Mitral Valve Prosthesis Research Articles

Stuck Mitral Valve with Thromboembolic Stroke Managed with Anticoagulation and Mechanical Thrombectomy

Heart valve replacements are commonly performed these days in India with mitral valve replacement being most common of all. Thromboemboli are a major source of morbidity in patients with prosthetic heart valves. The incidence of clinically recognizable events ranges from 0.6% to 2.3% per patient-year. Mechanical valve thrombosis is another common complication, incidence of which is estimated at 0.3% to 1.3% per patient-year in developed countries, but as high as 6% per patient-year in developing countries. Management of either complication in these patients requires adequate knowledge and clinical experience. We here describe a rare case of a patient who came to us with both complication of stuck mitral valve prosthesis and embolic stroke simultaneously. We here discuss the approach, monitoring and management of these patients, the clinical difficulties we faced in our case, immediate and short term prognosis of our patient.

P1521 Prosthetic heart valve-related stroke: a single center experience

Abstract OnBehalf YIG-CVR Introduction Thromboembolic events or bleeding are by far the most frequent complications of prosthetic heart valves. Cerebrovascular stroke is one of the major thromboembolic complications of anticoagulation-related issues of prosthetic heart valves. Aim of the work To determine the pattern and risk factors of acute stroke in patients with prosthetic heart valves. Methods and Patients A retrospective single-center analysis of the database registry of consecutive acute stroke patients with mitral or aortic heart valve prostheses admitted to a tertiary care stroke specialized center from 01/01/2012 to 01/12/2017. All patients were examined by a certified neurologist and underwent a complete work-up evaluation (Computed Tomography or Magnetic Resonance Imaging, Carotid Doppler ultrasound examination, complete blood tests, and electrocardiogram) and a transthoracic echocardiography (TTE) examination as well as transesophageal echocardiography (TOE) if valve dysfunction or thrombosis were suspected. Results 214 patients with mitral or aortic valve prostheses were admitted by acute stroke in the duration from 01/01/2012 to 01/12/2017 with a mean age of 44 ± 15 years, 132 were males (61.7%) and 178 patients had mechanical valves (83.2%). 135 patients had mitral prosthesis (63.1%) and ischemic stroke was encountered in 151 patients (70.6%). Conclusion In a single center experience, mechanical prosthesis at the mitral valve position was associated with higher incidence of ischemic stroke. Proper close follow-up of INR levels as well as the surgical shift to biological instead of mechanical valve should decrease significantly the incidence of prosthetic valve related strokes. Baseline, clinical and other parameters Patients (n = 214) Age (years) 44 ± 15 Mechanical valve 178 (83.2%) Atrial Fibrillation 101 (47.2%) Rheumatic Heart Disease 175 (81.8%) Left ventricular ejection fraction (%) 54 ±13 Mitral Only 135 (63.1%) Aortic Only 51 (23.8%) Double Valve Prosthesis 28 (13.1%) Ischemic stroke 151 (70.6%) Hemorrhagic stroke 47 (22%) Both ischemic and hemorrhagic stroke 16 (7.4%) Data are represented as mean(±SD) or number (Percentage) Abstract P1521 Figure. Valve sites

