Mitral Surgery Research Articles

Tricuspid surgery at time of mitral surgery improves survival free from severe tricuspid regurgitation but not quality of life

ObjectiveThe choice to operate on moderate tricuspid regurgitation (TR) during mitral surgery is challenging owing to limited mid-term data. We assess whether concomitant tricuspid operations improve mid-term quality of life, morbidity, or mortality. MethodsAn institutional database identified mitral surgery recipients with moderate TR at the time of surgery from 2010 to 2019. Patients were stratified by the presence of a concomitant tricuspid operation. Quality of life at the last follow-up was assessed with the Kansas City Cardiomyopathy Questionnaire (KCCQ-12). Morbidity was compared using the χ2 test, Mann-Whitney U test, and Student t test. Survival was analyzed with Kaplan-Meier estimation. ResultsOf 210 mitral surgery recipients, 67 (31.9%) underwent concomitant tricuspid surgery. The concomitant tricuspid surgery cohort had greater preoperative dialysis use (10.5% vs 3.5%; P = .043) but similar age, New York Heart Association class, and cardiac surgery history relative to the nonconcomitant cohort (P > .05 for all). The concomitant tricuspid surgery cohort had a longer cardiopulmonary bypass time (144 minutes vs 122 minutes; P = .005) but a similar rate of mitral repair (P = .220). Postoperative KCCQ-12 scores reflected high quality of life in both cohorts (95.1 vs 89.1; P = .167). The concomitant tricuspid surgery cohort trended toward a higher perioperative pacemaker placement rate (22.8% vs 12.7%; P = .088) but were less likely to develop severe TR (0.0% vs 13.0%; P = .004). Overall survival was comparable between the 2 cohorts at 1 year (84.9% vs 81.6%; P = .628) and 5 years (73.5% vs 57.9%; P = .078). Five-year survival free from severe TR was higher in the concomitant cohort (73.5% vs 54.3%; P = .032). ConclusionsConcomitant tricuspid surgery for moderate TR is associated with increased 5-year survival free from severe TR but not with increased quality of life.

Anticoagulant Management of Mechanical Heart Valve Patients During Perioperative Surgery: A Case Report

Background: Patients with mechanical heart valves require lifelong oral anticoagulation. It will be a dilemma if a patient with a mechanical heart valve has surgery. This case report aims to discuss how to interrupt oral anticoagulants and bridging therapy in patients with mechanical heart valves who will be undergoing non-cardiac surgery. Case Report: A 26-year-old pregnant woman, G1P0A0, aterm with a mechanical mitral valve, will have elective Sectio Caesarian Transperitonealis (SCTP) surgery and Intra Uterine Device (IUD) insertion. The patient had a history of mitral valve replacement surgery (MVR) in 2014 and was routinely treated with 4 mg of warfarin at night. From the examination, blood pressure was 120/80 mmHg, heart rate was 90 beats per minute, and pulse rate was 90 beats per minute. The ECG examination found sinus rhythm with 1st-degree atrioventricular block, right axis deviation, 90 beats per minute, and left atrial enlargement. We decided to have oral anticoagulant interruption and bridging therapy by stopping warfarin three days before surgery. When the international normalized ratio (INR) falls <2, patients are given heparin injections (UFH) with an APTT target of 1.5-2.0 times from basic APTT. When the patient was about to be operated on, UFH was stopped 6 hours before surgery and resumed 12 hours after surgery. Warfarin was given one day postoperatively. Patients were adjusted to the dose of UFH according to the target. This patient had no thromboembolic events or bleeding before, during, or after surgery. The patient was allowed to be an outpatient and was given home therapy with Warfarin 5 mg at night. Results: We report a case of a 26-year-old female patient with a mechanical mitral valve who was going to undergo elective SCTP surgery and an IUD insertion. Patients at high risk of thrombo¬embolism due to surgery with a high risk of bleeding. Bridging therapy was performed using UFH. In the perioperative period, the patient did not experience thromboembolic events, and bleeding before, during, and after surgery could be well controlled. Conclusion: Perioperative management of patients with mechanical heart valves must be done carefully. Interruption of oral anticoagulants should be carefully considered considering the risk of thromboembolism and bleeding during the perioperative period. Guidelines recommend that in patients with mechanical heart valves, anticoagulation interruption for minor surgeries is avoided. Whereas in patients with major surgery, it is necessary to do bridging therapy with fast-acting anticoagulants such as UFH or LMWH. Keywords: mechanical heart valve, anticoagulant interruption, perioperative, bridging therapy Correspondence: Trisulo Wasyanto. Department of Cardiology and Vascular Medicine, Faculty of Medicine, Sebelas Maret University / Dr. Moewardi Hospital. Jl. Kol. Sutarto 132, Surakarta 57126, Central Java, Indonesia. Email: trisulo.wasyanto@staff.uns.ac.id. ORCID ID: 0000-0001-9900-0497. Mobile: +62811294225.

