Mitral Valve Prosthesis Research Articles

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Cardioembolic Stroke Due to Prosthetic Valve Endocarditis Caused by Candida parapsilosis: A Case Report

Embolic stroke due to prosthetic valve endocarditis (PVE) caused by Candida parapsilosis is a rare and serious complication. Successful management requires a combination of medical and surgical approaches. We present a case full of complexities in diagnosing and managing Candida PVE, emphasizing the importance of a multidisciplinary approach. A 50 year‐old male presented to the emergency department with vertigo and low‐grade fever and was found to have cerebellar stroke likely from the cardioembolic origin, and the patient had a history of uncontrolled diabetes and double prosthetic valves. The diagnosis was challenging and required transesophageal echocardiography (TEE) which showed two vegetations attached to the mitral valve prosthesis. The management involved antifungal therapy, but surgery was hindered by financial issues. The patient was considered for the AngioVac vegetation aspiration system due to persistent fungemia. Eventually, surgery was not performed, and the patient was discharged with a plan for long‐term suppressive antifungal therapy.

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

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

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

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

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

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

Mitral regurgitation decreases over time after successful thoracoscopic ablation, a subanalysis of a prospective cohort study

Abstract Background Patients with atrial fibrillation (AF) often present with mitral regurgitation (MR) without significant changes in the morphology of the valve leaflets. Even though these patients are at increased risk of developing and maintaining AF, concomitant mitral valve surgery still exclusively occurs in the setting of severe MR. The interplay between AF and MR is incompletely understood, particularly it has not been established how ablation of AF affects the grade of MR. We hypothesized that successful TA decreases the grade of MR. Purpose We aimed to to explore the course of MR severity after TA in patients with AF. Methods We performed a subanalysis of the MARK-AF registry, a single-arm single-center prospective cohort study on patients with paroxysmal and persistent AF undergoing thoracoscopic pulmonary vein isolation. Those with persistent AF were also treated with a roof and trigone line. All patients within this cohort without a history of morphological MR, prior mitral valve prosthesis and left ventricular ejection fraction (LVEF) &amp;lt;30% who underwent TA between January 2016-January 2022 were included. Transthoracic echocardiography (TTE) was performed 1 month preoperatively and at 6-9 months post-operatively. MR was graded ordinally 1-4 (1:None/Trivial, 2:Mild, 3:Moderate, 4:Severe). Successful TA was defined as absence of ≥1 episodes of AF, atrial flutter or atrial tachycardia lasting &amp;gt;30s on electrocardiogram or 24-hour Holter monitoring after a blanking period of 90 days, which were performed at 3, 6, and 12 months post-operatively. Results Of the 283 patients, 31 were excluded. The remaining 252 patients were on average 64 years old (IQR 49-71), 25% were women, and 75% had persistent AF. The median duration between AF diagnosis and TA was 4 years (IQR 2.2-8.0) and the median left atrial volume index (LAVI) 42.5 ml/m2 (IQR 35.1-50.7). Between baseline and follow-up, the median LAVI decreased from 43.5 (IQR 35-50) to 38.7(IQR 32-47) p&amp;lt;0.001, MR grade improved in 33% of patients by at least one grade, and worsened in 17%. In total, 70% of patients had no AF recurrences during follow-up of 12 months. 34% of patients with a successful TA improved in MR grade during follow-up, versus 26% after a failed TA. Mean MR grade improved after successful TA (2.22 ±1.01 versus 1.60± 1.4 p&amp;lt;0.001). MR improved less in patients with AF recurrence (2.13± 1.1 versus 1.80± 1.38 P=0.016). 40% of the patients with MR worsening had AF recurrence versus 23% in whom MR improved. In multivariable ordinal regression analysis, age &amp;lt;65 years and AF recurrence were negative predictors of MR grade at follow-up (OR 4.45: 95%CI 3.432–5.468 p=0.003and 3.83: 95%CI: 2.750–5.090 p=0.040, respectively). Conclusion Successful TA is associated with more MR grade improvement. More AF recurrence is observed in patients whose MR grade aggravates. Whether MR improvement relates to restoration of sinus rhythm or to a smaller left atrium, remains to be investigated.

