Mitral Valve Prosthesis Research Articles

Cost-Effectiveness of the Pharmacist-Managed Warfarin Therapy vs. Standard Care for Patients With Mechanical Mitral Valve Prostheses: An Egyptian Healthcare Perspective.

BackgroundDespite warfarin therapy had been used for decades for patients with mechanical mitral valve prostheses (MMVPs), serious and life-threatening complications are still reported worldwide with a significant economic burden. This study is aimed at assessing the clinical and the cost-effectiveness of adopting pharmacist-managed warfarin therapy (PMWT) services for optimizing warfarin treatment in Egypt.MethodsA prospective randomized trial in which 59 patients with MMVPs were randomly assigned to receive the PMWT services or the standard care and followed up for 1 year. The primary outcome was percentage time in the therapeutic range (TTR). For the cost-effectiveness analysis, a Markov cohort process model with nine mutually exclusive health states was developed from a medical provider’s perspective. A lifetime horizon was applied. All costs and outcomes were discounted at 3.5% annually.ResultsThe study results revealed a significantly higher median TTR in the intervention group as compared to the control group; 96.8% [interquartile range (IQR) 77.9–100%] vs. 73.1% (52.7–95.1%), respectively, p = 0.008. A significant association between standard care and poor anticoagulation control (p = 0.021) was demonstrated by the multivariate regression analysis. For the cost-effectiveness analysis, the total cumulative quality-adjusted life-years (QALYs) and total costs per patient were 21.53 and 10.43; 436.38 and 1,242.25 United States dollar (USD) in the intervention and the control groups, respectively, with an incremental cost-effectiveness ratio (ICER) of −72.5796 for the intervention group.ConclusionThe PMWT strategy was proven to provide a significantly better anticoagulation control and to be a cost-saving approach in Egyptian patients with MMVPs. Nevertheless, the dominance of this strategy is sustained by maintaining the therapeutic International Normalized Ratio (INR) control within the recommended range. Our findings will benefit Egyptian policy-makers who may seek novel health strategies for better resource allocation.Clinical Trial Registration[ClinicalTrials.gov], identifier [NCT04409613].

Causes, predisposing factors and clinical implications of spontaneous echocardiographic contrast

Spontaneous echocardiographic contrast is a manifestation of SLUDGE syndrome in the cavities of the heart. The factors that contribute to the emergence of this phenomenon are atrial fibrillation, mitral stenosis, mitral valve prosthesis, left atrial dilatation, decreased left ventricular ejection fraction, hypercoagulable blood conditions, inflammatory diseases, dyslipidemia. Spontaneous echo contrast is a prothrombogenic condition and increases the risk of thromboembolic events, including cerebrovascular complications. This article presents an analytical review of literary sources on this phenomenon for the purpose of its study and determination of treatment tactics in each clinical case.

Long-term outcomes of mechanical versus biological valve prosthesis in native mitral valve infective endocarditis

Objectives. To study the long-term outcomes of mitral valve replacement with mechanical or biological valve prostheses in native mitral valve infective endocarditis patients. Desing. We conducted a retrospective, nationwide, multicenter cohort study with patients aged ≤70 years who were treated with mitral valve replacement for native mitral valve infective endocarditis in Finland between 2004 and 2017. Results. The endpoints were all-cause mortality, ischemic stroke, major bleeding, and mitral valve reoperations. The results were adjusted for baseline features (age, gender, comorbidities, history of drug abuse, concomitant surgeries, operational urgency, and surgical center). The median follow-up time was 6.1 years. The 12-year cumulative mortality rates were 36% for mechanical prostheses and 74% for biological prostheses (adj. HR 0.40; CI: 0.17–0.91; p = 0.03). At follow-up, the ischemic stroke had occurred in 19% of patients with mechanical prosthesis and 33% of those with a biological prosthesis (adj. p = 0.52). The major bleeding rates within the 12-year follow-up period were 30% for mechanical prosthesis and 13% for a biological prosthesis (adj. p = 0.29). The mitral valve reoperation rates were 13% for mechanical prosthesis and 12% for a biological prosthesis (adj. p = 0.50). Drug abuse history did not have a significant modifying impact on the results (interaction p = 0.51 for mortality and ≥0.13 for secondary outcomes). Conclusion. The use of mechanical mitral valve prosthesis is associated with lower long-term mortality compared to the biological prosthesis in non-elder native mitral valve infective endocarditis patients. The routine choice of biological mitral valve prostheses for this patient group is not supported by the results.