P1720 Hammock mitral valve, a challenging echocardiographic diagnosis

Abstract We report a 43 year-old female with a past TTE echocardiography of rheumatic valve disease performed in her district hospital , ( No clear symptomatology of rheumatic fever in the past). She was transferred to our tertiary hospital for elective cardiac surgery. Preoperative echocardiogram showed a non-dilated left ventricle with preserved contractility, mild-moderate left atrium enlargement with severe mitral regurgitation and basal displacement of papillary muscles and severe tricuspid regurgitation.All of it resembling a hammock mitral valve instead of former echocardiogram described as rheumatic valve disease. Preoperative cardiac study showed severe pulmonary hypertension with increased pulmonary vascular resistances. Preserved biventricular cardiac output and increased proto and telesystolic pressures. During surgery , ifindings were described as a mitral valve with a large papillary muscle inserted in the distal third of the left ventricle with none tendinous cords at the anterior leaflet and without cords in the posterior leaflet with an isolated papillary muscle with cords at A3 and P3 scallops, compatible with hammock mitral valve. A tendinous muscle/fibrous or fibromuscular band connecting the septum to the posterior wall of the left ventricle was described. Moreover over, there was an enlarged tricuspid ring with very short tendinous cords on the septal leaflet, although the leaflet was bigger than usual. Surgery consisted of resection of the mitral valve preserving A3 and P3 scallops with a 29mm Bicarbon Sorin mechanical mitral prosthesis and a 32mm Carpentier tricuspid ring implantation and pulmonary veins ablation combined with occlusion of left atrial appendage. After 112 minutes of cross-clamping time, the patient was weaned from cardiopulmonary bypass. She had important left ventricle dysfunction which improved with dobutamine and AAI pacemaker at 90lpm. Postoperative TEE showed moderate dysfunction of right ventricle, mild left ventricular dysfunction, moderate tricuspid regurgitation and a good functioning of the prosthesis. TTE before discharge showed good function of mitral valve prosthesis, good left ventricle function, mild tricuspid regurgitation, mild-moderate right ventricular enlargement, although less than preoperatively. Conclusion Congenital mitral valulophaty is a rare condition in the adulthood. The estimated prevalence is 0,5%. The hammock mitral valve is a more uncommon pathology which affects the mitral valve and subvalvular apparatus. This anomaly, was first described in 1967 and it is characterised by anomalous papillary muscles directly connected to the anterior mitral valve by a fibrous bridge without chordae tendineae in between them. This fibrous bridge hampers the opening and closure of the mitral valve. Diagnosis requires a high index of suspicion, both ultrasound studies and medical history, to avoid misdiagnosis. Abstract P1720 Figure.

505 Car accident, an unusual cause of acute severe mitral regurgitation due to anterolateral papillary muscle rupture

Abstract A 52-year-old man was admitted to the emergency department of the University Hospital after being involved in a car crash. At first he was alert with stable vital parameters. There was bilateral rales on lung auscultation, without further prominent aberrant findings at the initial clinical examination. Shortly after, he became agitated with respiratory distress, resulting into respiratory insufficiency. Computed tomography (CT) scan of the thorax showed multiple rib fractures, a translated sternal fracture and pulmonary contusion. After intubation and stabilization he was transferred to the Intensive Care Unit (ICU), where his respiratory and cardiovascular parameters progressively worsened, leading to cardiogenic shock. An urgent chest X-ray revealed a tension pneumothorax with mediastinal shift to the right, for which a chest tube was inserted in the left hemithorax. No or little improvement was seen after this intervention. Therefore, an emergency transthoracic echocardiography (TTE) was performed. Subcostal view showed a severe mitral regurgitation with a mass in the left atrium. Because of a limited transthoracic window, we proceeded to a transoesophageal echocardiogram (TEE). A completely ruptured anterolateral papillary muscle of the mitral valve was seen, protruding in the left atrium and resulting in severe mitral regurgitation (Figure). Other echocardiographic findings were a hyperdynamic systolic function of the left ventricle, a hypo-contractile right ventricle with a mild-to-moderate quantity of pericardial effusion. Taking into account the increased cardiovascular risk profile of the patient, a coronary angiography was performed and showed normal coronary anatomy. Consequently, urgent surgical intervention was performed. Perioperative assessment confirmed the earlier described echocardiographic findings. Due to severe laceration of the left ventricular wall at the level of the attachment site of the anterolateral papillary muscle, reconstructive surgery was not possible. The anterolateral papillary muscle head with the attached mitral valve leaflet was fully excised with repair of the concealed myocardial rupture site. A mechanical mitral valve prosthesis and an intra-aortic balloon pump for hemodynamic support were placed. After four days the balloon pump was removed and the tenth day after admission the patient was extubated. Conclusion Acute severe mitral regurgitation due to papillary muscle rupture is a rare but potential fatal complication of a blunt trauma. TOE is essential in early diagnosis. Abstract 505 Figure 1

P1251 Percutaneous closure of two mitral perivalvular leaks: when the imaging guides the hands during threatening complications