Closed-chest robotic repair of mitral prolapse. Surgical technique and early results.

Robotic mitral repair is generally performed with four intercostal trocars and a minithoracotomy. We describe our technique and results with a totally-thoracoscopic closed chest approach using a 12 mm valveless trocar as "working port", without a minithoracotomy. We compared our results with this technique with a control group of robotic mitral repairs performed earlier with a minithoracotomy. Review of all patients with degenerative mitral valve disease who underwent robotic mitral valve repair surgery since December 2019 (n = 110). Patients with concomitant procedures (n = 8) were excluded. The remaining 102 patients were divided in two groups, depending on the approach used, minithoracotomy (n = 63) and totally thoracoscopic (n = 39). There were no significant differences between groups regarding preoperative characteristics. All procedures were completed robotically as planned, and repair rate was 100%. The minithoracotomy group showed a higher percentage of leaflet resections (17.9% vs. 38.7%; p = 0.03). All surgical times were significatively reduced in the totally thoracoscopic group: Cardiopulmonary bypass (97 vs. 115 min, p = 0.0008), ischemic time (67 vs. 80 min, p = 0.0013) and total surgical time (185 vs. 225 min; p < 0.00001). There were no differences in ICU length of stay (1 day, p = 0.07) but hospital length of stay was shorter in the totally thoracoscopic group (4 days; p = 0.0001). Postoperative complications were similar between groups. MR at discharge was mild or less in all cases. Robotic mitral repair for degenerative disease can be safely performed as a closed-chest procedure, using a 12 mm trocar as "working port" and avoiding the need for a minithoracotomy. This approach does not seem to negatively affect the quality of the procedure by any measure, providing similar excellent clinical outcomes and repair rate. All surgical times were shorter in the closed-chest group.

The Wave of Robotic Mitral Surgery is Here to Stay

The Wave of Robotic Mitral Surgery is Here to Stay

The factor related to the outcome of maze procedure in mitral valve replacement surgery

Objective: To evaluate the factors related to the outcome of Maze surgery to remove atrial fibrillation in mitral valve replacement surgery at Hanoi Heart Hospital.&#x0D; Methods: Study on all patients with simple mitral valve disease and atrial fibrillation who were assigned to have mitral valve replacement surgery with Maze IV surgery from 01/2022 to 07/2023. Retrospective and prospective, non-controlled studies.&#x0D; Results: 51 patients (17 men, 34 women, mean age 55.22 ± 9.13) were eligible to participate in the study. The rate of sinus rhythm restoration at the time of discharge - 3 months - 6 months after surgery was 56.9% - 90.2% - 94.1%, respectively. Preoperative echocardiographic parameters have no predictive value in predicting the likelihood of sinus rhythm re-establishment, while postoperative parameters have high prognostic value. Using ROC curve analysis, we provide cut-off thresholds with predictive value: postoperative left atrial diameter &lt; 42.5 mm (AUC = 0.798, sensitivity 75%, specificity) 63.8%, p=0.05), LA diameter at 6 months follow-up &lt; 45.5 mm (AUC = 0.929, sensitivity 75%, specificity 88.6%, p &lt; 0.01), left atrial volume index (LAVi) re-examination at 6 months &lt;62 ml/m2 (AUC = 0.827, sensitivity 75%, specificity 84.6%, p&lt;0.05), LAVi re-examination at 6 months &lt;60.5 ml/m2 (AUC = 0.867, sensitivity 67%, specificity 91.4%, p&lt;0.05) increased the success rate of sinus cardioversion.&#x0D; Conclusion: Maze surgery has a high success rate in patients who are indicated for mitral valve replacement surgery. Using ROC curve analysis, the parameters on echocardiography at 6 months after surgery: LA diameter &lt; 45.5 mm, LAVi &lt; 60.5 ml/m2 are factors that increase the success rate of ablation of atrial fibrillation and sinus cardioversion.

