Mitral Ring Research Articles

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.

Comprehensive Review of Shone's Syndrome: Pathophysiology, Clinical Manifestations, and Management Strategies

Shone's syndrome, a rare congenital heart disease, encompasses a complex array of obstructive lesions within the left heart. First described in 1963, this syndrome typically presents with a combination of supravalvular mitral ring, parachute mitral valve, subaortic stenosis, and coarctation of the aorta. The intricate nature of these anomalies presents significant diagnostic and therapeutic challenges. This review aims to elucidate the pathophysiological mechanisms underlying Shone's syndrome, provide a detailed account of its clinical manifestations, and discuss current management strategies, including surgical and medical interventions. Through an in-depth analysis of existing literature, we seek to enhance understanding and improve outcomes for patients afflicted with this multifaceted condition.

Concentric remodeling and the metabolic-associated steatotic liver disease in patients with type 1 diabetes: an exploratory study.

Diabetic cardiomyopathy in young patients with type 1 diabetes (T1D) usually presents as asymptomatic diastolic heart dysfunction with left ventricle (LV) remodeling. Its prevalence seems to be underestimated. One of the factors seemingly influencing LV remodeling is a metabolic-associated steatotic liver disease (MASLD), which was extensively investigated in patients with type 2 diabetes but not with T1D. This study aimed to describe the correlation between MASLD risk and relative wall thickness (RWT) in young patients with T1D without heart failure symptoms or treatment. Study participants were recruited at the inpatient diabetology department, in admission order. Patients underwent a set of laboratory tests and echocardiographic examinations. The risk of MASLD was estimated using fatty liver index (FLI). Acquired data was then statistically analyzed. The study group consisted of 55 patients. 25 participants had RWT > 0.42, suggesting LV remodeling. Study participants did not differ in HbA1c, NT-proBNP, HDL, LDL, non-HDL, and uric acid concentrations. However, patients with RWT > 0.42 had higher FLI (40.97 vs. 13.82, p < 0.01) and BMI (27.3 vs. 22.5, p < 0.01) and differed in transaminase concentrations. Moreover, patients with RWT > 0.42 had significantly higher LV mass index (85.6 vs. 68.2g/m2) and altered mitral ring velocities. In univariable logistic regression, FLI correlated with LV remodeling risk (OR 1.028, p = 0.05). The optimal cutoff point for FLI predicting the RWT > 0.42 was 26.38 (OR 10.6, p = 0.04, sensitivity 0.857, specificity 0.657). FLI correlates with RWT in patients with T1D independently of diabetes metabolic control and hypothetically may support recognizing T1D patients with a higher risk of LV remodeling.

New atrio-ventricular indices derived from conventional cine MRI correlate with functional capacity in patients with asymptomatic primary mitral regurgitation

Mitral regurgitation (MR) is associated with morphological and functional alterations of left atrium (LA) and ventricle (LV), possibly inducing LA–LV misalignment. We aimed to: (1) characterize angulation between LA and mitral annulus from conventional cine MRI data and feature-tracking (FT) contours, (2) assess their associations with functional capacity in MR patients, as assessed by oxygen consumption (peak-VO2) and minute ventilation to carbon dioxide production (VE/VCO2) slope, in comparison with MRI LA/LV strain indices. Thirty-two asymptomatic primary MR patients (56 [40; 66] years, 12 women) underwent cardiac MRI resulting in LA/LV conventional FT-derived strain indices. Then, end-diastolic angles were derived from FT LA contours: (1) α, centered on the LA centre of mass and defined by mitral valve extremities, (2) γ, centered on the mitral ring anterior/lateral side, and defined by LA centre and the other extremity of the mitral ring. Cardiopulmonary exercise testing with simultaneous echocardiography were also performed; peak-VO2 and VE/VCO2 slope were measured. While peak-VO2 and VE/VCO2 slope were not correlated to LA/LV strains, they were significantly associated with angles (α: r = 0.50, p = 0.003 and r = − 0.52, p = 0.003; γ: r = − 0.53, p = 0.002 and r = 0.52, p = 0.003; respectively), independently of age and gender (R2 ≥ 0.29, p ≤ 0.03). In primary MR, the new LA/mitral annulus angles, computed directly from standard-of-care MRI, are better correlated to exercise tolerance than conventional LA/LV strain.