Abstract With the contemporary development of structural interventional cardiology the prevalence of perivalvular leaks (PVL) is expected to grow. Advanced multimodality imaging is necessary for the guidance of transcatheter closure of PVL. We describe the case of a 57 year-old woman who underwent transcatheter mitral PVL closure. Past clinical history included a lymphoma treated with chemio and radiotherapy. Six months before she underwent a surgical replacement of the aortic and mitral valves with two mechanical prosthesis for severe aortic and mitral stenosis. Because of the calcium burden in both the annuluses, undersized mitral valve prosthesis was implanted leading to the presence of two moderate mitral PVL. The patient subsequently required hospitalization for acute HF and hemolytic anemia and received multiple blood transfusions. TEE confirmed the presence of a large antero-lateral PVL and a small medial PVL (3D VCA 0,32 cm2 and 0,2 cm2 respectively, associated with reverse flow in the pulmonary veins) with an extension of 33% of the circumference of the prosthesis. The regurgitation was considered severe and a percutaneous closure was planned with 3D-TEE and fluoroscopy image fusion guidance. Under general anesthesia a transeptal puncture was performed and the medial leak was closed with two vascular plugs (6mm each). During the deployment of the plugs an intermittent blockage of the medial disk of the prosthesis was noticed, which resolved completely after the removal of the wires previously positioned for the engagement of the leak. The lateral leak was then engaged and a second plug (10mm) was advanced causing a discontinuous interference with the two disks. The direct interference with the lateral disk caused a blockage in the closing position (leading to moderate stenosis, medium gradient 7mmHg) and in the opening position (leading to a massive regurgitation). The medial disk was intermittently blocked in the closing position due to the bulky effect of the devices provoking a traction and displacement of the prosthesis towards the medial region of the valve. To avoid this interference the plug was released with a marked atrial protrusion. Notably, after the removal of the wires no malfunctioning of the disks was noticed and the mild residual shunts appeared further decreased. The procedure was considered successful and at follow-up no residual leak was found. The percutaneous closure of PVL is a safe and effective intervention. Multimodality imaging is essential for the diagnosis, planning and procedural guidance. The knowledge of possible complications is warranted for the achievement of an optimal result. This case clearly show the possibility of interference with the prosthesis and overestimation of residual leaks. Abstract P1251 Figure. PVL closure:procedure and complications

P1458 Recurrent endocarditis on mitral valve prosthesis

Abstract Patient Presentation and initial work up A 72 years old man with history of hypertension was admitted to our hospital due to acute pulmonary oedema. He had no fever at that time and he had an history of known mitral valve prolapse but with no reported mitral valve regurgitation (MR). Transthoracic Echocardiogram (TTE) was performed and it showed a severe MR. Transesophageal echocardiogram (TOE) showed prolapse of the posterior leaflet of the mitral valve with suspicion of cordal rupture and the presence of an aneurysm of the anterior mitral valve leaflet with perforation of it (panel A and B). Diagnosis and Management Diagnosis of severe MR as the result of previous endocarditis was made. Blood cultures were negative, as well as there were no signs of active endocarditis. However, since there were heart failure and signs of uncontrolled infection, the patient underwent surgical mitral valve replacement (MVR) with bioprosthesis. Moreover, it was started antibiotic therapy with vancomycin, rifampin and ceftriaxone, which was continued for two weeks and then stopped since the microbiological culture of the valve was negative. Follow-up After two months he was re-admitted to the hospital due to a new onset of breathlessness. TTE showed a dehiscence of the mitral prosthetic valve in the inferolateral zone with rocking movement, subvalvular pseudoaneurysm and moderate paravalvular leak (panel C and D). Blood cultures were positive for Staphylococcus Aureus. Consequently, the patient underwent a new surgical MVR. Furthermore, six weeks of antibiotic therapy were carried out with daptomycin and rifampin. However, after another three months, he was admitted once again to the hospital for heart failure with a new evidence of abruption of the mitral prosthesis, again in the inferolateral region and, this time, with the evidence of a vegetation on the atrial side of the prosthesis (panel E and F). Again, blood cultures were positive for Staphylococcus Aureus, and the patient underwent the third surgical intervention of MVR. Another six weeks of antibiotic therapy with daptomycin and rifampin were performed. The patient was then discharged and he is now strictly followed clinically. Conclusion In conclusion, we reported the case of a recurrent relapse of endocarditis on mitral valve prosthesis due to Staphylococcus Aureus infection. Interestingly, the mitral prosthesis was involved always in the same zone (inferolateral area) with abruption of the prosthesis and significant paravalvular regurgitation. At the second relapse there was also a vegetation on it and both times blood cultures were positive. Moreover, antibiotic therapy was conducted for six weeks both times, but the recurrence of endocarditis showed us that he was a sensitive patient and that in cases of relapses like this it should be performed a more careful clinical follow up, involving frequent laboratory tests and clinical and echocardiographic evaluations. Abstract P1458 Figure.

