Mitral Valvular Disease Research Articles

Safety and Effectiveness of Oral Anticoagulants in Atrial Fibrillation: Real-World Insights Using Natural Language Processing and Machine Learning.

Background/Objectives: We assessed the effectiveness and safety of vitamin K antagonists (VKAs) versus direct oral anticoagulants (DOACs) in patients with atrial fibrillation (AF) using artificial intelligence techniques. Methods: This is a retrospective study in 15 Spanish hospitals (2014-2020), including adult AF patients with no history of anticoagulation, thrombosis events, rheumatic mitral valvular heart disease, mitral valve stenosis, or pregnancy. We employed EHRead® technology based on natural language processing (NLP) and machine learning (ML), along with SNOMED-CT terminology, to extract clinical data from electronic health records (EHRs). Using propensity score matching (PSM), the effectiveness, safety, and hospital mortality of VKAs versus DOACs were analyzed through Kaplan-Meier curves and Cox regression. Results: Out of 138,773,332 EHRs from 4.6 million individuals evaluated, 44,292 patients were included, 79.6% on VKAs and 20.4% on DOACs. Most patients were elderly [VKA 78 (70, 84) and DOAC 75 (66, 83) years], with numerous comorbidities (75.5% and 70.2% hypertension, 47.2% and 39.9% diabetes, and 40.3% and 34.8% heart failure, respectively). Additionally, 60.4% of VKA and 48.7% of DOAC users had a CHA2DS2-VASc Score ≥4. After PSM, 8929 patients per subgroup were selected. DOAC users showed a lower risk of thrombotic events [HR 0.81 (95% CI 0.70-0.94)], minor bleeding [HR 0.89 (95% CI 0.83-0.96)], and mortality [HR 0.80 (95% CI 0.69-0.92)]. Conclusions: Applying NLP and ML, we generated valuable real-world evidence on anticoagulated AF patients in Spain. Even in complex populations, DOACs have demonstrated a better safety and effectiveness profile than VKAs.

Real-world insights on anticoagulation therapies in non-valvular atrial fibrillation: a comprehensive electronic health record-based study using natural language processing and machine learning

Abstract Background Limited evidence exists regarding real-world practices and outcomes of oral anticoagulation in patients with Non-Valvular Atrial Fibrillation (NVAF). Purpose To conduct a retrospective real-world data (RWD) study using Natural Language Processing (NLP) and Machine Learning (ML) on Electronic Health Records (EHRs) to evaluate the efficacy and safety of Direct Oral Anticoagulants (DOACs) and vitamin K antagonists (VKAs) in NVAF patients. Methods Retrospective study in 15 Spanish hospitals between 2014-2020 including adult NVAF patients treated with oral anticoagulants without anticoagulation history, recent thrombotic events, rheumatic mitral valvular heart disease, mitral valve stenosis, venous thromboembolism, nor pregnancy. We employed EHRead®, a free text analysis engine utilizing NLP and ML to extract RWD from EHRs based in SNOMED CT (standardized coding system). Free-text information was extracted and organized in an anonymized database for population-based descriptive and comparative analysis. After matching patients using propensity-score matching (PSM), we used Kaplan-Meier curves to compare VKA vs DOAC efficacy on thrombotic prevention, safety, and mortality. Results After evaluating 138,773,332 EHRs from 4.6 million patients, 44,292 NVAF patients were included; 35,267 (79.6%) treated with VKA and 9,025 (20.4%) with DOAC. Half of them were men (53.0%) with a mean (SD) age of 76.3 (12.7) years. VKA-treated patients tended to be older, with more cardiovascular comorbidities and higher CHA2DS2-VASc scores than DOACs-treated patients (Table 1). Using PSM, 8,930 patients were matched per subgroup with standardized mean differences below 10% for all confounders. The comparative analysis showed that DOAC-treated patients had a significant lower risk of thrombotic, minor bleeding events, and mortality than VKA-treated ones, with no significant differences in major bleeding (Figure 1). Conclusion The application of NLP and ML allowed us to create an extensive, plausible, and detailed database of Spanish NVAF patients from RWD in EHRs. In our cohort, we found a higher efficacy and lower mortality and minor bleeding events with DOACs over VKAs, without differences in major bleeding events. This study was sponsored by Pfizer and Bristol Myers Squibb. JCS, MA & CS were paid consultants to Pfizer and Bristol Myers Squibb in connection with the development of this abstract. CAC & LMS are employes of the SAVANA who were paid consultants to Pfizer and Bristol Myers Squibb in connection with the development of this abstract. DA & SFC are employees of Pfizer.Table 1Figure 1

Disparities in Mitral Valve Disease Associated with Heart Failure.