Study of the Acute Hemodynamic Effects of Inhaled Milrinone versus Inhaled Nitroglycerin on Mechanically Ventilated Patients with Pulmonary Hypertension after Mitral Valve Replacement Surgeries

Abstract Background Pulmonary hypertension is a usual complication of long-standing mitral valve disease. Perioperative pulmonary hypertension is a risk factor for right ventricular failure and is an important cause of morbidity and mortality in patients with pulmonary hypertension undergoing mitral valve surgery. Aim of the Work To compare inhaled milrinone and inhaled nitroglycerin hemodynamic effects on mechanically ventilated patients with pulmonary hypertension after mitral valve replacement surgery by measuring invasive blood pressure, heart rate, central venous pressure and bedside transthoracic echocardiography to assess pulmonary artery pressure. Patients and Methods The study was conducted in National Heart Institute, Giza, Egypt during the six months between October, 2020 and March, 2021. This study was conducted on 40 patients. Patients were randomized on the basis of computer-generated random numbers into two equal groups (20 patients each) Using PASS11 program for sample size calculation. In group A, patients received inhaled nitroglycerin (50 µ/kg) and in group B, patients received inhaled milrinone (50 µ/kg) through jet nebulizer. Results Both inhaled milrinone and inhaled nitroglycerin proved to be selective pulmonary vasodilators, since they induced significant reductions in mPAP, SPAP, and DPAP. The favorable effects of both agents on the pulmonary vasculature was confirmed by both hemodynamic and echocardiographic measurements. At the same time, both agents were devoid of systemic side effects, since mean arterial pressure, systolic arterial pressure and diastolic arterial pressure were not affected. Conclusion There was no significance between two groups, so inhaled nitroglycerin appears to be an effective, easy to administer, inexpensive, available and save alternative for treatment of PH in mechanically ventilated patients after mitral valve replacement surgeries as there was no significance between two groups.

Echocardiographic diagnosis of rupture of mitral valve papillary muscle

ObjectiveTo explore the value of echocardiography in diagnosing papillary muscle rupture (PMR) of the mitral valve, and summarize the characteristic echocardiographic features of different types. MethodsEchocardiograms of 13 PMR patients confirmed by surgery in Wuhan Union Hospital between January 2009 and December 2022 were retrospectively analyzed and their preoperative transthoracic echocardiography (TTE) was compared with surgical findings. ResultsA total of 9020 patients underwent mitral valve repair or replacement surgery during the study period including 13 (0.14%) for PMR. Of the 13 PMRs, 8 cases were partial PMR(P-PMR), 5 cases were complete PMR(C-PMR); 3 cases were anterolateral PMR, and 10 were posteromedial PMR. The diagnostic accuracy, sensitivity, and specificity of the preoperative TTE were 99.9%, 53.8% and 99.9% respectively. Echocardiographic features of 10 patients (5-C-PMR and 5 P-PMR) with detailed TTE and intraoperative transesophageal echocardiography (TEE) data included: both anterior and posterior leaflets prolapse (C-PMR 60% vs P-PMR 60%); flail leaflet (C-PMR100% vs P-PMR 40%); All C-PMRs and P-PMRs have severe, eccentric and lateral regurgitation; flail attachment (chordae tendinae and ruptured PM) at the tip of prolapsed leaflet (C-PMR100% vs P-PMR 60%); high-echo masses resembled “champagne glasses” in 100% of the C-PMR; high-echo masses resembled “lotus-seedpod” in 60% and “dumbbell-shaped” torn PM in remaining 40% of the P-PMR. ConclusionsDifferent PMR subtypes have different echocardiographic characteristics. Combining TTE and TEE can accurately identify the typical features of PMR such as ipsilateral hemipetal leaflet prolapse, high-echoic mass at the tip of the leaflet, massive eccentricity and lateral regurgitation.