In-Hospital Outcomes and Predictors of Mortality for Redo Surgical Mitral Valve Replacement Versus Transcatheter Mitral Valve-in-Valve Replacement

Durability is a major limitation with bioprosthetic heart valves. For mitral valve prosthesis dysfunction, redo surgical mitral valve replacement (rSMVR) has been the mainstay of treatment; however, transcatheter mitral valve-in-valve replacement (mViV) has emerged as a viable alternative. Data comparing these procedures remains limited; therefore, we sought to compare the real-world in-hospital mortality, likelihood of adverse peri-operative outcomes, and predictors of mortality between rSMVR versus mViV using the National Inpatient Sample. During the study period, a weighted total of 1,890 patients (78%) underwent rSMVR, and 520 (22%) underwent mViV. After propensity matching, there were 310 patients in each cohort. There was no statistically significant difference in mortality with these procedures (odds ratio 1.53; 95% confidence interval 0.67 to 3.45; p=0.31). rSMVR was associated with increased length of hospitalization (13 vs 7.5days; p <0.001), increased medical costs ($324,124 vs $241,147; p <0.001), and increased peri-operative complications compared with mViV. Predictors of mortality unique to rSMVR were age >75 years, cirrhosis, sleep apnea, malnourishment/low body mass index, and obesity, signalizing greater suitability for mViV in these populations.

Adherence to Anticoagulation Ambulatory during the Beginning of Coronavirus Pandemic

INTRODUCTION: Treatment with Vitamin K Antagonists is already proven to be significant in reducing thromboembolic events in patients with indications for systemic anticoagulation. In the context of ambulatory adherence, the SARS-CoV2 coronavirus pandemic emerged as a challenge for managing patients undergoing anticoagulation. &#x0D; &#x0D; METHODS: To avoid crowding and follow the recommended measures of social distancing, the Anticoagulation Ambulatory of the Hospital Universit&amp;aacute;rio de Santa Maria started to adopt a differentiated model of care, with a collection of hospital prothrombin time and immediate home return, followed by teleconsultation, with medication adjustment, as necessary. The present study aimed to assess adherence to the new care model, as well as the profile of patients seen. A retrospective cohort study was conducted, analyzing consultations between March and May 2020. &#x0D; &#x0D; RESULTS: The results demonstrate a low-educated population (76% had completed elementary school at most). The most common indications for the use of oral anticoagulation were atrial fibrillation (33.6%), followed by mechanical aortic valve prosthesis (31.3%) and mechanical mitral valve prosthesis (17.2%). Regarding adherence, especially to blood collection in the scheduled period, there was low adherence in the initial weeks of the pandemic declaration, with substantial improvement in adherence in the last two weeks of analysis. &#x0D; &#x0D; CONCLUSION: Determining the clinical characteristics and profile of patients helps to determine the local needs of this population and implement active search strategies to improve adherence rates, which may reduce unfavorable outcomes.

Management of Pulmonary Hypertension Secondary to Valvular Heart Disease with Angiotensin-Receptor Neprilysin Inhibitor

<h3>Introduction</h3> Pulmonary hypertension secondary to left-sided valvular disease (VHD-PH) is associated with high morbidity and mortality. Angiotensin-receptor neprilysin inhibitor (ARNI) is a novel pharmacotherapy, which reduces afterload with natriuresis and peripheral vasodilation. Whether ARNI can also reduce pulmonary vasculature resistance is unknown. We present two cases of VHD-PH that improved after treatment with ARNI. <h3>Case Report</h3> Case 1: Ms. M is a 63-year-old woman with past medical history of rheumatic mitral valve (MV) stenosis (mean gradient = 12 mm Hg at a heart rate = 69 beats/minute) who presented with New York Heart Association (NYHA) Class IIIB symptoms. The initial workup showed normal left ventricular function (LV) but severe combined pre- and post-capillary PH (Cpc-PH). She was deemed to be a high-risk surgical candidate given the severity of PH. Subsequently, she was treated with ARNI for three months, and repeat right heart catheterization showed significant improvement in Cpc-PH (see Table). Case 2: Mr. S is a 59-year-old man with past medical history of MV endocarditis s/p remote bovine MV replacement in 1984 complicated by paravalvular leak and redo replacements who presented with worsening shortness of breath. The workup demonstrated a well-functioning MV prosthesis and normal LV function, but elevated filling pressures. After two months of diuresis, Mr. S continued to have NYHA Class IIIB symptoms with persistent Cpc-PH. He was subsequently started on ARNI, and two months later had complete resolution of his symptoms. Repeat evaluation showed normalization of pulmonary vascular resistance (PVR, see Table). <h3>Summary</h3> This report is the first to describe treatment of VHD-PH with ARNI along with invasive hemodynamic data showing successful reduction in PVR. In these two cases, treatment with ARNI led to reduction in not only mean pulmonary arterial pressures but also PVR. Future prospective trials are needed to evaluate role of ARNIs in treatment of VHD-PH.