Heart failure (HF) affects millions of people around the world and is a prevalent health issue in the United States. In many cases, HF has an intricate connection with mitral valvular disease (MVD), which can alter a patient's disease course. Factors such as gender, race, ethnicity, and social determinants of health impact the prevalence, etiology, and treatment of MVD associated with HF. This literature review examines the connection between MVD and HF among adult patients, considering MVD as both a cause and an outcome of HF. This article also identifies the differences in epidemiology and treatment of MVD associated with HF across different gender, ethnicity, race, and socioeconomic groups. This is in an effort to not only identify currently overlooked disparities but to highlight potential ways to improve them. MVD was analyzed based on its hemodynamic subtypes, mitral regurgitation (MR) and mitral stenosis (MS), as these subtypes encompass different etiologies of MVD. The purpose of this article was to identify broad disparities in MVD in association with HF in the adult population. The results of this study found stark differences between prevalence, treatment, and disease outcomes across groups. Women and Black patients were identified as high-risk for under-utilization and prescription delay of treatment options. Women were often treated at more advanced stages of MVD, while treatment was often delayed in Black patient populations. Factors such as these impact treatment outcomes. Conversely, men and White patients were identified as lower-risk groups for treatment inadequacies and poor HF and MVD related outcomes. Socioeconomic status (SES) was also found to play a role, with low SES being a risk factor for developing rheumatic heart disease. Low SES groups are also more likely to develop HF, which predisposes to secondary MR. Despite general knowledge of these disparities, few studies analyze HF and MVD for specific groups. This literature review is thus necessary to identify current inequities in care and underscore potential solutions to raise awareness for further research efforts and funding. This analysis identifies MVD treatment guidelines and contributing social determinants of health as areas that must be addressed to minimize HF and MVD disparities.

Isolated dextrocardia and rheumatoid arthritis with mitral stenosis with pulmonary hypertension with atrial fibrillation: A rare association

This case presents a rare occurrence of rheumatoid arthritis (RA) in a 50-year-old woman with concurrent mitral valvular disease and dextrocardia. Diagnosed with seropositive RA 5 years earlier, the patient exhibited fever, cough, and progressive dyspnea. Clinical examination revealed irregular tachycardia, elevated jugular venous pressure, and signs of heart failure. Laboratory results confirmed seropositive RA, anemia, and elevated inflammatory markers. Electrocardiogram and echocardiogram indicated dextrocardia, atrial fibrillation, and moderate mitral stenosis. This case highlights the unusual association of RA with valvular heart disease and the added complexity of dextrocardia. Recognizing diverse cardiac manifestations in RA is crucial, contributing to the growing evidence linking autoimmune disorders to cardiovascular complications. Further research is essential to understand the intricate relationship between RA and unique cardiac abnormalities.

Mitral Annular Calcification-Related Valvular Disease: A Challenging Entity

Mitral valve annular calcification-related valvular disease is increasingly common due to the rising prevalence of age-related mitral annular calcifications. Mitral annular calcification alters the structure and function of the mitral valve annulus, which in turn causes mitral valve regurgitation, stenosis, or both. As it frequently coexists with comorbid conditions and overlapping symptoms, mitral annular calcification-related valvular disease poses significant diagnostic and therapeutic challenges. For instance, left ventricular diastolic dysfunction hinders the assessment of mitral valvular disease. Detection of mitral annular calcifications and assessment of related mitral valve disease hinge on two-dimensional echocardiography. Comprehensive assessment of mitral annular calcifications and related mitral valve disease may require multidetector computed tomography and three-dimensional echocardiography. Invasive hemodynamic testing with exercise helps identify the cause of symptoms in patients with comorbid conditions, and transcatheter interventions have emerged as a viable therapeutic option for older patients. After an outline of the normal mitral annulus, we examine how mitral annular calcifications lead to mitral valve disease and how to accurately assess mitral regurgitation and stenosis. Lastly, we review surgical and transcatheter approaches to the management of mitral annular calcification-related mitral valve regurgitation, stenosis, or both.