A simple transseptal approach versus the conventional left atrial approach for mitral valve procedures: a retrospective study.

Having good exposure to the mitral apparatus during mitral valve replacement is a vital decision every cardiac surgeon must take. This study was conducted to compare the simple transseptal approach and the conventional left atrial approach for mitral valve procedures, to evaluate the safety and efficacy of the simple transseptal approach during open heart mitral valve procedures, as the conventional left atrial approach may not provide optimal exposure, especially in unfavorable anatomical and operative situations. This is a retrospective study. It has been conducted on 140 patients who were diagnosed with heart diseases that required mitral valve replacement. Surgeries were performed in the Cardiothoracic Surgery Department. Mitral procedure was done through median sternotomy incision under general anesthesia on a cardiopulmonary bypass machine with cold antegrade cardioplegia. Demographic data, preoperative diagnosis, intraoperative findings, hospital stay, complications, and mortality were documented and revised. One hundred and forty patients were enrolled in this study with a median age of 39years, and no significant differences as regards the baseline demographic data as age, sex, and body mass index (BMI). A total of 68 patients underwent mitral valve replacement through the simple transseptal approach and 72 patients through the conventional left atrial approach. Both studied groups had insignificant differences as regards bypass time, re-operation rate, postoperative complications, hospital stay, and mortality. The simple transseptal approach through the midpoint of the fossa ovalis could be a safe and even favorable alternative to the traditional left atriotomy approach in certain difficult operative situations during mitral valve replacement surgery.

Mid-term results of endoscopic mitral valve repair and insights in surgical techniques for isolated posterior prolapse.

The adoption of minimally invasive techniques to perform mitral valve repair surgery is increasing. This is enhanced by the compelling evidence of satisfactory short-term results and lower major morbidity. We analyzed mid-term follow-up results of our experience, and further compared two techniques: isolated leaflet resection and neochord implantation for posterior leaflet prolapse. Data for all consecutive endoscopic mitral valve repairs via video-assisted right anterior mini-thoracotomy were analyzed between December 2012 and September 2021. The early and mid-term follow-up results were ascertained. The main outcome was the incidence of mortality and the recurrence of significant mitral regurgitation during follow-up which were summarized by the Kaplan-Meier estimator and compared between treatment arms using the stratified log-rank test. Secondary outcomes were the early-postoperative results including 30-days mortality and the occurrence of major complications. A total of 309 patients were included. Along with ring annuloplasty, 136 (44.4%) patients received posterior leaflet resection (122 isolated) whereas 97 (31.1%) underwent posterior leaflet chords implantation (88 isolated). Forty-nine patients had annuloplasty alone. In-hospital mortality was 1.0%. Mean follow-up was 28.8 ± 22.0 months (maximum 8.3 years). Kaplan-Meier survival rate at 5 years was 97.3 ± 1.0%, mitral regurgitation ([Formula: see text]3+) or valve reoperation free-survival at 5 years was estimated as 94.5 ± 2.3%. Subgroup time-to-event analysis for the indexed outcomes showed no statistical significance between the techniques. Endoscopic mitral valve repair is safe and associated with excellent short- and mid-term outcomes. No differences were found between leaflet resection and gore-tex chords implantation for posterior leaflet prolapse.