Abstract 16659: Neo LVOT Prediction With the Innovalve TMVR System - CT Preliminary Results

Introduction: The Innovalve TMVR is a novel self-expandable trans-catheter mitral valve prosthesis, delivered trans-septally using femoral venous access. It is deployed in an intra-valvular posterior position after sub-valvular anchoring by rotation of 6 circumferential arms. LV outflow tract (LVOT) compromise is of great concern in TMVR. A predicted Neo LVOT area of 170 mm 2 is the currently accepted cut-off for LVOT obstruction. Hypothesis: CT can accurately predict the Neo LVOT area prior to Innovalve TMVR procedure. Methods: CT was performed as a screening tool to evaluate the Neo LVOT area prior to Innovalve TMVR procedure. CT protocol: Retrospectively ECG gated with full cardiac cycle coverage. CT was performed before and after the procedure. Predicted Neo LVOT (pNLVOT) was calculated using a dedicated simulation valve prior to TMVR, actual Neo LVOT (aNLVOT) was calculated with the inserted valve in place following TMVR. The native LVOT (nLVOT) area, the predicted % LVOT reduction (nLVOT area-pNLVOT area /nLVOT area), the actual % LVOT reduction (nLVOT area-aNLVOT area /nLVOT area) and the difference between them (pNLVOT%-aNLVOT%) were calculated. Results: One hundred patients were screened for Innovalve TMVR procedure based on Neo LVOT criteria. pNLVOT≥ 170 mm 2 was found in 11 patients (11%), (7 males) average age 68±10 years, these patients underwent Innovalve TMVR procedure. The median calculated LVOT was 647.8+/-260 mm 2 (range 373-1312), the median pNLVOT reduction was 16% ±15 (range 3-53), the median aNLVOT reduction was 5%±14 (range -5-40) and the median difference between the pNLVOT and aNLVOT was 8±12 (range -4-31). In 8/11 patients (73%), the aNLVOT was larger than the pNLVOT (range difference 1 to 31%). In 3/11 patients (27%), the aNLVOT was smaller than the pNLVOT (range difference -1 to -4%). Conclusions: Underestimation of neoLVOT reduction, was uncommon and documented only minor and clinically insignificant difference between the pNLVOT and aNLVOT. As overestimation of NLVOT reduction allows a margin of safety for MTVR, we conclude that CT can serve as reliable NLVOT screening tool.

Abstract 16590: Left Ventricular Remodelling Following Transcatheter Mitral Valve Replacement With the Innovalve System

Introduction: Transcatheter Mitral Valve Replacement (TMVR) using a trans-septal approach is a new therapeutic option for patients with severe mitral regurgitation (MR). However, both surgical as well as currently under-testing trans-catheter approach, are shown to cause decrease in LV function. The Innovalve TMVR is a novel self-expandable transcatheter mitral valve prosthesis, delivered trans-septally using femoral venous access. It is deployed in an intravalvular posterior position after subvalvular anchoring by rotation of 6 circumferential arms Hypothesis: TMVR procedure (Innovalve system) leads to LV anatomical and functional changes Methods: CT was performed before the Innovalve TMVR procedure, and after 3 to 6 months. CT protocol included retrospective ECG gating with full cardiac cycle coverage. LV end diastolic and end systolic diameters (LVEDD, LVESD) were measured in the left ventricular outflow tract orientation at the most basal level. Tip to tip papillary muscle distance was measured in the short axis orientation at the most basal slice demonstrating the papillary muscle tips. LV ejection fraction (LVEF) was calculated using the end systolic and end diastolic volumes. All measurements were performed at end systole and end diastole before MTVR and after 3-6 months using a dedicated platform (3Mensio). Results: Ten patients (7 males) average age 69+/-10 years, underwent the Innovalve TMVR procedure. Average LVESD decreased from 52±15 mm at baseline to 44±15mm (P=0.016) at 3-6 months. Similarly, LVEDD decreased from 60±14 mm at baseline, to 52±13mm at 3-6 months (P=0.039). Average papillary muscle tip to tip distance at end diastole (ED) decreased from 31.7±7mm at baseline to 28.4±6.5mm at 3-6 months (P=0.047).A trend of LVEF improvement was evident with an increase from 35%±12 average at baseline compared with 39%±12 average after 3-6 months (P=0.346). Conclusions: These preliminary results show that the TMVR procedure using the Innovalve system may result in favourable LV reverse remodelling changes including reduction of LVESD, LVEDD and ED papillary muscle distances, with improved LVEF. This encouraging data might suggest favourable postprocedural structural LV change.