The dilatation factor of left atrium in remote period after the mitral valve prosthesis

Objective. Studying of the morphometry indices and contractility of the heart left compartments in the left atrium reduction after prosthesis of a mitral valve.
 Materials and methods. Into the investigation 634 consequently operated patients with isolated mitral failure were included, who were surgically treated in Amosov National Institute of Cardiovascular Surgery from the 1st of January to the 1st of January 2007 yr. In all the patients the mitral valve prosthesis was performed. In the left atrium dilatation in 49 (7.7%) patients additionally its reduction was done, using paraanular plication of posterior wall of left atrium with the aim to achieve its size lesser than 5,0 cm.
 Results. Of 49 patients, suffering constant form of atrial fibrillation, thromboembolic complications have occurred in 3 (6.1%) while performance of paraanular plasty of left atrium with simultaneous elimination of its auricle. All thromboembolic complications were nonsevere, and a left atrium size did not exceeded 5.5 sm.
 Conclusion. The left atrium reduction and elimination of its auricle in the left-sided atriomegaly constitutes a significant element of the result improvement in the mitral valve prosthesis in late period of follow-up.

Transfemoral transcatheter aortic valve replacement in the presence of a mitral prosthesis.

In the current case series, we present our experience with the self-expanding CoreValve or Evolut R (Medtronic Inc.) in patients with severe symptomatic aortic valve stenosis and concomitant mitral valve prosthesis. Twelve patients with previous mitral valve prosthesis underwent transcatheter aortic valve replacement for severe symptomatic aortic valve stenosis and/or aortic valve regurgitation. All patients underwent evaluation with an echocardiogram, computed tomography and coronary angiogram. After the index intervention and before discharge all patients underwent transthoracic echocardiography. All outcomes were defined according to the Valve Academic Research Consortium-2 criteria. Eleven patients underwent transcatheter aortic valve replacement for severe symptomatic aortic valve stenosis and one patient for severe aortic valve regurgitation. There was immediate improvement of patients' hemodynamic status; no cases of procedural death, stroke, myocardial infarction, or urgent cardiac surgery occurred. There was no 30-day mortality and all patients improved, with 91.6% in functional New York Heart Association class I-II. The current study demonstrates that in patients with severe aortic valve stenosis or regurgitation and mitral valve prosthesis, the implantation of a self-expanding aortic valve via the transfemoral route is safe and feasible, with maintained long-term results.

Predicting the outcome of transcatheter mitral valve implantation using image-based computational models

BackgroundThe appropriate placement and size selection of mitral prostheses in transcatheter mitral valve implantation (TMVI) is critical, as encroachment on the left ventricular outflow tract (LVOT) may lead to flow obstruction. Recent advances in computed tomography (CT) can be employed for pre-procedural planning of mitral prosthetic valve placement. This study aims to develop patient-specific computational fluid dynamics models of the left ventricle (LV) in the presence of a mitral valve prosthesis to investigate blood flow and LVOT pressure gradient during systole. MethodsPatient-specific computational fluid dynamics simulations of TMVI with varied cardiac anatomy and insertion angles were performed (n = 30). Wide-volume full cycle cardiovascular CT images prior to TMVI were used as source anatomical data (n = 6 patients). Blood movement was governed by Navier-Stokes equations and the LV endocardial wall deformation was derived from each patient's CT images. ResultsThe computed pressure gradients in the presence of the mitral prosthesis compared well with clinically measured gradients. Analysis of the effects of prosthetic valve angulation, aorto-mitral annular angle, ejection fraction, LV size and new LVOT area (neo-LVOT) after TMVI in silico revealed that the neo-LVOT area (p < 0.001) was the most significant factor affecting LVOT pressure gradient. Angulation of the mitral valve can substantially mitigate LVOT gradient. ConclusionsComputational fluid dynamics simulation is a promising method to aid in pre-TMVI planning and understanding the factors underlying LVOT obstruction.