Abstract P2100: Highly Localized Myocardial Expression Of Brain Natriuretic Peptide In Patients With Mitral Valve Prolapse

Mitral valve prolapse (MVP) is a common cause of mitral regurgitation (MR), adverse left ventricular (LV) remodeling and arrhythmias. MVP induces mechanical stretch to the inferobasal (INF) myocardium and papillary muscles. The underlying regional and molecular pathology of MVP-induced LV remodeling remains incompletely understood. The aim was to characterize the molecular effects of mechanical stretch by comparing the regional gene expression of the INF region of LV in patients with MVP. Biopsies were obtained from the INF LV and the interventricular septum during mitral valve repair surgery for MVP-induced primary MR. Spatial transcriptome sequencing results correlated with histological staining of fibrosis in the INF and septal regions (R=0.97, P&lt;0.0001). The extent of fibrosis was similar between the INF region and the septal control in the respective patients with MVP. The localized fibrotic areas of the INF region showed decreased expression of cardiac myocyte genes and increased expression of fibrous and EndMT markers. In the INF region, we identified a transition zone between healthy myocardium and fibrous tissue. This transition zone showed increased expression of the NPPB gene encoding brain natriuretic peptide (BNP), whereas NPPB was not increased in the septal region of the same patients, and was confirmed by qPCR (NPPB +6.4-fold, N=11, P=0.004). The INF border zone is characterized by increase expression of NPPB, IGFBP2 and MFGE8, which have been described to be associated with adverse LV remodeling in heart failure. The serum NT-proBNP levels (mean 276.8 ± 121.6 pg/ml) of the patients correlated with NPPB levels from the INF region (R=0.76, P=0.01, N=9), whereas no correlation was found with NPPB levels from the septal control regions (R=0.17, P=0.65) of the same patients. In conclusion, spatial transcriptome analysis in MVP patients identifies a transition zone of the INF region of LV which is exposed to high mechanical stretch. This localized transition zone has a specific gene expression profile, e.g. with increased NBBP expression that correlates with increased NT-ProBNP serum concentrations. Our results indicate that mechanical stretch induces highly localized myocardial pathologies with systemic consequences.

HEMOLYTIC ANEMIA AFTER MITRAL VALVE REPAIR: A CASE REPORT

We present a case report of a 52-year-old male who de­veloped hemolytic anemia after undergoing mitral valve repair surgery. Hemolytic anemia is a rare complication of mitral valve repair, occurring in less than 1% of pa­tients. Fragmentation of the mitral regurgitant jet is the leading cause of intravascular hemolytic anemia after the surgery. In this particular case, the jet was following the anterior leaflet and hitting the mitral annulus. The pre­sence of schistocytes and echocardiographic evaluation help diagnose the mechanical origin of hemolysis after mitral valve repair. Hemolytic anemia is managed with blood transfusions and treated with mitral reoperation. In this case, the patient required mechanical mitral valve replacement surgery, and their condition improved fol­lowing the surgery.

Correlation between the Leaflet-Annulus Index and Echocardiographic Indices in Maltese Dogs with Myxomatous Mitral Valve Disease.

Myxomatous mitral valve disease (MMVD) is the most common chronic heart valve disease, leading to left-sided cardiomegaly in dogs. The leaflet-annulus index (LAI) was originally used in humans as a predictor of mitral regurgitation (MR) after mitral valve repair surgery. This index represents the quantity and severity of MR since it is affected by annular dilation. Recently, LAI was adapted to veterinary medicine, and its usefulness as an indicator of annular dilation on 2D transthoracic echocardiography in MMVD dogs was suggested. For this study, 135 Maltese dogs were selected and divided into groups of control, B1, and B2, according to the American College of Veterinary Internal Medicine consensus statement. The following data were collected: radiographic indices including the vertebral heart score and vertebral left atrial size, echocardiographic indices including the left-atrium-to-aortic-root ratio (LA:Ao), left ventricular internal diameter at diastole, normalized for body weight, and anteroposterior length and LAI measured on right parasternal long-axis view. The results showed a significant difference in LAI between each group, becoming smaller as the disease progressed. Also, there was a significant correlation between LAI and each index, showing the strongest correlation with LA:Ao. LAI could be helpful as a new indicator used for the determination of severity and prognosis in Maltese dogs with MMVD.

Mitral valve surgery in octogenarians: Identifying factors that can guide clinical decision-making.