Double-layer horizontal cross sutures for intra-atrial mitral valve implantation: An effective surgical method for severe mitral annular calcification

ObjectiveSevere mitral annular calcification (MAC) can make prosthetic implantation extremely difficult. Although intra-atrial mitral valve prosthesis implantation without annular decalcification offers a simpler approach, it poses a potential rupture risk due to high left ventricular pressure. We developed a double-layer (DL) horizontal cross-suture technique, which ensures close proximity of the valve prosthesis to the calcified annulus and segregates the left atrial wall from the left ventricle. The aim of this study was to compare the outcomes of DL suture with conventional single-layer (SL) suture in patients with severe MAC. MethodsThis retrospective cohort study consecutively enrolled patients with severe MAC undergoing mitral valve replacement at Beijing Anzhen Hospital from May 2018 to December 2022. A detailed description of the DL suture method is described. Follow-up medical evaluations, including transthoracic echocardiography measurements, were obtained through outpatient chart reviews. ResultsThe study included 10 patients in the DL suture group and 20 in the SL suture group. All patients in the DL group and all but 3 in the SL group achieved technical success. Compared with the SL group, the DL suture technique was associated with lower rates of perivalvular leakage, stroke, new-onset atrial fibrillation, reoperation, and 30-day mortality. Follow-up was complete, with 1 late mortality in the DL group due to stroke and 4 cardiovascular deaths in the SL group. ConclusionsThe DL horizontal cross-suture technique offers a more effective and safer approach for intra-atrial mitral valve implantation in severe MAC cases than the conventional SL suture method.

Mitral valve surgery in acute infective endocarditis: long-term outcomes of mitral valve repair versus replacement.

Timing and surgical strategies in acute infective endocarditis are still questionable. We sought to investigate clinical outcomes of patients undergoing mitral valve repair (MVR) compared with mitral valve replacement [mitral valve prosthesis (MVP)] for acute infective endocarditis. From 2004 to 2019, 109 consecutive patients with acute mitral valve infective endocarditis were retrospectively investigated. Patients were divided into two groups according to surgical strategy: MVR 53/109 (48.6%) versus MVP 56/109 (51.4%). Primary end points were in-hospital mortality and overall survival at 10 years. Secondary end point was the freedom from infective endocarditis relapse. Our institutional surgical approach for infective endocarditis allowed us to achieve MVR in 48.6% of patients. Hospital mortality was comparable between the two groups [MVR: 1/53 (1.9%) versus MVP: 2/56 (3.6%), P = 1.000]. Overall 10-year survival was 80.0 ± 14.1 and 77.2 ± 13.5% for MVR and MVP, respectively ( P = 0.648). MVR showed a lower incidence of infective endocarditis relapse compared with MVP (MVR: 93.6 ± 7.1 versus MVP: 80.9 ± 10.8%, P = 0.041). At Cox regression, infective endocarditis relapse was an independent risk factor for death (hazard ratio 4.03; 95% confidence interval 1.41-11.52; P = 0.009). The tendency to postpone surgery in stable patients with mitral infective endocarditis allowed achievement of MVR in almost 50% of patients. Although repair remains the approach of choice in our institution, no differences between MVR and MVP were reported in terms of early/late survival. However, MVP had a higher incidence of infective endocarditis relapse that represents an independent risk of mortality.