Transcatheter Aortic Valve Replacement as a bridge to minimally invasive endoscopic mitral valve surgery in Elderly Patients in the era of ERAS and Fast Track TAVI concepts.

In this bicentric study, we report the outcomes of combined transcatheter aortic valve replacement combined with minimally invasive mitral valve surgery. We included a cohort of six patients (79.6 ± 3.2 years, 83% women) with high-risk profiles and deemed to be non-operable with combined mitral and aortic valvular disease. All patients had unsuitable anatomies for transcatheter mitral valve edge-to-edge repair (TEER). Moreover, most of the patients (5/6) suffered a combined aortic valve lesion, which complicates the efficiency of cardioplegia in the case of CBP through minimally invasive incisions. The first stage was implanting a TAVI valve to achieve aortic valve competency and hence facilitate the infusion of cardioplegia after clamping the aorta during endoscopic mitral valve surgery. After one week, we performed the minimally invasive mitral valve repair. Most patients (n = 5; 83%) underwent successful endoscopic mitral valve repair. Intraoperatively, the mean ischemic time was 42 min, and the total bypass time was 72 min. Postoperatively, the mean intubation time was 0 h. Postoperative complications included reoperation for bleeding in one patient (16.7%) and a new heart block requiring pacemaker implantation in one patient (16.7%). There was neither in-hospital mortality nor 1-year mortality.

Mitral valvular surgery outcomes in a centre with a dedicated mitral multi-disciplinary team.

International guidelines recommend 'heart teams' as the preferred method for decision-making. Heart team processes, mandatory attendees and investigations vary significantly between hospitals. We assessed outcomes following mitral valvular surgery in a tertiary referral centre with a dedicated mitral multi-disciplinary team (MDT). This was a single-centre retrospective review of prospectively collected data within the 'mitral database' of mitral valvular disease patients. The 'mitral MDT' meeting involved pre-operative imaging and clinical data review, including mandatory transoesophageal echocardiography; recommendation for planned procedure, as well as an appropriate surgeon; and review of echocardiography images and clinical outcomes after surgery had been performed. Between 2016 and 2020, 395 patients with mitral valvular disease were discussed at MDT. Of these, 310 patients underwent surgery. During the same time interval, 75 patients had surgery without MDT discussion: 84% of patients not discussed were urgent or emergent procedures and, in these, the most common pathology was degenerative mitral regurgitation (DMR, 46%) followed by infective endocarditis (30%). Of those discussed at MDT the pathology was: DMR 65%; mitral stenosis 14%; functional mitral regurgitation (MR) 5%; rheumatic MR 4%; endocarditis 4%; ischaemic MR 4%; and other pathologies 4%. For patients with DMR having elective surgery, the repair rate was 93% with mortality 2% and median (IQR) length of stay 5 (4-6) days. Postoperative transthoracic echocardiography demonstrated 99% of elective DMR patients had ≤2+ MR and <1% severe (3+) MR. In conclusion, a dedicated 'mitral MDT' can enhance the safe delivery of care with consistently high repair rates for DMR patients with excellent outcomes.

Female Gender in Cardiac Surgery: Is it Still a Significant Risk? A Retrospective Study in Saudi Arabia.

Female sex is considered an independent predictor for mortality and morbidity following cardiac surgery. This study is to review the outcomes of adult cardiac surgery between males and females in a Saudi tertiary referral hospital. This was a retrospective study for 925 adult patients operated on for ischemic coronary artery disease and acquired aortic and mitral valvular heart disease from 2015 to August 2023. We analyzed patient characteristics, intraoperative data, and postoperative results to compare outcomes between males and females. Preoperative risk factors were not significantly different in both groups. Postoperative outcomes showed gender-based differences. In univariable analysis, females, compared to males, had significantly greater odds of prolonged postoperative ventilation (>24 hours), 32.8% of females compared to 20.7% of males (p < 0.001). Also, sternal wound infection was notably higher among females (13.3%) (p < 0.001). Mortality also exhibited a significant association, with 14.2% of females experiencing mortality compared to 9.4% of males (p = 0.049). In the multivariable analysis for elevated postoperative troponin, the use of pre-operative intra-aortic balloon pump, urgent/emergent surgery, elevated pre-operative troponin and combined bypass grafting with valve surgery, were also predictive of higher post-operative troponin concentrations (beta = 0.43, 95% CI: 0.25 to 0.62, p < 0.001). Females in Saudi Arabia have an increased risk of short-term morbidity and mortality after cardiac surgery compared to males. Vague and delayed presentation and then the late diagnosis and referral are likely the main contributing factors. This highlights the need to implement preoperative measures to improve early diagnosis and referral to eliminate gender bias.