Prognostic Implications of Left Ventricular Global Longitudinal Strain in Patients With Surgically Treated Mitral Valve Disease and Preserved Ejection Fraction.

BackgroundThis study investigated whether left ventricular (LV) global longitudinal strain (LV-GLS), as an LV function parameter less affected by mitral valve (MV) repair or prosthesis, is associated with clinical outcomes in patients with surgically treated MV disease.MethodsAmong 750 patients who underwent MV surgery, we assessed LV-GLS by speckle tracking echocardiography in 344 patients (148 men, mean age 58 ± 13 years) who showed preserved LV ejection fraction on echocardiography between 6 months and 2 years after MV surgery and who did not undergo aortic valve surgery. The assessed clinical events included admission for worsening of heart failure and cardiac death.ResultsDuring a period of 42.4 ± 26.0 months, 32 (9.3%) patients were hospitalized for worsening heart failure, and 3 (0.8%) died due to cardiac causes. The absolute value of LV-GLS (|LV-GLS|) was significantly lower in patients with clinical events than in those without (12.1 ± 3.1 vs. 15.0 ± 3.2%, p < 0.001) despite comparable LV ejection fraction between groups. |LV-GLS| showed predictive value for clinical events (cut-off 13.9%, area under the curve 0.744, p < 0.001). Patients with |LV-GLS| ≤14.0% had poorer outcomes than those with |LV-GLS| >14.0% (log-rank p < 0.001). Prognosis was worse in patients with |LV-GLS| ≤14.0% and pulmonary hypertension than among those who with |LV-GLS| ≤14.0% without pulmonary hypertension (log rank p < 0.001). In nested Cox proportional hazard regression models, reduced |LV-GLS| was independently associated with the occurrence of clinical events.ConclusionsIn patients with surgically treated MV and preserved LV ejection fraction, assessment of LV-GLS provides functional information associated with cardiovascular outcomes.

Five-year outcomes of transcatheter mitral valve implantation and redo surgery for mitral prosthesis degeneration.

Transcatheter mitral valve replacement (TMVR) has emerged as a feasible alternative to redo surgical mitral valve replacement (SMVR) in patients with degenerated mitral prostheses, with limited comparative data. We compared mid-term outcomes in patients with degenerated mitral valve prostheses treated with TMVR or redo SMVR. The primary endpoint was survival at 5 years of follow-up. From 2014 to 2020, 215 patients presented with degenerated mitral valve prostheses. Of whom 86 (40%) were treated with TMVR (75[87%] valve-in-valve and 11[13%] valve-in-ring), while 129 patients (60%) underwent SMVR. The TMVR cohort was older (p < 0.0001), more symptomatic (p = 0.0003) and had more chronic lung disease (p = 0.02), worse renal function (p = 0.02) and higher right ventricular systolic pressures (p < 0.0001). Thirty-day mortality was lower with TMVR versus SMVR (2.4% vs. 10.2%, OR4.69 [95% CI 1.25-30.5], p = 0.04) with probability of mortality at 1, 2, and 5 years being 14.7% versus 17.5%, 24.5% versus 20.7%, and 49.9% versus 34.0%, respectively. Mode of prosthesis degeneration, baseline hemodynamics, and valve selection did not appreciably impact outcomes. TMVR for degenerated mitral prostheses is associated with better early survival compared to SMVR despite a greater burden of comorbidities. In contrast, 5 year survival rates appear more favorable with SMVR, which may reflect the lower baseline risk of this population. Clinical, hemodynamic, and echocardiographic follow-up support the mid-term durability of TMVR for degenerated mitral prostheses. Further dedicated studies, however, are required to optimize outcomes in this challenging patient cohort and to navigate the choice of approach for each individual patient.