Outcomes after transcatheter mitral valve implantation in valve-in-valve, valve-in-ring, and valve-in-mitral annular calcification.

We aimed to evaluate transcatheter mitral valve implantation (TMVI) using predominantly balloon-expandable transcatheter heart valves (THV) in patients with a landing zone for a percutaneously delivered prosthesis. Patients with a degenerated mitral valve bioprosthesis, annuloplasty ring, and mitral annulus calcification (MAC) considered at high surgical risk currently represent a treatment challenge. TMVI is an alternative treatment option. Retrospective analysis of patients with symptomatic degenerated mitral valve bioprosthesis, or annuloplasty ring, and MAC treated with TMVI between November 2011 and April 2021. Endpoints were defined according to Mitral Valve Academic Research Consortium (MVARC) criteria and included device and procedure success at 30 days as well as mortality at 30 days and 1 year after the procedure. A total of 77 patients underwent TMVI (valve in valve [ViV = 56], valve in ring [ViR = 11], and valve in MAC [ViMAC = 10]). There was a trend toward higher technical success (all = 93.5%, ViV = 96.4%, ViR = 90.9%, ViMAC = 80%, p = 0.06) and lower 30-day (all = 11.7%, ViV = 10.7%, ViR = 9.1%, ViMAC = 20%, p = 0.49) and 1-year mortality (all = 26%, ViV = 23.2%, ViR = 27.3%, ViMAC= 40%, p = 0.36) after ViV and ViR compared to ViMAC. TMVI represents a reasonable treatment option in selected patients with MAC or who are poor candidates for redo mitral valve surgery. Technical success and survival up to 1 year were not significantly dependent on the subgroup in which TMVI was performed.

Doing a double take: when transthoracic echocardiography fails for mitral valve annuloplasty ring endocarditis with Streptococcus pyogenes: a case report

BackgroundThis case highlights several complications of a late and rare presentation of culture-negative Streptococcus pyogenes endocarditis of a previously repaired mitral valve with an annuloplasty ring including recurrent cardioembolic strokes, which was initially missed on transthoracic echocardiography.Case presentationA 66-year-old Caucasian female with prior mitral valve prolapse status post mitral valve annuloplasty and left atrial appendage occlusion, followed by two strokes, presented with supraventricular tachycardia that resolved spontaneously. During an inpatient admission, she developed symptoms of another stroke, and imaging studies were suggestive of recurrent cardioembolic phenomenon. Additional workup revealed two small intra-atrial masses adherent to the mitral annuloplasty ring missed on prior evaluation for recurrent stroke. She underwent surgical repair in the setting of a chronic culture-negative infectious endocarditis with Streptococcus pyogenes and recovered well with no further cardioembolic phenomenon.ConclusionThis case serves to highlight the importance of having a higher index of suspicion in any cardiac prosthesis patient for endocarditis when presenting with symptoms such as recurrent stroke, arrhythmias, and abnormal cardiac lab work. It also demonstrates the need for appropriate imaging with transthoracic echocardiography followed by transesophageal echocardiography and reviews surgical indications to diagnose and treat culture-negative endocarditis.

First-in-Man Study of a Novel, Balloon-Adjustable Mitral Annuloplasty Ring.

Objectives: Mitral valve repair is the current standard approach for mitral valve regurgitation. However, patients suffering from functional mitral regurgitation have a significant risk of recurrent regurgitation. Adjustable mitral rings may provide a solution for this adverse event. Methods: A single-center, first-in-man clinical study was performed on patients suffering from mitral valve regurgitation. Patients were implanted with the study ring and followed for six months. A balloon catheter can be inserted into the study ring frame at any time after implantation and inflated independently in the areas P1, P2, or P3, which reduces the anterior-posterior diameter. Results: Five patients (75.4 ± 6.1 years; EuroSCORE II 2.1 ± 0.9%; three female) were successfully implanted. Mechanisms of mitral regurgitation were prolapse of the P2-segment in three patients and annular dilation in two patients. Surgical implantation according to the protocol was feasible and is described herein. Median cardiopulmonary bypass time and cross clamp time were 105 (118; 195) and 94 (90; 151) min, respectively. The median intensive care unit stay was 2 (2; 3) days. No perioperative, 30-day, or 6-month mortality was observed, and the repair was stable without residual or recurrent regurgitation ≥ grade 2. All patients reached the primary endpoint without device-related morbidity. Conclusions: Successful implantation was completed in five patients without device-related adverse events. Ring implantation was safe and feasible for all patients. The opportunity of post-implant adjustment to improve leaflet coaptation is a promising new therapeutic strategy that is assessed in a phase II study.