Abstract 13286: Co-Morbidities Clustering According to Imaging Diagnostic Criteria in Cardiac Sarcoidosis

Background: Cardiac sarcoidosis (CS) diagnostic guidelines updated in 2006 and in 2017 now include imaging findings of left ventricular (LV) dysfunction (LV EF &lt; 50%) on cardiac MRI and echocardiography as major diagnostic criterion. Limited data is available with regards to co-morbidities clustering in sarcoidosis and CS according to the 2017 updated guideline diagnostic criteria. Methods: A case control, single tertiary medical center study included 558 sarcoidosis patients with documented extracardiac sarcoidosis and completed electrocardiogram and/or cardiac MRI imaging. CS 2006 and 2017 diagnostic criteria and co-morbidity data were extracted from electronic charts and were available for comparison in 540 patients. Results: The total study population was composed of 52.7% (281/540) females, aged 58.9+/-12.6 years old, with diabetes mellitus (DM) present in 29.6% (160/540), HTN in 51.7% (279/540), CAD in 13.3% (72/540), moderate to severe aortic, mitral, or tricuspid valvular disease in 14.8% (80/540), ESRD in 2.4% (13/540), and COPD or asthma in 21.9% (118/540). There was a significant clustering of co-morbidities according to the imaging CS diagnostic criteria. Patients meeting the 2017 CS imaging criteria were found to be older (61.4+/-11.3 vs 58.8+/-12.8 years old in patients not meeting criteria, p=0.085), predominantly male (69.2%, (54/78) vs. 44.4%, (205/462), p&lt;0.001), and demonstrated significantly increased prevalence of DM (39.7%, (31/78) vs. 27.9%, (129/462), p=0.034), and valvular disease (33.3%, (26/78) vs. 11.7%, (54/462), respectively, p&lt;0.001). However, there were no statistically significant difference in the prevalence of HTN (60.3%, (47/78) vs. 50.2%, (232/462), p=0.101), ESRD (3.9%, (3/76) vs. 2.2%, (10/456), p=0.361), and COPD or asthma (19.2%, (15/78) vs. 22.3%, (103/462), p=0.544) in patients meeting 2017 CS criteria compared to those that did not. Conclusion: CS patients meeting 2017 imaging diagnostic criteria were found to have statistically significant clustering of the following co-morbidities: male gender, DM, and valvular disease. These findings underscore importance of comprehensive care in CS patients and warrant caution in assigning LV abnormalities observed on imaging solely to CS etiology.

Cutting-Edge Trials in Structural Heart Disease at The Texas Heart Institute.