P3663Prevalence of infective endocarditis in patients with a left-sided heart valve prosthesis: a nationwide study

Abstract Background Increasing attention has been given to patients with blood stream infection (BSI) and the concurrent prevalence of infective endocarditis (IE). However, there exist a gap in knowledge on the prevalence of IE among patients with a left-sided heart valve prosthesis and BSI. Purpose To examine the prevalence between different BSI and IE in patients with a left-sided heart valve prosthesis. Methods By linking Danish nationwide registries, we were able to identify patients with a left-sided prosthetic heart valve and first-time BSI of interest (Enterococcus faecalis, Staphylococcsus aureus, streptococci species (spp.), and coagulase negative staphylococci [CoNS]) in the period of 2010–2016. Concurrent admission for IE was identified from the Danish National Patient Registry in a period of up to 14 days after the BSI. Results A total of 1,465 patients with BSI were included (1,319 patients with an aortic valve prosthesis [82.6% bioprosthetic] and 146 patients with a mitral valve prosthesis [48.6% bioprosthetic]). Among the included patients, 244 had E. faecalis (median age: 78.3 years, 77.0% male), 301 had S. aureus (median age: 76.9 years, 69.1% male), 401 had streptococci spp. (median age: 78.0 years, 69.1% male) and 519 had CoNS (median age: 76.4 years, 64.2% male). The percentage of patients with a diagnosis of IE in relation to the BSI was 44.3%, 33.6%, 34.4%, and 7.9% for E. faecalis, S. aureus, streptococci spp., and CoNS, respectively. No difference in the overall results was seen by type of valve prosthesis, sex, or age group. Percentage of patients with endocarditis Conclusion In patients with a left-sided heart valve prosthesis, IE was diagnosed in almost half of the patients with E. faecalis, in 1/3 with S. aureus or streptococci spp. and in 1 in 12 with CoNS BSI. Future studies may try to explain why some microbes are more likely to cause prosthetic heart valve endocarditis, than others are.

P1484Exploring the grey zone of E/e' ratio: does left atrial strain help?

Abstract Background The combination of early trans-mitral inflow and mitral annular tissue Doppler velocities (E/e' ratio) is widely applied to noninvasively estimate left ventricular (LV) filling pressures. However E/e' ratio has a significant gray zone that restrict its accuracy and left atrial (LA) deformation analysis by speckle tracking echocardiography (STE) was recently proposed as an alternative approach to estimate LV filling pressures, but the clinical application of LA strain in the subgroup of patients with E/E' between 8 and 14 has been under-investigated. Aims This study aimed to analyze the role of LA longitudinal function by STE (PALS) to estimate intra-cardiac pressures as assessed by systolic pulmonary artery pressure (sPAP), measured by Doppler, specifically in patients with an E/e' ratio &gt;8 and ≤14. Methods We enrolled 142 consecutive, non-selected patients, referred to our echocardiography laboratory for a comprehensive transthoracic echocardiography. Exclusion criteria were: organic mitral valve disease or prosthesis and presence of disease possibly associated with pre-capillary pulmonary hypertension. Particular care was used for accurate measurement of maximal tricuspid regurgitation velocity and of right atrial pressure and consequently sPAP estimation. PALS values were obtained by averaging all segments, and by separately averaging segments measured in the 4-chamber and 2-chamber views. Results Seventy-four patients (52% of total) showed an E/e' ratio &gt;8 and ≤14, with the following characteristics: mean age 65.5±11.9 years, LVEF 54.5±11.2, E/e' 11.2±1.9, sPAP 33±7 mmHg, PALS 31.6±11.7%. A negative correlation between PALS and sPAP was found (r=−0.55, p&lt;0.0001). From receiver operating characteristic (ROC) curves, PALS demonstrated a high diagnostic accuracy (AUC 0.78 (95% CI: 66%–90%)); the cutoff value of 23% showed an excellent specificity of 90% with a sensibility of 60%, to predict sPAP higher than 35 mmHg. Correlation between sPAP and PALS Conclusions LA function measured by STE is a simple parameter able to predict increased intra-cardiac pressure even in the intermediate E/E' group. This parameters might help in improving the diagnostic algorithm of diastolic function.