Patient-tailored low-voltage-guided ablation of atrial fibrillation: initial experience using a novel ultra-low-temperature cryoablation system

Abstract Introduction The ideal ablation strategy for patients (pts) with persistent atrial fibrillation (PersAF) is still debated. In recent randomized studies, strategies of ablating electrically abnormal atrial regions in addition to pulmonary vein isolation (PVI) have shown promise, and a novel ultra-low-temperature cryoablation (ULTC) system might overcome the limitations of radiofrequency (RF) energy to create transmural lesions in diseased tissue. Purpose Aim of this study is to report procedural aspects, acute efficacy, and safety of our initial experience in treating AF pts with this novel ULTC system. Methods Patients scheduled for catheter ablation who had a high likelihood of having left atrial (LA) low voltage zones (LVZ) underwent ablation with the ULTC system. A detailed high-density LA 3D-electronatomical map was created in sinus rhythm using a multi-electrode catheter. Bipolar LVZs were defined as at least 1cm2 surface of bipolar voltage &amp;lt;0.5mV. The ablation strategy consisted of PVI and linear ablation of the LVZs, transecting (if narrow) or isolating (if broad) the areas of abnormal signals and anchoring these lines to electrically silent structures (PVs or mitral valve ring). Electrical isolation and block across linear ablations were tested as universally accepted. Continuous variables are expressed as median (and interquartile ranges). Results From April to September 2023, 25 pts (10 female) were included (see table for patients´ and procedural characteristics). Procedure duration was 210 (135-270) min, and diminished over time from initially (in the first 12 pts) 260 (203.75-302.50) min to 190 (135-235) min (p=0.047). PVI was achieved in 15/18 pts (83%) using the ULTC, in the remaining 3 pts RF energy touch-up was needed. Linear ablation and isolation of LVZs were always (41/41 in 22pts, 100%) successfully achieved with the ULTC (see figure for an example). Except for 1 right phrenic nerve palsy, no major acute complications were observed. Post-procedural chest pain was not reported by any patient, in 1 patient mild pericardial effusion was detected and treated conservatively. During the 48h post-procedural ECG-monitoring, no sustained atrial arrhythmias occurred. Conclusions This is the first report of patient-tailored low-voltage-guided AF-ablation using a novel ULTC system. Despite representing our initial clinical experience, acute efficacy was very good (95% of acute bidirectional block across lines). Procedure-duration decreased over time, indicating an initial learning curve. Acute safety was reassuring but particular attention should be paid for phrenic nerve function during ablation of the right PVs. The absence of post-procedural pain, pericardial effusion, or acute post-procedural arrhythmias indicates limited ablation-induced inflammation.Result of ULTC ablation in a diseased LA