HYDROACOUSTICS OF THE MECHANICAL BILEAFLET HEART VALVE

The results of experimental researches of hydrodynamic noise generated by a jet flow through the mechanical bileaflet mitral valve prosthesis of the Italian company Sorin are given. Physical simulation was carried out in laboratory conditions on the model of the left atrial chamber and the left ventricular chamber of the heart. The hydrodynamic noise of the flow through the artificial bileaflet mitral valve increased with increasing water flow. It was found that the greatest intensity of hydrodynamic noise and its spectral components was observed near the central jet of the bileaflet mitral valve. The obtained average pressure values in the near wake of the open mitral valve near the side jet are (10 – 20) % higher than near the central jet. It was determined that the power spectral densities of pressure fluctuations near the central jet are higher than near the side jet, especially in the frequency range (10 – 100) Hz. It was established that the small-scale vortex structures, which broke away from its leaflets and generated pressure fluctuations in the frequency range (20 – 70) Hz, degenerated starting from a distance of 2.5 valve diameters downstream. Increased levels of pressure fluctuations were observed near the central jet by more than (12 – 13) dB relative to hydrodynamic noise inside the atrial chamber and by more than (5 – 7) dB higher relative to pressure fluctuations near the side jet inside the left ventricular chamber in the frequency range (12 – 15) Hz. With an increase in water flow in the near wake of the mitral valve, an increase in the spectral levels of pressure fluctuations in the frequency range (60 – 80) Hz was observed. At a distance of more than below the open mechanical bileaflet mitral valve, the hydrodynamic noises near the central and side jets became approximately equal in the entire frequency range under consideration. The research results showed that hydroacoustic diagnostics of the operation of the mechanical bileaflet heart valve can be an effective means of diagnosing thrombus formation on the artificial valve leaflets.

Early outcomes of the "Chimney" commando procedure in the small aortic and mitral annuli.

Commando procedure, the surgical replacement of the mitral and aortic valves combined with reconstruction of the fibrosa fibrous body, is a technical challenge in patients with small aortic and mitral annuli. In this study, we evaluated the safety and early outcomes of the "Chimney" modality of the Commando procedure, in patients with small aortic and mitral annuli, after prior valve surgery, using a self-assembled valved conduit. From April 2021 to April 2022, 30 consecutive cases of the "Chimney" Commando procedure, with a self-assembled valved conduit and other combined cardiac procedures, were fully performed for re-operative patients with small aortic roots. Data were obtained through a medical record review, at the Asian Heart Hospital in Wuhan, China. The patient's mean age was 52.7 ± 13.53 years, with 93.3% females. All patients had a previous heart valve surgery, 90% of which had double valve replacement (DVR). Hospital death occurred in 3.3% (n = 1) of the patients, due to malignant arrhythmias and multiorgan failure. Postoperative echocardiogram exams showed that the sizes of the aortic and mitral valve prostheses were 24.23 ± 1.60 mm and 28.33 ± 1.21 mm, respectively. All patients had intact intervalvular fibrosa (IVF) repair and no patient had any aberration in the left heart chamber communication. With the exception of one postoperative sick sinus syndrome and one re-sternotomy for bleeding, there were no significant postoperative complications, such as mortality, renal failure requiring ongoing dialysis, or mediastinitis. Echocardiography exams in the sixth postoperative month showed that the mean gradients of the aortic and mitral valves were 16.26 ± 6.44 mmHg and 11.24 ± 4.90 mmHg, respectively. In comparison with the standard Commando operation, the early outcomes and safety of the "Chimney" Commando procedure proved to be a feasible therapeutic option for patients with small aortic and mitral annuli, after prior valve operations. This approach enables the enlargement of the aortic and mitral annuli and the implantation of the necessary valve prosthesis.