Mitral and tricuspid valvular disease have been managed surgically; however, multiple transcatheter technologies have diversified the therapeutic arsenal and expanded the number of patients eligible for treatment. These new technologies and active trials currently being performed at The Texas Heart Institute will be highlighted.Transcatheter edge-to-edge repair (TEER) with MitraClip (Abbott Structural Heart) plays an important role in the management of degenerative and functional mitral regurgitation (MR). Despite its success, the limitations of MitraClip include challenging anatomy that may not be amenable to TEER, the common need for multiple devices, risk of device-related mitral stenosis, and a not-trivial rate of residual MR.1 Delivered via a 22F sheath, the PASCAL device (Edwards Lifesciences) offers several improvements.2 Its 3-catheter system (including a guide, steerable, and implantation catheter) offers easy maneuverability in 3 independent planes. It has a spacer that fills the interleaflet area, helping reduce regurgitation. Additionally, its relatively larger “clasps” are designed to reduce leaflet stress by better distributing tension. Similar to the latest generation of MitraClip, PASCAL has independent gripper action.The CLASP IID and CLASP IIF trials randomized patients with degenerative and functional MR, respectively, to PASCAL vs MitraClip. The CLASP IID trial, which has completed enrollment, reported noninferiority of the PASCAL device with relation to procedural safety and effectiveness.3 It also showed durable reductions in MR to ≤1+ (87.2% at discharge and 83.7% at 6 months in the PASCAL arm; 88.5% at discharge and 71.2% at 6 months in the MitraClip arm). The CLASP IIF trial is currently enrolling.Compared with TEER, transcatheter mitral valve replacement (TMVR) theoretically offers treatment for complex mitral valvular anatomies, including mixed valvular disease and the potential for lower rates of residual regurgitation.4 The Intrepid valve (Medtronic) is a promising transcatheter device being studied in the APOLLO trial. Intrepid is designed as a double stent composed of a nitinol mesh, with an inner stent containing a bovine, trileaflet valve and a larger, outer stent that fixates onto the mitral annulus. It is available in 42- and 48-mm outer diameter sizes, with a 54-mm size currently in development.5 The APOLLO trial initially began as a randomized controlled trial comparing transapical TMVR to surgery, but because of developments in TEER technology, has evolved into a single-arm trial of patients who are not candidates for TEER or conventional mitral valve surgery. More recently, a 35F transfemoral delivery platform for the Intrepid system has been developed.One particularly important complication of TMVR is left ventricular outflow tract obstruction that is caused by displacement of the anterior mitral valve leaflet. Multiple efforts have been made to prevent this complication, including sophisticated computed tomography–based prediction of the neo–left ventricular outflow tract that help guide patient selection and the use of interventional techniques including leaflet laceration and alcohol septal ablation.6Early results of the Intrepid valve show excellent procedural success (96%) with mild or less MR in 100% of patients at a median 173-day follow-up.5 Whereas the early experience with transapical delivery of the Intrepid valve in a high-risk patient cohort was associated with high mortality (14% at 1 month),5 the development of a transfemoral delivery platform promises to reduce procedural morbidity and mortality.Often labeled the “forgotten valve,” tricuspid valvular regurgitation (TVR) is common and associated with substantial morbidity and mortality—as low as 34% survival at 5 years.7 However, late patient presentation, high comorbidity burden, and a high associated surgical mortality preclude many patients from receiving surgical treatment. Additionally, whether tricuspid valve intervention can improve patient outcomes is unclear because TVR is usually secondary to right ventricular dysfunction rather than being primary valvular disease. Therefore, it may often be a marker of severe disease rather than a pathophysiologic mediator.Nonetheless, transcatheter technologies are being studied for their potential to improve clinical outcomes of patients with severe TVR. The CLASP-TR trial, in which patients are being randomized to TEER with the PASCAL device vs medical therapy, should provide insight into the natural history of TVR and the utility of intervention.8 One of the major challenges is imaging. Owing to its more anterior position, clear transesophageal windows of the tricuspid valve are more difficult to obtain than are those with the mitral valve. Whereas the tricuspid valve has traditionally been viewed as trileaflet, tricuspid anatomy is actually quite diverse, often consisting of 4 or even 5 leaflets.9 New structural imaging guidelines aid in the evaluation of tricuspid valve disease and procedural guidance.10New transcatheter valve repair devices and transcatheter valve replacement technologies hold the promise of increasing the number of patients with structural heart disease who are eligible for transcatheter technologies and may permit more complete, durable responses to treatment; this will hopefully translate into better long-term patient outcomes.

PO-03-048 CLINICAL UTILITY OF IMPLANTABLE LOOP RECORDERS AFTER CRYPTOGENIC STROKE: INSIGHTS FROM A LARGE ACADEMIC STROKE CENTER