Mitral valve surgery in octogenarians is a clinical challenge due to the impact of inherent, age-related comorbidities. Within the context of an aging population, the number of mitral surgery candidates over 80 has been gradually increasing. We sought to evaluate our institutional experience with mitral valve surgery in octogenarians to identify factors that may prove useful during the process of clinical decision-making. We retrospectively reviewed our institutional database for all patients over 80 years of age who underwent mitral valve surgery in our department from October 2002 up to February 2021. The primary endpoints of our study were 30-day all-cause mortality and long-term survival after the first postoperative month. In total, 99 octogenarians underwent mitral valve surgery for various types of mitral pathology. In particular, 70 patients underwent mitral valve replacement with or without concomitant procedures and 29 underwent mitral valve repair with or without concomitant procedures. There was no difference between the two approaches in terms of 30-day mortality and long-term survival. Chronic kidney disease and total operative time were independent predicting factors for 30-day mortality. Etiology of mitral valve pathology and EuroSCORE II was independent predicting factors for long-term survival. The type of mitral valve surgery did not affect 30-day and long-term mortality rates in our study. Renal impairment and EuroSCORE II were independent predictors of 30-day mortality and long-term prognosis, respectively. Rheumatic valve disease was also associated with a poorer prognosis.

Aortic valve replacement for moderate aortic stenosis during mitral surgery improves survival free from severe stenosis.

Optimal management of moderate aortic stenosis during surgery for another indication is unclear. We assessed the effects of surgical aortic valve replacement for moderate aortic stenosis during mitral surgery. An institutional mitral surgery database was queried for patients with preoperative moderate aortic stenosis. Patients were stratified by whether they underwent concomitant surgical aortic valve replacement. Morbidity was analyzed using Student's t tests, Wilcoxon rank sum, chi-squared, and Fisher's exact tests. Survival was analyzed using Kaplan-Meier estimation and Cox regression. Of 85 mitral surgery recipients with moderate aortic stenosis from 2012 to 2019, 62 (73%) underwent concomitant surgical aortic valve replacement. Surgical aortic valve replacement recipients were more likely to have bicuspid (11% vs. 0%, p = 0.019) or rheumatic (18% vs. 0%, p = 0.019) aortic valves, and to undergo mitral repair (32% vs. 9%, p = 0.028). Groups did not differ with respect to mitral etiology, New York Heart Association class, or cardiac intervention history (p > 0.05). Postoperatively, groups had similar stroke and gastrointestinal bleed rates (3% vs. 0% and 2% vs. 0% in the surgical aortic valve replacement vs. no surgical aortic valve replacement group respectively, both p > 0.99). Five-year survival free from severe aortic stenosis was higher in the surgical aortic valve replacement group (66% vs. 17%, p = 0.002). Surgical aortic valve replacement protected against the composite of death and progression to severe aortic stenosis at 5 years (hazard ratio: 0.32, p = 0.003). Surgical aortic valve replacement for moderate aortic stenosis at time of mitral surgery is a well-tolerated strategy to reduce aortic disease progression.

An Overview about Mitral Valve Replacement Surgery Options: Review Article

An Overview about Mitral Valve Replacement Surgery Options: Review Article

A Case of an Unusual Clinical Course of Mitral Stenosis

Background. The stage 4 mitral stenosis is accompanied by atrial fibrillation which significantly worsens the prognosis due to the possibility of thromboembolic complications. However, sinus rhythm does not exclude the possibility of thrombosis which sometimes requires differential diagnosis with heart tumors.&#x0D; The aim. To present a case of unusual thrombus formation in a patient with significant mitral stenosis on the background of sinus rhythm and describe the specifics of determining indications for surgical intervention.&#x0D; Case report. Female patient K., 42 years old, who was admitted on January 12, 2023 to the National Amosov Institute of Cardiovascular Surgery, had been suffering from rheumatism for the past 20 years. In this case, the clinical course of mitral stenosis could be classified as stage 4, since there were signs of severe heart failure (shortness of breath on light exertion, peripheral edema, right-sided pleuritis, pulmonary thrombosis). However, the patient had sinus rhythm, which is more characteristic of the stage 3 mitral stenosis. The patient underwent mitral valve prosthetic surgery and removal of an unusual thrombus from the pulmonary valve cavity on January 23, 2023.&#x0D; Conclusions. The course of mitral stenosis, despite its thorough study, may have unusual clinical and instrumental manifestations, which requires differential diagnosis with heart tumors and other diseases. In some cases, the mechanism of thrombus formation can be extremely unusual, which can be a subject for discussion by cardiologists.