Mitral valve paravalvular leaks: Comprehensive review of literature

Mitral paravalvular leaks (mPVL) are a recognized complication for patients with mitral valve prostheses. Although clinically insignificant for many patients, it may pose life-threatening haemolysis and regurgitation-induced heart failure, and so clinicians should have a high index of suspicion in the presence of new symptoms. This review discusses the pathogenesis, clinical features, diagnosis, imaging and treatment of mPVLs. A comprehensive literature search was performed using PubMed, EMBASE, Cochrane database, Google Scholar and Ovid. Search terms used included "mitral valve paravalvular leak," "transthoracic echocardiography," "2D transoesophageal echocardiography," "3D transoesophageal echocardiography," "cardiac computed tomography," (CT) "cardiac magnetic resonance imaging," "intracardiac echocardiography," "cinefluoroscopy," "fluoroscopy," and "percutaneous closure." All patients with mPVLs should undergo regular full evaluation, including patient history, physical examination, laboratory work-up, imaging, and referral, if necessary. Echocardiography is fundamental to the diagnosis, and is augmented with cardiac magnetic resonance imaging, cardiac computerized tomography and fluoroscopy for further characterization and procedural planning amongst the structural heart team. The prevalence of mPVL is expected to increase proportionally to the growing number of surgical and transcatheter valve replacements conducted in the ageing population. Multimodal imaging is instrumental in guiding diagnostic and therapeutic strategies when managing mPVLs. Advances in imaging and capabilities of transcather devices will prompt growing uptake of percutaneous treatment over conventional, higher-risk surgery for mPVL management.

Abstract 14354: Optimal Anticoagulation Use in Patients Undergoing Transcatheter Mitral Valve Replacement a Quest for More Data

Background: Multiple studies have demonstrated an increased risk of valve thrombosis in patients with mitral valve prostheses. Data to guide decision-making in regards to the choice of anticoagulation agent and duration of the therapy is lacking. We present our single-center experience with oral anticoagulation use in patients undergoing transcatheter mitral valve replacement (TMVR). Methods: 32 patients underwent the TMVR procedure at our center from 1/1/2017 to 12/31/2020. Data points on baseline characteristics, STS-PROM, functional status (NYHA and KCCQ), baseline laboratory values, echocardiographic parameters (including LVEF, MV area, gradient, grading of MS, and MR was collected. We analyzed patterns of anticoagulation therapy including the type of agent, duration of therapy, and complications occurring related to anticoagulation use. Results: Our registry included 32 patients that underwent TMVR. 70.5 % were females, 96.8 % Caucasian with a mean NYHA class of 3.25. STS-PROM of 6.25 (5.56-9.43) and KCCQ score of 38.04 (SD 19.9). Out of 32 patients, 31 had retrievable data. Vitamin K antagonist (VKA) was used in 60 % (18), apixaban in 26.6 % (8), rivaroxaban in 16.6 % (3), and no anticoagulation was used in 0.03 % (1) of patients.74 % (22) of the patients were on anticoagulation at the time of TMVR for another indication. 33.3% (6) of patients on VKA suffered a complication such as gastrointestinal/genitourinary bleed, while 54.45% (6) of patients on DOAC reported similar complications. Conclusion: The choice of anticoagulant and optimal duration of anticoagulation in patients undergoing TMVR remains a gap in our evidence base. We present our single-center experience of anticoagulant use in this patient population. Further randomized studies are needed to address this knowledge gap.

Abstract 14148: Transcatheter Mitral Valve Replacement: A Single Center Tertiary Care Experience