Detection of occult AF using implantable loop recorders (ILR) has become routine practice in the evaluation of cryptogenic stroke, yet there are few data demonstrating that ILRs reduce risk of recurrent stroke. Our aim was to determine if the diagnostic yield for ILR-detected AF in patients with cryptogenic stroke may be improved using clinical characteristics, and if ILR-directed changes in medical therapy reduce risk of recurrent stroke. We observed 282 consecutive patients with cryptogenic stroke (n=255) or transient ischemic attack (TIA, n=27) implanted with ILR at an academic stroke center for the clinical outcomes of first detected AF, recurrent stroke or TIA, and the temporal relation between AF and recurrent stroke/TIA. Collected data included demographics, comorbid medical conditions, stroke and imaging details, ECG and echocardiographic findings, and routine laboratory testing. During 557 days median follow-up, 50 (18%) patients manifested AF after a median 107 days, including 15% at 1 year, 20% at 2 years, and 23% at 3 years. All but 1 patient were started on a direct anticoagulant (n=48) or warfarin (n=1) upon AF diagnosis. Age (HR 1.04 per year, 95% CI 1.02-1.07; p<0.001) and middle cerebral artery stroke (HR 2.20, 95% CI 1.06-4.58; p=0.035) were independently associated with shorter time to first detected AF. Only 2 of 20 patients with recurrent stroke (n=17) or TIA (n=3) had ILR-detected AF; in both cases AF was first seen >1 year after recurrent stroke or TIA despite continuous monitoring. Age 65-years old best delineated risk of detected AF (area under ROC curve 0.66, p<0.001). Among 157 patients <65 years old, only 13 (8%) had AF; all had left ventricular end-diastolic dimension >4.60 cm (median LVEDD 4.90) and cortical stroke. Among 125 patients ≥65 years old, 37 (30%) had AF; mitral regurgitation (HR 1.98, 95% CI 1.06-3.72; p=0.03) was independently associated with shorter time to first AF detection. Detection of AF after cryptogenic stroke is highest within the first year of ILR monitoring. Consideration of age, stroke territory, and mitral valvular disease increases specificity for detecting AF and thus informs who should receive ILR. Correlation between recurrent AF and recurrent stroke or TIA is poor, raising concern that routine ILR use may not prevent additional strokes.

Auricle Myxoma, Evidence from the Clinic to Cardiovascular Emergency Surgery, Triad: Cardiac, Systemic, Embolic

Cardiac tumors are infrequent, primary tumors, such as atrial myxoma, are estimated at 000017 to 0.13% of all cardiac neoplasms, postmortem records, n relation to its frequency, it is more than the other primary ones, in 67% the left atrial myxoma, 23% in the right atrium and less frequent the biaurals left. age group from 30 to 60 years, more in the female sex, in the childhood is more related to alterations in skin lentiginosis, nevi as Carney.autosomica dominant síndrome. In genetic studies, alterations in the PRKAR1A gene on chromosome 17 are found. We present the case of a patient with a request for pre-surgical evaluation, urological prolapse of the bladder, with systemic manifestations, weight loss, chronic anemic syndrome treated with vitamins and trace elements, by a private physician, without remission. It is worth mentioning that the physical and cardiovascular examination revealed semiotic onygomatic seizures of Duroziez in the mitral area, with auscultatory changes in the left lateral decubitus position, for which reason I propose the diagnosis of mitral valvular heart disease vs atrial myxoma, with 2 elements of clinical judgment of the classic triad of myxoma, in the performance of the transcutaneous echocardiogram, a cardiac mass was observed, at the level of the left atrium, spherical, of 5.5 cmt diameter, hyperechogenic. Great mobility in cycles cardiac, prolapse of the mitral valve in diastole with stenosis, the emergency consultation was made to cardiovascular surgery in a hospital of greater complexity, a procedure with complete excision of the tumor of approx 12 cmt by 5.5 cmt diameter, with satisfactory evolution of the patient