Novel Transcatheter Mitral Valve Prosthesis for Patients With Severe Mitral Annular Calcification

BackgroundTreatment of mitral regurgitation (MR) in the setting of severe mitral annular calcification (MAC) is challenging due to the high risk for fatal atrioventricular groove disruption and significant paravalvular leak. ObjectivesThe objective of this study was to evaluate the potential for transcatheter mitral valve replacement in patients with severe MAC using an anatomically designed mitral prosthesis. MethodsNine patients (77 ± 6 years of age; 5 men) were treated with the valve, using transapical delivery performed under general anesthesia and with guidance from transesophageal echocardiography and fluoroscopy. ResultsDevice implantation was successful with relief of MR in all 9 patients. There were no procedural deaths. In 1 patient, left ventricular outflow tract obstruction occurred due to malrotation of the prosthesis, and successful alcohol septal ablation was performed. During a median follow-up of 12 months (range 1 to 28 months), there was 1 cardiac death, 1 noncardiac death, no other mortality, and no prosthetic dysfunction, and MR remained absent in all treated patients. Rehospitalization for heart failure occurred in 2 patients who did not die subsequently. Clinical improvement with mild or no symptoms occurred in all patients alive at the end of follow-up. ConclusionsTranscatheter mitral valve replacement in severe mitral annular calcification with a dedicated prosthesis is feasible and can result in MR relief with symptom improvement. Further evaluation of this approach for these high-risk patients is warranted.

Tricuspid Valve Ring Annuloplasty in a Patient with 36-year &lt;i&gt;in-situ&lt;/i&gt; Functioning Bjork-Shiley Valve in Mitral Position

The Bjork-Shiley valve (BSV) was one of the first tilting disc valve prosthesis used. We report a patient with a still functioning BS mitral valve prosthesis implanted and required a redo surgery for tricuspid valve regurgitation.

A case of non-invasive topical diagnostics with successful ablation during persistent atrial fibrillation

Treatment of persistent and long-persistent forms of atrial fibrillation remains a pressing issue. Using a personalized approach can help to more successfully eliminate arrhythmias and reduce the return probability. One of these approaches is the use of radiofrequency ablation in conjunction with modern high-tech research methods. The article describes a clinical case of successful catheter ablation of persistent atrial fibrillation in a patient with a mechanical mitral valve prosthesis, due to the use of non-invasive topical diagnostics prior to surgery.

Prognostic role of diastolic dysfunction in patients undergoing transcatheter aortic valve replacement.

Prior studies have shown that left ventricular diastolic dysfunction (DD) is associated with increased mortality after surgical aortic valve replacement but studies on transcatheter aortic valve replacement (TAVR) are limited and have not taken into account mitral annular calcification (MAC), which limits the use of mitral valve annular tissue Doppler imaging. We performed a single-center retrospective analysis to better evaluate the role of baseline DD on outcomes after TAVR. After excluding patients with atrial fibrillation, mitral valve prostheses and significant mitral stenosis, 359 consecutive TAVR patients were included in the study. Moderate-to-severe MAC was present in 58% of the patients. We classified patients into severe versus nonsevere DD based on the evaluation of elevated left ventricular filling pressure. The outcome measure was all-cause mortality or heart failure hospitalization. Over a mean follow-up time of 13 months, severe DD was associated with an increased risk for the outcome measure (HR 2.02 [1.23-3.30], p = .005). However, this association was lost in a propensity-matched cohort. In multivariate analysis, STS score was the only independent predictor of all cause mortality of heart failure hospitalization (HR 1.1 [1.05-1.15], p < .001). We evaluated the role of baseline DD on outcomes after TAVR by taking into account the presence of MAC. Severe DD was associated with increased all-cause mortality or heart failure hospitalization but not independently of other structural parameters and known predictors of the outcome measure.

