC) for patients with atrial fibrillation (AF) undergoing valvular intervention is uncertain. Mitral valve prostheses are believed to be more thrombogenic than the aortic due to lower flow velocity across the valves. The only randomized controlled trial of AF patients with biological valve prostheses included only patients receiving mitral valve prostheses (1). It is unclear if these findings could be extrapolated to patients receiving aortic valve prostheses. Purpose To describe baseline characteristics and comorbidities of patients receiving biological valve prostheses in aortic or mitral valve position and to investigate possible associations between valve position and the incidence of cardiovascular (CV) death, ischemic stroke or systemic embolism and major bleeding. Methods All patients in Sweden undergoing open heart surgery with aortic or mitral valve replacement with biological prostheses between 2010-2016 with known AF were included. The study cohort was identified in the SWEDEHEART registry. Information on comorbidities, drug exposure and occurrence of outcome events was collected from SWEDEHEART and other national registries. Association between the position of valve prosthesis (mitral and aortic) and incidence of outcome events was investigated using Cox regression analysis. Multivariable adjustments were made for comorbidities. Results In total, 2359 patients with AF underwent aortic (n=2103) or mitral (n=256) valve replacement. The median age was 75 and 73 years, respectively. Hypertension, diabetes mellitus and previous TIA were more common in the aortic valve group, whereas heart failure and previous major bleeding was more frequently observed in the mitral group. In both groups, about 50% of the patients were not on OAC treatment at time of discharge from valve intervention, despite that the mean CHA2DS-VASc score was 3.3 and 3.2, respectively. Mitral valve prostheses were associated with similar risk of CV death (hazard ratio (HR) 1.09; 95% confidence interval (CI), 0.77 – 1.56), ischemic stroke and systemic embolism (HR 1.27; 95% CI, 0.85-1.92) compared to aortic valve prostheses. In contrast, receiving mitral valve prosthesis was associated with lower risk of major bleeding compared to aortic prosthesis (HR 0.58; 95% CI 0.38 – 0.88). Conclusion(s) The study indicated similar risk of CV death, ischemic stroke and systemic embolism among patients with AF undergoing valve replacement with biological prostheses in either aortic or mitral position. Mitral valve replacement was associated with lower risk of major bleeding.