SEVERE MITRAL REGURGITATION TREATED WITH TRANSCATHETER AORTIC VALVE IMPLANTATION IN MITRAL RING (TMVIR): A CASE REPORT

Abstract Introduction The increasing prevalence of mitral regurgitation (MR), combined with a growing population of elderly patients at risk of being unsuitable for surgical options, has led to a greater interest in the use of less invasive treatments such as transcatheter heart valve (THV) implantation. This case involves the use of transcatheter aortic valve implantation in a patient with a previous mitral annuloplasty (TMViR). Case Presentation A 77–year–old woman had previously undergone mitral annuloplasty (Physio Ring II 32 mm, Medtronic), Neocord implantation and closure of the posterior commissure for severe MR due to anterior leaflet prolapse. She presented to our attention with worsening dyspnea (NYHA Class III) and a sudden weight gain. Transesophageal echocardiogram (TEE) revealed findings indicative of a previous mitral annuloplasty failure, with residual severe MR along with severe tricuspid regurgitation (TR). The case was discussed in the Heart Team and given the elevated surgical risk and the patient‘s anatomical unsuitability for edge–to–edge therapy, it was decided to perform a TMViR implantation. Under echocardiographic guidance and general anesthesia, right common right femoral vein access was obtained. After transseptal puncture, predilation of the interatrial septum was performed with balloon (Evercross 12 mm, Medtronic). Subsequent access to the left ventricle was achieved with a 6F PigTail catheter, and a stiff exchange guide (Safari S, Boston Scientific) was used to advance the 16Fr Delivery system. With the assistance of TEE, aortic valve implantation on the mitral ring was performed (Sapien 29 mm, Edwards Lifesciences) with rapid pacing via transvenous temporary PM placed in right ventricle (Spikeflow, Fiab). At the end of the procedure, two closure systems (Proglide, Abbott) were used for right femoral vein access. Post–implantation TEE showed a trivial paravalvular leak external to the annulus and a mean transvalvular gradient of 5 mmHg. The postoperative course proceeded without complications, facilitating the patient‘s discharge on the third postoperative day. Currently no further hospitalization in the last 6 months. Conclusion Despite surgical intervention remaining the gold standard in treating severe MR in patients who have undergone a previous annuloplasty, in patients at high surgical risk for a re–operation, who are not eligible for other percutaneous options, TMViR could be a safe and effective option for treatment.

Mechanical Analysis of the Connection Structure of a Double-Layered Valve Stent within an Annuloplasty Ring

Background: In this study, to address the failure of mitral valve repair surgery, a novel valve-in-ring model for an artificial mitral valve annuloplasty ring and a new double-layer mitral valve were established. A suitable number and length of ventricular fixation struts within the annuloplasty ring, as well as the implantation depth, result in variations in stress and strain for the inner and outer stent layers. Methods: The compression and self-expansion model of the stent was established via finite element analysis. The changes in stress and strain were analyzed by setting the length and number of the ventricular fixed struts and implantation depth. Results: When only affected by factors such as blood pressure, the maximum stresses of stent structures with three and six ventricular fixed struts are 476 and 222 MPa, respectively, in the right posterior annular region. At implantation depths of 0, 0.5, 1, and 2 mm, the maximum stresses are located in the left posterior annular region of the outer stent and are 740, 697, 709, and 742 MPa, respectively, and the maximum displacements of the inner stent are all in the right posterior ventricular fixed strut region of the posterior annulus and are 3.71, 3.10, 2.48, and 1.87 mm, respectively. In the three and six ventricular fixed strut stents, when the ventricular fixed strut length is 3, 4, and 5 mm, the maximum stresses are 570, 557, and 621 MPa and 674, 666, 644 MPa, respectively. Conclusions: Appropriately increasing the number of ventricular fixed struts can effectively reduce damage to the stent inside the body, and the damage to the stent is relatively consistent across different implantation depths; however, the right side of the stent's posterior annulus is particularly susceptible to damage. However, if the implantation depth is lower, the impact on the inner stent will be more significant. As the number of ventricular fixed struts increases, the strut length variation has a relatively stable impact on stent damage.

A Modified Tip-to-Base LAMPOON to Prevent Left Ventricular Outflow Tract Obstruction in Valve-in-Ring or Valve-in-Valve Transcatheter Mitral Valve Replacement.