Background: Transcatheter mitral valve replacement (TMVR) using transcatheter aortic valves is considered an advanced structural heart procedure performed at comprehensive valve centers in patients with degenerated mitral valve prostheses. We present our single-center experience of patients undergoing Valve in Valve (ViV) and Valve in Ring (ViR) TMVR. Methods: We identified patients who underwent the TMVR procedure at our center from 1/1/2017 to 12/31/2020. We analyzed baseline characteristics, STS-PROM score, functional status (NYHA and KCCQ), baseline laboratory values, echocardiographic parameters (including LVEF, MV area, gradient, grading of MS and MR was collected. Follow-up data on functional status, echocardiographic parameters, and mortality were collected at 30 days and 1-year post-procedure. Results: A total of 32 patients were identified during this time period. 70.5 % were females, 96.8 % Caucasian. Mean NYHA class was 3.25, STS-PROM was 6.25% (5.56-9.43), and KCCQ score of 38.04 (SD 19.9). 94 % (30) of patients had a previous history of MV replacement and 6 % (2) of them had a history of MV repair. Baseline mean LVEF was 57% (46.5-67), at 30 days 55% (47.5-64.5) at 1 year 53.5% (46.5-58.25). NYHA decreased from 3.25 (1-4) to 2 (1-2) at 30 days and 2 (1.5-2) at 1 year with KCCQ following a similar trend. MV area at baseline was 1.2 (0.66-1.63) which increased to 1.45 (SD 0.44) at 30 days and 1.63 (SD 0.4) at 1 year. MV mean gradient decreased from 12.43 (SD 5.2) to 8 (7-10) at 30 days and remained stable at 9 (6-11) at 1 year. MR gradient decreased from severe MR in 11 patients (35.48 5 at baseline) to 6 (18.75 %) and 0 at 1 year. TR gradients followed the trend. The mortality rate at 30 days was 6.25 % (2) and 15.62% (5) at 1 year. Conclusion: TMVR offers acceptable outcomes in patients with symptomatic bioprosthetic mitral valve dysfunction. Follow-up data at 30 days and 1 year demonstrates improvement in functional status and sustained decrease in mitral valve gradients.

Hemolysis following a mitral valve prosthesis surgery: etiology, diagnosis and treatment

Domas Grigoravičius1 1 Vilnius University, Faculty of Medicine, Vilnius, Lithuania Abstract Introduction: anemia caused by heart valve prostheses is not a common but significant type of hemolytic anemia, despite the lack of information on this complication in the literature. There is no clear pathogenesis of the etiology of this condition. The primary mechanism of hemolytic anemia after valve replacement surgery is regurgitation due to valve leakage. Aim: this work aims to review the literature on the etiology, diagnosis, and treatment of valve-induced hemolytic anemia. Literature search strategy: the literature search was conducted using the PubMed and Google Scholar databases. The following keywords and their combinations were used: “hemolysis,” “valve replacement,” “treatment,” “diagnosis,” “surgery”. Conclusions: the diagnosis of hemolytic anemia caused by valve prostheses is problematic because it can be an early and late postoperative complication, and the condition must be differentiated from other possible causes of hemolysis even after the detection of hemolytic markers. Medication is sufficient to treat mild hemolytic anemia caused by valve prostheses, but surgical treatment and replacement of a defective valve are the most common. Keywords: valve replacement; hemolytic anemia; postoperative complication.

Mitral surgical redo versus transapical transcatheter mitral valve implantation.

Transcatheter methods have been rapidly evolving to provide an alternative less invasive therapeutic option, mainly because redo patients often present with multiple comorbidities and high operative risk. We sought to evaluate and compare our experience with transapical transcatheter mitral valve replacement (TA-TMVR) to conventional redo mitral valve replacement in patients presenting with degenerated biological mitral valve prostheses or failed valve annuloplasty. Between March 2012 and November 2020, 74 consecutive high-risk patients underwent surgical redo mitral valve replacement (n = 33) or TA-TMVR (n = 41) at our institution. All patients presented with a history of a surgical mitral valve procedure. All transcatheter procedures were performed using the SAPIEN XT/3™ prostheses. Data collection was prospectively according to MVARC criteria. The mean logistic EuroSCORE-II of the whole cohort was 19.9±16.7%, and the median STS-score was 11.1±12.5%. The mean age in the SMVR group was 63.7±12.8 years and in the TMVR group 73.6±9.7 years. Patients undergoing TA-TMVR presented with significantly higher risk scores. Echocardiography at follow up showed no obstruction of the left ventricular outflow tract, no paravalvular leakage and excellent transvalvular gradients in both groups (3.9±1.2 mmHg and 4.2±0.8 mmHg in the surgical and transcatheter arm respectively). There was no difference in postoperative major adverse events between the groups with no strokes in the whole cohort. Both methods showed similar survival rates at one year and a 30-day mortality of 15.2% and 9.8% in SAVR and TMVR group, respectively. Despite using contrast dye in the transcatheter group, the rate of postoperative acute kidney failure was similar between the groups. Despite several contraindications for surgery, we showed the non-inferiority of TA-TMVR compared to conventional surgical redo procedures in high-risk patients. With its excellent hemodynamic and similar survival rate, TA-TMVR offers a feasible alternative to the conventional surgical redo procedure in selected patients.