Warfarin induced leukocytoclastic vasculitis: an extraordinary side effect

Warfarin is one of the most commonly used anticoagulants in the management of thromboembolic events. Herein we report a rare case of warfarin induced leukocytoclastic vasculitis in a patient with history of rheumatic heart disease and a mechanical mitral valve prosthesis who presented with heart failure and palpable purpura. Upon clinical suspicion of cutaneous small vessel vasculitis, a comprehensive laboratory panel was performed. Warfarin induced vasculitis was suspected when withdrawal of warfarin, due to rising INR, led to improvement of the skin lesions. The diagnosis was finally confirmed when re-instatement of warfarin reproduced the skin lesions and a skin biopsy showed evidence for leukocytoclastic vasculitis with eosinophilic infiltration. A third of cases of leukocytoclastic vasculitis are due to drug hypersensitivity which being a diagnosis of exclusion with varying manifestations, requires a high index of clinical suspicion. Since drug induced leukocytoclastic vasculitis may affect multiple organ systems and even cause mortality, clinicians must be aware of this rare adverse event, promptly discontinue the drug, and commence anti-inflammatory or immunosuppressive treatment when necessary.

The Golden Proportion in the scallop geometry of normal mitral valves. When nature plays with jigsaw puzzles.

The Golden Proportion is a particular geometric ratio between two segments. It results in an irrational number, commonly rounded to 1.618, or 0.618, and showing unique geometrical/mathematical properties. Its presence has been documented in a huge amount of natural settings, as well as the human body and the heart. In light of a previous research of ours, about its presence in the Coaptation Triangle, we investigated the dimensions of both mitral leaflets in healthy mitral valves and then compared our results to literature data, in order to search whether this proportional pattern could be extended to other valve aspects. Forty-one adults, with healthy mitral valves, underwent 2D echocardiography. Adequate long-axis three-chamber view images were chosen, at mid-diastole, where the central scallop of both the anterior and posterior leaflets (A2 and P2, respectively) could be well identified and measured. We then investigated these measurements, calculating their ratio and comparing our findings to literature data on normal mitral anatomy. The ratio between the two scallop heights appeared very close to the Golden Ratio. Literature data supported our results and, apparently, showed the mitral leaflets to be like a jigsaw puzzle of components highly interconnected each other with an extremely simple geometry, based on the Golden Proportion. The Golden Proportion looks to determine the geometry of normal mitral scallops. Studying such a pattern of anatomical proportions could improve surgical techniques for conservative surgery, as well as innovate the design of mitral repair rings and valve prostheses.

The levels of markers of the myocardium damage and state of the oxygen budget in patients, suffering the mitral valve insufficiency in surgical correction, using crystalloid cardioplegia

Objective. Аnalysis of levels of the myocardium damage markers and state of the oxygen budget in patients, suffering the mitral valve insufficiency, in surgical correction, using crystalloid cardioplegia, was performed.&#x0D; Маterials and methods. There were examined 40 patients, suffering the mitral valve insufficiency and ageing (56.2 ± 4.5) yrs old, admitted to the Institute of the Heart MH of Ukraine for surgical correction of the failure. The therapy and operative intervention, the mitral valve prosthesis, were conducted in the patients in accordance to actual local protocol of intraoperative cardioprotection, using the crystalloid cardioplegia (Bretschtider’s solution). The markers levels, concerning the myocardium affection (troponin I, sodiumuretic peptide, alaninaminotranspherase, aspartataminotransphefase, creatinphosphokinase, МВ fraction of creatinephosphokinase), indices of the oxygen budget (hemoglobin, hematocrit, hemoglobin saturation by oxygen in arterial and venous blood, partial pressure of oxygen in arterial and venous blood, lactate) were performed in the patients while exit from perfusion, before admittance to the Department of Intensive Therapy and discharge from it. There were calculated: the ratio of creatinephosphokinase-MB towards creatinephosphokinase, аrterio-venous difference of hemoglobin saturation by the oxygen, content of oxygen in arterial and venous blood, transport, consumption of oxygen and coefficient of the oxygen extraction by the tissues.&#x0D; Results. The levels of markers investigated, concerning affection of myocardium in the patients, did not exceeded the norm range, while statistically significant dynamics was registered only for concentration of sodiumuretic peptide and ratio of creatinephosphokinase-MB towards creatinephosphokinase. The indices of hemic chain of the oxygen transport trustworthily lowered while exit from perfusion only. Тhe oxygen transport and consumption after the failure correction have reduced trustworthily, while coefficient of the oxygen extraction by the tissues did not change essentially. Arterio-venous difference for the oxygen content have reduced trustworthily, but on this background the lactate level have raised significantly.&#x0D; Conclusion. The levels of markers studied, concerning the myocardium damage, did not differ during the investigation course essentially, what witnesses satisfactory state of myocardium.