Aetiology and Clinical Profile of Giant Left Atrium – An Observational Study

Background: The predominant cause of giant left atrium (GLA) is rheumatic mitral valvular disease. GLA is commonly defined echocardiographically by measuring the left atrial diameter (LAD). In the context of changing epidemiology of rheumatic heart disease (RHD) globally, and introduction of left atrial volume index (LAVI), the aetiology of GLA and utility of LAVI for defining GLA may be necessary. Methods: The prospective observational study was carried out at a dedicated tertiary care cardiac centre of a developing country to know the aetiology and clinical pattern of GLA over 8 years. GLA was defined echocardiographically as a left atrium (LA) having a diameter ≥80 mm in the left parasternal long-axis view. Follow-up was made over the telephone. Results: Thirty cases of GLA were diagnosed over 8 years from 2013 to 2021. Twenty two were due to rheumatic heart disease (RHD), 7 due to MVP, and 1 due to flail anterior mitral leaflet. Mean LAD was 92.13 ± 16.72 mm, and the mean LAVI was 288.77 ± 134.40 ml/m2. LA thrombus was present in 5 patients, 6 had spontaneous echo contrast (SEC) in LA, 2 had both LA thrombus and SEC. Mean follow-up was 0.99 ± 1.06 years. Out of 15 patients, 5 died, while 10 were alive. Mean survival was 1.8 ± 1.17 years, ranging from less than 1 year to 4 years. Conclusion: RHD continues to be the predominant cause of GLA; however, MVP is also important. The cut-off value of LAVI for defining GLA needs further study. Cardiovasc j 2023; 15(2): 151-158

Incomplete right bundle branch block associated with coagulation disturbance in mitral valvular disease in a dog – case report

An incomplete right bundle branch block (RBBB) associated with coagulation disturbance in mitral valvular disease was diagnosed in a five-year-old female Dachshund. Morphologically moderate mitral valvular thickening and nodularity could be noticed on echocardiography. Prolonged activated partial thromboplastin time and thrombocytopaenia supported the probable underlying mechanism for myocardial infarction and RBBB. The animal showed clinical improvement after one month of therapy with enalapril and torasemide for mitral valve insufficiency.

Risk Factors and Hospital Outcomes of Acute Kidney Injury in Patients Operated on for an acquired Valvular Heart Disease.

Aim To determine predictors of acute kidney injury (AKI) related with surgeries for correction of acquired valvular heart disease (HD) and to evaluate the incidence of in-hospital complications in patients with postoperative AKI.Material and methods This study included 62 patients after surgery for correction of acquired valvular HD (mean age, 61±10.9 years) with a disease duration of 11±5.3 years. NYHA functional class (FC) 1 chronic heart failure (CHF) was observed in 1.6 % of patients, FC 2 in 64.5 %, and FC 3 in 33.9 %.17.7% of patients had chronic kidney disease (CKD). Coronary lesions of ≥50 % of vascular lumen were detected in 27.4 % of patients. Surgical correction of mitral valvular disease was performed in 32 cases, aortic valvular disease in 36 cases, tricuspid valvular disease in 8 cases, and combined operations for correction of valvular disease and coronary bypass in 8 cases. Creatinine concentrations were measured according to the Jaffe method; glomerular filtration rate (GFR) was estimated with the CKD-EPI equation. AKI was diagnosed based on KDIGO (2012) criteria.Results The AKI incidence related with surgeries for correction of valvular HD was 16.1 % (8.1 % of patients had stage 1 AKI, 3.2 % had stage 2 AKI, and 4.8 % had stage 3 AKI), and 3.2% required kidney replacement therapy. AKI was associated with the presence of CKD at baseline (р=0.044), development of hemopericardium requiring drainage (р=0.012), more pronounced coronary lesions (in the AKI group: stenoses from 50 to 70 % in 20% of patients, from 70 to 90 % in 30 % of patients, and ≥90 % in 0 %; without AKI: from 50 to 70 % in 13.4 % of patients, from 70 to 90 % in 3.8 %, and ≥90 % in 5.8 % of patients, respectively; р=0.032). Probability of postoperative AKI significantly increased with the development of hemopericardium requiring drainage. Patients with postoperative AKI compared to persons without AKI had higher mortality (20 % and 0 %; р=0.001), greater incidence of decompensated CHF (40 and 9.6 %; р=0.012) and hemopericardium requiring drainage (30 and 1.9 %; р=0.012).Conclusion The development of postoperative AKI is associated with CKD at baseline, more pronounced coronary injury, and hemopericardium requiring drainage.