The Laceration of the Anterior Mitral leaflet to Prevent Outflow ObtructioN (LAMPOON) procedure may be performed from the leaflet tip to base to prevent left ventricular outflow tract obstruction (LVOTO) in patients with high-risk anatomy undergoing valve-in-valve (VIV) or valve-in-(complete)-ring (VIR) transcatheter mitral valve replacement (TMVR). Thirteen consecutive patients (6 females, average age 67.7 years) with a mean left ventricular ejection fraction of 60%, a median STS score of 3.2%, and degenerative surgical mitral bioprosthesis or ring were treated with a combined, single-stage procedure of preventive LAMPOON and trans-septal TMVR with SAPIEN 3 valves (Edwards Lifesciences, Irvine, CA). Under real-time 3-dimensional transesophageal echocardiography (RT 3D-TEE) guidance, we included the rendezvous technique in the LAMPOON procedure, and all 13 patients were successfully treated by tip-to-base LAMPOON and TMVR. The use of a modified LAMPOON procedure, aided by a rendezvous technique and guided by RT 3D-TEE imaging, offers precise guidance for positioning and aligning the guidewire. This approach not only reduces the need for fluoroscopy and shortens procedure times, but also significantly increases the likelihood of a successful outcome. Importantly, none of the patients in our study experienced unintentional aortic or aortic valve injuries, nor did they develop significant LVOTO following TMVR. In 11 of the 13 (85%) patients, we used a transcatheter SENTINELTM cerebral protection device (Boston Scientific, Marlborough, MA) for stroke prevention and capture of debris ≥ 2 mm were detected in 8/11 (73%) of the cases. Utilizing intra-operative RT 3D-TEE in conjunction with the rendezvous technique can make the tip-to-base LAMPOON procedure even safer and more effective for patients undergoing VIV or VIR TMVR. Our study also suggests that cerebral protection is indicated in patients undergoing TMVR.

The study of loading mode with in-vitro fatigue testing for mitral annuloplasty ring

To maintain the physiological dynamics of the mitral annulus, mitral annuloplasty rings (MAR) must be flexible. Enhanced flexibility implies decreased resistance to fatigue and potential for fatigue fracture. This study established new methods to test the flexible fatigue life of MAR in-vitro using numerical analysis; the purpose is that the fatigue test could reflect the real stress distribution in-vivo.Based on the conventional test methods (C1, D1), this paper presents a novel test method (C2, D2). Four testing methods for open-end annuloplasty rings (C1, C2) and closed-end annuloplasty rings (D1, D2) were modelled and their stress distribution calculated by finite element analysis. The mean absolute error (Χ) and the Pearson correlation coefficient (Φ) were used to quantify the difference in stress distribution between the loading modes in-vivo and in-vitro.For closed-end annuloplasty rings, the novel test method (D2) is not obvious better than conventional test methods(D1) in duplicating the stress distribution (ΦD1 = 0.88 vs ΦD2 = 0.92). However, the maximum values of stress in the novel test method are closer to the maximum value of stress under in-vivo loading (ΧD1 = 5.2Mpa vs ΧD2 = 4.4Mpa).For open-end annuloplasty rings, the novel test method(C2) is obviously superior to the conventional test method(C1) in duplicating both the stress distribution and the stress peak values of the in-vivo loading (ΦC1 = 0.22 vs ΦC2 = 0.98; ΧC1 = 59.1Mpa vs ΧC2 = 11.0Mpa).The in-vitro loading methods described in this article more closely approximated in-vivo conditions compared to traditional methods. They are simpler to operate, more efficient and can help manufacturers expedite new product development, assist regulatory agencies with product quality oversight.

Proof of Concept: Development of a Mitral Annuloplasty Ring With Crosshatch Net.

Here we report our preclinical, proof-of-concept testing to assess the ability of a novel device to correct mitral regurgitation. The Milwaukee Heart device aims to enable any cardiac surgeon to perform high-quality mitral valve repair using a standard annuloplasty ring with a crosshatch of microporous, monofilament suture. Hemodynamic, echocardiographic, and videographic data were collected at baseline, following induction of mitral regurgitation, and after repair using porcine hearts in an ex vivo biosimulator model. A commercially available cardiac prosthesis assessment platform was then used to assess the hydrodynamic characteristics of the study device. Porcine biosimulator pressure and flow metrics exhibited successful correction of mitral regurgitation following device implantation with similar values to baseline. Hydrodynamic results yielded pressure gradients and an effective orifice area comparable to currently approved prostheses. The study device effectively reduced mitral valve regurgitation and improved hemodynamics in our preclinical model with similar biophysical metrics to currently approved devices. Future in vivo trials are needed to evaluate the efficacy, biocompatibility, and freedom from the most likely adverse events, such as device thrombosis, embolic events, and hemolysis.