Outcome of Patients Undergoing Transcatheter Implantation of Aortic Valve With Previous Mitral Valve Prosthesis (OPTIMAL) Study

BackgroundTranscatheter aortic valve replacement (TAVR) is the gold standard for severe valvular aortic stenosis in patients at high/prohibitive surgical risk. This procedure has also been used in patients with previous mitral valve (MV) prostheses, with contrasting outcomes reported. The aim of this study is to describe procedural and early outcomes of patients with previous MV prostheses undergoing TAVR. MethodsThis is a retrospective registry of 154 patients with previous MV prostheses who underwent TAVR across high-volume medical centres at a mean of 11.7 ± 8.4 years after mitral surgery. ResultsMean mitroaortic distance at computed tomography was 9.7 ± 4.8 mm. Procedural success was achieved in 150 (97.4%) patients, with reduction of aortic gradients (42.6 ± 14.2 to 10.0 ± 7.0 mm Hg; P < 0.001). Device success was achieved in 133 (86.3%) patients. MV prosthesis interference by the TAVR device was observed in 2 patients; in both, the mitroaortic distance was <5 mm, with 1 complicated by TAVR prosthesis embolization. Periprocedural complications included 4 (2.6%) cerebrovascular accidents, 10 (6.6%) major vascular complications, 22 (14.4%) severe bleedings, 1 (0.7%) myocardial infarction, and 5 (3.2%) in-hospital deaths (all cases cardiovascular or procedure related). At a median follow-up of 13.5 (interquartile range 1.0 to 36.0) months, 26 (16.9%) deaths occurred; 15 (9.7%) were cardiac related. Late fatal mitral prosthesis thromboses occurred in 2 patients. We recorded a case of fatal hemorrhagic stroke; hospital readmission was observed in 25 (16.2%) patients due to worsening heart failure. ConclusionsTAVR in patients with previous mitral prostheses appears to be safe and feasible, with good hemodynamic results at 30-day and at longer-term follow-up.

Analysis of length of hospital stay after Transfemoral Transcatheter Aortic Valve Implantation: Results from the FRANCE TAVI (FRench Transcatheter Aortic Valve Implantation) Registry

Transcatheter aortic valve implantation (TAVI) is playing a growing role in the management of patients with symptomatic severe aortic stenosis. However, length of hospital stay (LOS) after transfemoral (TF) TAVI remains widely variable. We aimed to evaluate LOS after TF TAVI and the variability of LOS among French centers using data from the FRANCE TAVI registry. TAVI was performed in 12,804 patients in 48 French centers between January 2013 and December 2015. LOS was evaluated in 5,857 (45.7%) patients treated via a TF approach and discharged directly at home. LOS was calculated from TAVI procedure (day 0) to discharge. The study population was divided into 2 groups based on tertile LOS values. The median LOS in the studied population was 7 (5–9) days and was extremely variable among centers. Patients in the lowest tertile (LOS < 6 days, n = 2,233) constituted the “Early Discharge” group, and patients with a length of stay > 6 days ( n = 3,624) constituted the “Late Discharge group”. Variables independently associated with late discharge were comorbidities (history of mitral valve prosthesis, respiratory failure, atrial fibrillation, and severe pulmonary hypertension), complications occurring during or after TAVI (need for a new pacemaker, tamponade, stroke, vascular complications and acute kidney injury), the use of self-expandable valve and general anesthesia with a significant center effect. In contrast, the history of previous pacemaker before TAVI was a protective factor. Finally, we did not observe any significant difference in the rate of death and re-admission in the early versus late discharge groups. LOS remain high after TF TAVI in France and extremely variable. As expected, co-morbidities and complications were predictive factors of late discharge after TAVI. Furthermore, our results suggest that the use of self-expandable prosthesis and general anesthesia also contributes to late discharge.