Клінічний випадок лікування підгострого ендокардиту в пацієнта після закриття оклюдером відкритого овального вікна

The role of transcatheter closure of the patent foramen ovale in the occurrence of various complications remains a controversial issue. Atrial arrhythmias and bleeding are common complications, while infectious complications are extremely rare. In this clinical case we would like to report a patient who underwent transcatheter closure of a patent foramen ovale complicated by subacute endocarditis of a fully endothelized device 5 years after surgery. A 49-year-old patient was admitted to the surgical department with diffuse chest pain, sweating and fever. Three weeks earlier the patient had a fever associated with a cold. The data of the general and biochemical blood analysis indicated the presence of an inflammatory reaction of the body. After transthoracic and transesophageal echocardiography, infective endocarditis was diagnosed. The patient underwent surgery as planned. After removal of the occluder and excision of the mitral valve cusps, implantation of a mechanical mitral valve prosthesis was performed. At the site of the removed occluder, the atrial septal defect was repaired with an autologous pericardial patch. Transesophageal echocardiography showed no residual blood flow through the interatrial septum. The postoperative period was uneventful. The patient was discharged in satisfactory condition 10 days after surgery. The total duration of the antibiotic therapy was 5 weeks. Key words: open oval window, infectious endocarditis, transcatheter closure of the defect.

Preoperative mitral annulus size - Can we get it right?

Objective:We looked for a correlation between the surgically measured mitral valve size and the cardiac dimensions (left ventricle internal diameter, left atrial size, aorta size, and body surface area) measured by preoperative and intraoperative echocardiography. We also assessed to see if we could predict the mitral prosthesis size based on the correlation data obtained.Methods:The hospital records of 180 patients who underwent mitral valve replacement (MVR) with TTK Chitra valve between January 2008 and December 2012 at our hospital, were studied. The correlation between surgically measured mitral annulus size to left ventricular internal diameter systolic (LVIDS) and diastolic (LVIDD), left atrial size (linear measurement), and aorta size on echocardiography and body surface area was calculated using Pearson correlation coefficient. Mean LVIDS was calculated for each valve prosthesis size separately and the correlation was studied.Results:The correlation between mitral valve prosthesis size and left ventricular internal diameter (systolic) showed a Pearson coefficient of 3.3 with significance at the level 0.01. Mitral valve size and left atrial size showed a correlation coefficient of 2.7 with significance at the level 0.01. The correlation coefficient for mitral valve size with left ventricular internal diameter diastolic, aorta and body surface area were 2.5, 1.9, and 1.8, respectively. There was a gradual increase in the mean LVIDS with increase in the prosthetic valve size. Box plot and scatter plot showed linear correlation between valve size and mean LVIDS.

Giant Left Atrium and Atrial Fibrillation in Rheumatic Heart Disease Patient with Normally Functioning Mitral Valve Prosthesis

Giant Left Atrium and Atrial Fibrillation in Rheumatic Heart Disease Patient with Normally Functioning Mitral Valve Prosthesis

A case of left atrial free ball thrombus in a patient with prosthetic mitral valve.

A free left atrial ball thrombus is relatively a rare diagnosis and usually leads to systemic embolization or fatal complication of thrombus incarceration in left ventricle inflow. We report a case of 52-year-old woman who was admitted to hospital with symptoms of heart failure. Routine echocardiography showed a free-floating ball thrombus in the left atrium. The free-floating thrombus was round with smooth surface and about 37 mm in diameter. The mitral valve prosthesis was well-functioning. The computed tomography of the patient also showed the left atrial ball thrombus. The erratic finding was that the patient was compliant on oral anticoagulants for the last 6 months with her INR in theraputic range. This suggested that this thrombus had been there for a some time and anticoagulants failed to resolve this problem. She was referred to cardiac surgery for thrombus extraction but the patient refused to have the operation.