ECMOLIFE intra-hospital transport in life-saving for pulmonary vein obstruction

BackgroundTransport with extracorporeal membrane oxygenation (ECMO) in the hospital setting can become a challenge as well as in the out-of-hospital setting. In particular, the management of intra-hospital transport with ECMO support of the critically ill patient foresees his shift from the intensive care to the diagnostic areas, from the diagnostic areas to the interventional and surgical areas.Case presentationIn this context, we present a life-saving transport case with the veno-venous (VV) configuration of the ECMOLIFE Eurosets system, for right heart and respiratory failure in a 54-year-old woman, due to thrombosed obstruction of the right superior pulmonary vein, following mitral valve repair surgery in minimally invasive approach in a patient already operated on for complex congenital heart disease. After stabilizing the vital parameters with Veno-venous ECMO for 19 h, the patient was transported to hemodynamics for angiography of the pulmonary vessels, where the diagnosis of obstruction of the pulmonary venous return was made. Subsequently, the patient was brought back to the operating room for a procedure of unblocking the right superior pulmonary vein using a minimally invasive approach, passing from the ECMO to the support in extracorporeal circulation.ConclusionsThe transportable ECMOLIFE Eurosets System was safe and effective during transport in maintaining the vital parameters of oxygenation and CO2 reuptake and systemic flow, allowing the patient to be mobilized for diagnostic tests instrumental to diagnosis. The patient was extubated 36 h after the surgical procedures and was discharged 10 days later from the hospital.

TAPSE/PAPS ratio as a predictor of hospital staying in patients affected by severe degenerative mitral regurgitation undergoing mitral valve surgery

Abstract Funding Acknowledgements Type of funding sources: None. Background Chronic severe degenerative mitral regurgitation (DMR) is a progressive disease with a negative impact on prognosis and surgical repair or replacement represents the standard of care. Recently, the coupling between right ventricular (RV) function and the pulmonary circulation (Pc) emerged as a prognostic index in patients undergoing transcatheter edge-to-edge mitral repair. However, the relationship between pulmonary circulatory right ventricular uncoupling and clinical outcomes in patients undergoing surgery for DMR has poorly been investigated. Purpose In a cohort of patients affected by DMR undergoing mitral valve surgery (repair or replacement), we investigated the association between the degree of RV-to-Pc uncoupling, assessed by the ratio between tricuspid annular plane systolic excursion (TAPSE) to pulmonary artery systolic pressure (PAPS), and the time of hospitalization. Methods 389 consecutive patients affected by DMR who underwent mitral surgery (repair or replacement) were retrospectively enrolled. In the pre-operatory phase, all patients underwent a transthoracic echocardiography. The degree of RV-to-PC uncoupling was defined by TAPSE/PASP ratio with a cut-off of 0.4 mm/mmHg and was correlated with the time of hospitalization expressed in days. Results A total of 389 eligible patients (mean age 52±14 y, 65% male, 85% in sinus rhythm) who were admitted for mitral valve surgery at San Raffaele hospital (85% repair, 15% replacement) for hemodynamically significant DMR were retrospectively enrolled from January 2019 to June 2022. Mean hospital stay was 11±8 days. At baseline, only 28% of the cohort exhibited normal left ventricular (LV) and left atrial (LA) size and function, with the majority of the cohort exhibiting increased LA dimension (mean LAVi 49±10 ml/m2). RV to PC coupling was measured before surgery (mean TAPSE/PAPS: 0.8±0.2 mm/mmHg) and only 15% of the cohort had a TAPSE/PAPS≤0.4 mm/mmHg. Interestingly, patients with lower TAPSE/PAPS ratio had longer hospitalization (TAPSE/PAPS≤0.4 mm/mmHg: 15±8.2 days vs TAPSE/PAPS &amp;gt;0.4 mm/mmHg: 11±7.5 days; p = 0.04) and an inverse relationship was found between TAPSE/PAPS values at admission and the length of hospitalization (r=0.4, CI 95% 0.21–0.57; p&amp;lt;0.001; Figure 1). Conclusions In DMR, a strong association was noted between TAPSE/PAPS ratio and length of hospitalization in patients undergoing mitral valve surgery. These data, although preliminary, underline the impact of RV dysfunction and PC uncoupling on clinical outcomes also in the short-term evolution after surgery.