Mitral valve leaflet blood cyst treated with minimally invasive approach: a case report and review of literature

IntroductionCardiac blood cyst is a very rare benign tumor of the heart in adults. Though it is very common in the first half year of life, it regresses with time and its occurrence is very rare in children older than six months and in adults. Until now less than 100 valvular blood cyst cases have been reported in adults.Case presentationWe present a case of a 66-year-old male who presented to us with exertional chest tightness, shortness of breath, and right leg weakness for two weeks. He was diagnosed with a cardiac mass two months ago in another hospital. The physical examination was unremarkable. Abdominal ultrasound showed a cyst in the liver and left kidney. Echocardiography showed a mass-occupying lesion of a cystic nature in the mitral valve with moderate mitral regurgitation. Based on echocardiography findings and computed tomography report, the preliminary diagnosis of mitral valve cystic tumor was made. The patient underwent minimally invasive resection of the cyst. The posterior mitral cusp was repaired and a mitral annuloplasty ring was placed. The postoperative recovery was uneventful. The histopathology report confirmed the diagnosis of a cardiac blood cyst. The patient was followed up for six months without any complications. This case is presented to enrich the medical literature on the cardiac blood cyst.ConclusionAlthough a cardiac blood cyst is a rare entity in adults, it still should be considered in the differential diagnosis of cardiac tumors. Because the natural history and hemodynamic effects are very diverse, large symptomatic cardiac blood cysts, especially in the left heart should be resected to avoid complications.

A Report of Two Cases with Caseous Annular Calcification of the Mitral Valve.

Introduction: Caseous calcification of the mitral annulus (CCMA) is a rare variant of mitral annulus calcification, a chronic and degenerative mitral valve fibrous ring process. It usually carries a benign prognosis. The prevalence of CCMA is about 0.06%-0.07% of the population. CCMA is generally diagnosed incidentally and can be confused with other intracardiac masses such as cardiac tumors, abscesses, vegetation, or calcified thrombi. Multimodality imaging, including TEE, cardiac computed tomography, and cardiac magnetic nuclear resonance, can easily differentiate CCMA from other masses and help avoid unnecessary surgery. CCMA is typically located in the basal area of the posterior mitral valve, and the calcification seems like a round, large, soft mass with a central echo-dense location. CCMA may have a benign course, but it may sometimes be complicated with mitral valvular dysfunction, systemic embolization, or conduction abnormalities in the scenarios mentioned above, as well as when the diagnosis is unclear, surgery is indicated. Mitral valve replacement should be preferred compared to mitral valve repair.&#x0D; Conclusions: It is important to note that the decision for mitral valve replacement, including CAC cases, should be individualized based on various factors, including the patient's clinical condition, symptoms, severity of valve disease, and associated comorbidities.&#x0D; As scientific understanding and research progress, there may be ongoing developments and refinements in the conservative and surgical management of CCMA.

Abnormal aortic origin of coronary arteries

The anomalous aortic origin of the coronary arteries has an estimated prevalence of 0.02-5.7%. It can be associated with sudden death when it has an interarterial or intramural pathway or be damaged during interventions on the mitral, pulmonary and/or aortic annulus or percutaneous closure of an interatrial septal defect. To identify these patients by imaging techniques such as transthoracic color Doppler echocardiography (TTE), computed tomography (CT) multislice angiography or coronary angiography. The imaging techniques used for the detection of coronary anomalies were TTE, multislice coronary angiography or coronary angiography according to what is generally accepted. Fifteen patients were identified; in 12 of them the suspicion was due to TTE and in the remaining 3, CT multislice angiography was diagnostic. The circumflex artery was the coronary artery most involved, associated or not with another coronary anomaly (12/15 patients) and in the other three cases, the anomalous coronary artery had an interarterial course, with the right coronary arteries and the anterior descending coronary arteries being involved. The under diagnosis by TTE of coronary artery abnormalities may be due to the difficulty of visualization that is accentuated with age. Their detection is crucial because they can both, lead to sudden death associated with an intramural and/or interarterial pathway and complicate an interventional procedure on the interatrial septum or within the mitral, pulmonary and/or aortic rings.

Perioperative and Anesthetic Considerations in Shone's Complex.

Shone's complex is a congenital cardiac disease consisting of the following four lesions: parachute mitral valve, supravalvar mitral ring, subaortic stenosis, and aortic coarctation. Though not all components are required for a diagnosis, the end result is both left ventricular inflow and outflow obstruction, which typically present in patients as congestive heart failure. The complex pathology requires careful management and surgical decision-making to ensure an optimal outcome. This review will focus on the anatomy, physiology, and perioperative anesthetic management of patients with Shone's complex.