Incorporating the anterior mitral leaflet to the annulus impairs left ventricular function in an ovine model

ObjectivesTranscatheter mitral valve prostheses are designed to capture the anterior leaflet and surgical techniques designed to fully preserve the subvalvular apparatus at prosthetic valve insertion both serve to shorten the anterior mitral leaflet height, thus effectively incorporating it into the anterior annulus. This study quantifies the acute effects of incorporating the anterior mitral leaflet into the annulus on left ventricular function. MethodsFourteen adult sheep (weight, 48.7 ± 6.2 kg) underwent a mechanical mitral valve insertion on normothermic beating-heart cardiopulmonary bypass, with full retention of the native mitral valve but with placement of exteriorized releasable snares around the anterior mitral leaflet. Continuous measurements of left ventricular mechano-energetics were recorded throughout, alternating incorporating and releasing of the anterior mitral leaflet to the mitral annulus. Echocardiography confirmed the incorporation into the annulus and release. ResultsThe independent indices of left ventricular contractility (ie, end systolic pressure volume relationship and preload recruitable stroke work) were both significantly impaired when the anterior mitral leaflet was incorporated to the annulus and restored after release, as were the hemodynamic parameters: cardiac output, stroke volume, stroke work, and left ventricular pressure decreased by 15%, 17%, 23%, and 11%, respectively. Echocardiography demonstrated increased sphericity of the left ventricle during anterior mitral leaflet incorporation. ConclusionsIncorporating the anterior mitral leaflet to the anterior annulus adversely affected left ventricular contractility, caused distortion of the left ventricle in the form of increased sphericity, and impaired hemodynamic parameters in normal ovine hearts.

Impact of Mitral Valve Prosthesis on Stroke after Insertion of Veno-Arterial Membrane Oxygenation for Postcardiotomy Shock

Purpose Veno-arterial membrane oxygenation (VA-ECMO) is used in profound postcardiotomy shock (PCS). Previous study raised the possibility that use of VA-ECMO after mitral valve replacement (MVR) may pose a risk of valve thrombosis and embolism including stroke likely due to low transvalvular flow. This study focused on stroke after valve surgery requiring VA-ECMO. Methods Of 482 adult patients undergoing VA-ECMO from January 2011 to July 2020, 113 received VA-ECMO for PCS: coronary artery bypass Grafting (CABG): N=44; Mitral valve repair: N=12; Aortic valve replacement (AVR), N=28; MVR, N=29. Precautions taken to limit thromboembolism included: (1) low VA-ECMO flows were maintained between 1.5-2.2 L /min/m2, if possible, to provide hemodynamic support while maximizing trans-valvular flow and prosthesis washing; (2) anticoagulation was initiated within 24 hours postoperatively; (3) A bioprosthesis was used for 98.2% of valve replacements. The incidence of stroke and survival to discharge were primary outcomes. Results Peripheral VA-ECMO cannulation was performed in 87.6% (CABG, 79.5%; MV repair, 100%; AVR, 96.4%; and MVR 86.2%, p=0.483). Of these, 65.7% of peripheral cannulation was axillary VA-ECMO. The overall survival for PCS was 57.5%, with an incidence of stroke of 11.5% (CABG, 6.8%; MV repair, 8.3%; AVR, 10.7%; and MVR 20.7%; CABG or MV repair vs MVR, p=0.066; CABG or MV repair vs. AVR, p=0.889). Median support length of VA-ECMO was 6 days. In 6 patients who had stroke after MVR, 5 patients (83.3%) developed stroke after decannulation with a median interval of 1 day. The incidence of postoperative atrial fibrillation was 15.9%, 25%, 28.6%, and 32.1%, respectively (P=0.405). In univariable logistic regression analysis, MVR was a predisposing factor for postoperative stroke (odds ratio: OR, 3.39: p=0.078), but AVR (OR, 1.56: p=0.579) and central cannulation (OR, 3.03: p=0.178) were not. Conclusion The incidence of stroke after MVR was significant in PCS requiring VA-ECMO which suggests that an intracardiac embolic source may cause stroke with recovery of heart function. An alternative mechanical support or treatment strategy may be considered after MVR given the high rate of stroke during VA-ECMO support.

Successful retrieval of a broken PentaRay catheter spine in a patient with mechanic mitral valve prosthesis.

Successful retrieval of a broken PentaRay catheter spine in a patient with mechanic mitral valve prosthesis.