Spontaneous calcific cerebral embolization revealing a calcified rheumatic mitral stenosis: a case report

BackgroundCerebral cardiac embolism accounts for an increasing proportion of ischemic strokes and transient ischemic attacks. Calcified cerebral emboli are rare and mostly iatrogenic secondary to heart or aorta catheterization. However, spontaneous cerebral calcified embolism in the case of calcified aortic valve is very rare and there are less than 10 case reports in the literature. And a more interesting fact is that such an event, in the context of calcified mitral valve disease, has never been reported, at least to our knowledge. We are reporting a case of spontaneous calcified cerebral embolism revealing a calcified rheumatic mitral valve stenosis.Case presentationWe report a case of a 59 year-old Moroccan patient, with a history of rheumatic fever at the age of 14 and no history of recent cardiac intervention or aortic/carotid manipulation, who was admitted to the emergency department after a transient ischemic attack. Physical examination at admission found normal blood pressure of 124/79 mmHg and heart rate of 90 bpm. A 12-lead electrocardiogram showed an atrial fibrillation, no other anomalies. Unenhanced cerebral computed tomography imaging was performed, revealing calcified material inside both middle cerebral arteries. Transthoracic echocardiography was performed, showing severe mitral leaflets calcification with a severe mitral stenosis, probably due to rheumatic heart disease. Cervical arteries Duplex was normal. A vitamin K antagonist (acenocoumarol) was prescribed, targeting an international normalized ratio of 2–3 and mitral valve replacement surgery was performed using mechanical prosthesis. Short- and long-term health, with a 1-year follow-up, were good and the patient did not experience any stroke.ConclusionSpontaneous calcified cerebral emboli secondary to mitral valve leaflet calcifications is an extremely rare condition. Replacement of the valve is the only option to prevent recurrent emboli and outcomes are still to be determined.

Quality of Mitral Valve Surgery Does Not Differ by Hospital Volume in New Jersey

Background and Aim of the Study. To investigate if mitral valve (MV) surgery quality differs by hospital volume in New Jersey (NJ). Methods. Using the NJ State Inpatient Database, patients ≥18 years undergoing MV repair or replacement from 2016–2019 were identified. Centers were considered high-volume if they performed more than 50 mitral operations annually. Baseline characteristics and outcomes (in-hospital mortality, seven-day readmission, hospital length of stay (LOS), and postoperative complications) were evaluated for the population and by center volume. Subanalysis by center volume within each procedure was conducted. Results. Among 2,560 mitral operations, MV replacement (92.3% (n = 2,362)) was performed more often than repair. High- (4) and low-volume (15) centers performed 1,180 (46.1%) and 1,380 (53.9%) mitral surgeries, respectively. Charlson Comorbidity Indices did not differ by center volume, including in subgroup analyses. Low-volume centers had higher rates of Hispanic patients, low-income patients, and readmission rates. High-volume centers had more transfers, urgent/emergent admissions, higher rates of in-hospital mortality, and longer LOS. Postoperative complications did not differ by volume. The MV replacement cohort reflected many of the differences seen in the total population, in addition to seeing higher rates of heart failure at high-volume centers and stroke at low-volume centers. Within MV repairs, significantly more Hispanic patients presented to low-volume centers and high-volume centers had longer LOS. Multivariable analysis indicated that hospital volume was not correlated to in-hospital mortality for the total population and within each procedure. Conclusions. MV replacement is performed more frequently than repair. Hospital volume is not correlated with MV surgical quality, and more representative quality measures are needed.