Caseous calcification of the mitral annulus

Caseous calcification of the mitral annulus (CCMA) is a rare form of degenerative lesion of the mitral valve fibrous ring. It’s a biochemical transformation of calcification area accompanied with formation of masses of a curdled consistency (caseosis). It is usually located in the area of the posterior mitral valve. In most cases, it is asymptomatic or minimally symptomatic, and is an incidental finding during imaging studies. The causes and pathogenesis of CCMA are unknown, however, there is a connection with disorders of calcium and phosphorus metabolism and there is no connection with an valve infection. There is no specific treatment. In cases where CCMA leads to significant disturbances of cardiac hemodynamics and/or there is a high probability of ebolism, it needs to be treated surgically.Differential diagnosis is carried out with other cardiac mass.

Euclidean and Shape-Based Analysis of the Dynamic Mitral Annulus in Children using a Novel Open-Source Framework

The dynamic shape of the normal adult mitral annulus has been shown to be important to mitral valve function. However, annular dynamics of the healthy mitral valve in children have yet to be explored. The aim of this study was to model and quantify the shape and major modes of variation of pediatric mitral valve annuli in four phases of the cardiac cycle using transthoracic echocardiography. The mitral valve annuli of 100 children and young adults with normal findings on three-dimensional echocardiography were modeled in four different cardiac phases using the SlicerHeart extension for 3D Slicer. Annular metrics were quantified using SlicerHeart, and optimal normalization to body surface area was explored. Mean annular shapes and the principal components of variation were computed using custom code implemented in a new SlicerHeart module (Annulus Shape Analyzer). Shape was regressed over metrics of age and body surface area, and mean shapes for five age-stratified groups were generated. The ratio of annular height to commissural width of the mitral valve ("saddle shape") changed significantly throughout age for systolic phases (P<.001) but within a narrow range (median range, 0.20-0.25). Annular metrics changed statistically significantly between the diastolic and systolic phases of the cardiac cycle. Visually, the annular shape was maintained with respect to age and body surface area. Principal-component analysis revealed that the pediatric mitral annulus varies primarily in size (mode 1), ratio of annular height to commissural width (mode 2), and sphericity (mode 3). The saddle-shaped mitral annulus is maintained throughout childhood but varies significantly throughout the cardiac cycle. The major modes of variation in the pediatric mitral annulus are due to size, ratio of annular height to commissural width, and sphericity. The generation of age- and size-specific mitral annular shapes may inform the development of appropriately scaled absorbable or expandable mitral annuloplasty rings for children.

The Relationship Between Echocardiographic Calcification Score and Grade of Knee Osteoarthritis.

Background and objective It has been suggested that knee osteoarthritis (KOA) is associated with the development of calcification and an increased risk of cardiovascular (CV) disease, while the contribution of KOA grade is not clearly known enough. This study aimed to investigate the relationship between the grade of KOA, the echocardiographic calcification score (echo-CCS), and CV risk assessment. Methods This cross-sectional study involved 204 patients diagnosed with KOA and classified according to the Kellgren-Lawrence staging criteria. Echo-CCS was obtained according to the presence of calcification in the aortic valve, aortic root, mitral ring, papillary muscle and ventricular septum. Framingham risk score (FRS) was used for CV risk assessment. Results Calcification was detected in 79.4% of patients. The median FRS, echo-CCS, andhigh-sensitivityC-reactive protein (hs-CRP) levels increased as the KOA grade increased (p<0.05). A one-grade increase in KOA increased the odds of echo-CCS 1-2 group by 5.15 fold (vs. no calcification group) (OR=5.15, p=0.003), while it increased the odds of echo-CCS ≥3 group by 4.61 fold (vs. echo-CCS 1-2 group) (OR=4.61, p=0.003). Median echo-CSS and hs-CRP were higher in the high CV risk group than in the moderate and low CV risk groups. Conclusion The majority of patients with KOA had intracardiac calcification.An increased KOA grade was associated with higher echo-CSS and FRS. These findings indicate that patients with higher grades of KOA may be predisposed to developing subclinical atherosclerosis.