Pregnancy outcomes in women with a mitral valve prosthesis: A systematic review and meta-analysis

ObjectivesTo evaluate the ongoing debate concerning the choice of valve prosthesis for women requiring mitral valve replacement (MVR) and who wish to conceive. Bioprostheses are associated with risk of early structural valve deterioration. Mechanical prostheses require lifelong anticoagulation and carry maternal and fetal risks. Also, the optimal anticoagulation regimen during pregnancy after MVR remains unclear. MethodsA systematic review and meta-analysis was conducted of studies reporting on pregnancy after MVR. Valve- and anticoagulation-related maternal and fetal risks during pregnancy and 30 days’ postpartum were analyzed. ResultsFifteen studies reporting 722 pregnancies were included. In total, 87.2% of pregnant women had a mechanical prosthesis and 12.5% a bioprosthesis. Maternal mortality risk was 1.33% (95% confidence interval [CI], 0.69-2.56), any hemorrhage risk 6.90% (95% CI, 3.70-12.88). Valve thrombosis risk was 4.71% (95% CI, 3.06-7.26) in patients with mechanical prostheses. 3.23% (95% CI, 1.34-7.75) of the patients with bioprostheses experienced early structural valve deterioration. Of these, the mortality was 40%. Pregnancy loss risk was 29.29% (95% CI, 19.74-43.47) with mechanical prostheses versus 13.50% (95% CI, 4.31-42.30) for bioprostheses. Switching to heparin during the first trimester demonstrated a bleeding risk of 7.78% (95% CI, 3.71-16.31) versus 4.08% (95% CI, 1.17-14.28) for women on oral anticoagulants throughout pregnancy and a valve thrombosis risk of 6.99% (95% CI, 2.08-23.51) versus 2.89% (95% CI, 1.40-5.94). Administration of anticoagulant dosages greater than 5 mg resulted in a risk of fetal adverse events of 74.24% (95% CI, 56.11-98.23) versus 8.85% (95% CI, 2.70-28.99) in ≤5 mg. ConclusionsA bioprosthesis seems the best option for women of childbearing age who are interested in future pregnancy after MVR. If mechanical valve replacement is preferred, the favorable anticoagulation regimen is continuous low-dose oral anticoagulants. Shared decision-making remains priority when choosing a prosthetic valve for young women.

Monocyte to HDL ratio may predict thrombosis in patients with mechanical mitral and aortic valve prosthesis.

Increased inflammatory biomarkers have been reported in prosthetic heart valve thrombosis (PHVT). Monocyte to HDL ratio (MHR) and albumin to CRP levels (CAR) are two biomarkers used widely for systemic inflammation but there is a lack of data on prosthetic heart valves. This study aimed to find out the potential predictive value of MHR and CAR for PHVT. Patients who had the diagnosis of mechanical mitral/aortic PHVT and normally functioning prosthesis were retrospectively analyzed. Laboratory data including complete blood count and biochemistry were recorded. Transesophageal echocardiography was performed to diagnose PHVT. The study included 118 patients with mechanical PHVT and 120 patients with normally functioning prosthesis. White blood count, monocyte levels, C-reactive protein, MHR and CAR were significantly higher whereas the lymphocyte, HDL and INR levels on admission were lower in patients with PHVT. Multivariate analysis showed that as well as inadequate anticoagulation, MHR, but not CAR, was found to be an independent predictor of thrombosis in patients with PHVT. Receiver operating characteristic curve analysis was performed to detect the best cut-off value of MHR in the prediction of thrombosis in patients with prosthetic valves. MHR level of > 12.8 measured on admission, yielded an AUC value of 0.791 [(CI 95% 0.733-0.848 p < 0.001) sensitivity 71%, specificity 70%]. Inadequate anticoagulation is the primary cause that leads to thrombosis in mechanical prosthetic valves. Increased MHR, but not CAR, was also shown to be an independent predictor of thrombosis in patients with mechanical mitral and aortic prosthetic valves.