Surgical Outcomes After Reconstruction of the Aortomitral Curtain

Repair of concomitant aortic and mitral valvular disease with involvement of the aortomitral curtain requires a technically complex operation colloquially termed the commando procedure. Surgical outcomes of this procedure are not well described. The objective of this study was to examine outcomes of the commando procedure at our center. We identified all patients undergoing concomitant aortic and mitral valve replacements from 2004-2021. Of 363 patients, 41 underwent reconstruction of the aortomitral curtain. Survival analysis and multivariable modeling were used to examine outcomes and risk factors for mortality. The median age was 52 (IQR 44-71) years. Preoperatively, 4 of 41 (9.8%) patients had renal failure, and 10 of 41 (24.4%) had a stroke. The most common surgical indication was endocarditis in 25 of 41 (61.0%) patients. 25 of 41 (61.0%) patients underwent redo sternotomy, and 23 of 41 (56.1%) had previous prosthetic valves. Operative mortality was 14 of 41 (34.1%), and 8 of 41 (9.5%) patients received a permanent pacemaker. Survival at 1, 3, and 5 years was 55.4% (95% confidence interval (CI), 40.6-75.5%), 50.3% (35.0-72.3%), and 37.7% (19.3-73.9%) respectively. Cox proportional hazards regression identified previous sternotomy (HR 4.76, 95% CI 1.21-18.73), and female gender (HR 1.39, 95% CI 1.17-13.82) as risk factors for mortality. Patients undergoing reconstruction of the aortomitral curtain represent a high-risk population with complex surgical indications. Due to high perioperative morbidity and mortality, this procedure should be performed only when necessary. Despite a high up front morbidity burden, outcomes remain favorable for patients who survive the initial hospitalization.

Preclosure of large bore venous access sites in patients undergoing transcatheter mitral replacement and repair.

We aim to report on the efficacy and safety of large bore venous access (LBVA) preclosure with Perclose™ (Abbott Vascular Devices) suture-mediated device use following transcatheter edge-to-edge (TEER) and replacement (TMVR). Patients requiring TEER and TMVR require LBVA. Clinical outcome data on the use of suture-mediated devices for LBVA site closure are limited. Between 2012 and 2019, 354 consecutive high-risk patients with mitral valvular heart disease underwent TEER (n = 287) with MitraClip and TMVR (n = 67) with Edwards Sapien Valves. Patients had LBVA with 24 or 16 French sheaths. All patients underwent preclosure of LBVA except for one that underwent manual hemostasis. There were no closure device failures. None of the cases required surgical repair of the access site following venous preclosure. Two cases had large hematomas (>6 cm) following Perclose in each group. Six cases had small hematomas (<6 cm and >2 cm) with three in each group. There was one major bleeding using Mitral Valve Academic Research Consortium 2 definition (retroperitoneal bleed from arterial puncture) unrelated to the venous closure. Transfusion related to vascular access complication was required in five cases. There were two immediate acute deep venous thromboses postprocedure; one of which occurred after preclosure. There were no arteriovenous malformations, pseudoaneurysms, or access site infections reported following Perclose. In this large sample size analysis, Proglide preclosure technique is a feasible and safe alternative approach to achieving hemostasis after removal of LBVA sheaths in patients undergoing TEER and TMVR. Randomized trials are needed to compare the different modalities of hemostasis.

Intractable/ Persistent Hiccups Due to Acute Subdural Haemorrhage as a Result of Prolonged Inr in a 55 Year Old Man with Rheumatic Mitral Valvular Heart Disease and Atrial Fibrillation: A Case Report

A 58 year old man was brought to hospital in state of deep coma following severe headache for one day. His GCS was 3/15 and had flaccid all 4 limbs with equivocal planter response on both sides on arrival. NECT head showed acute subdural haemorrhage with surrounding cerebral oedema, mid-line shift and corning of brain stem. After giving mannitol and dexamethasone, four hours later, he became fully conscious and orientated; his motor power returned to normal. He was on warfarin 3mg daily for rheumatic mitral valvular heart disease with atrial fibrillation and his INR on arrival was 3.5. He had intractable hiccups once he regained consciousness. Both pharmacological and non-pharmacological measures were tried for distressing hiccups; there was no therapeutic success. His hiccups disappeared completely only after removing the haematoma by burr hole surgery.

Abstract 11984: Impact of Underlying Pulmonary Hypertension on In-Hospital Outcomes Among Patients With Septic Shock

Background: Pulmonary Hypertension (PHTN) patients typically have chronic multiple comorbidities and are more vulnerable to acute clinical conditions leading to decreased survival. The impact of pulmonary hypertension on outcomes in patients with septic shock remains unknown. Methods: Adult patients with a diagnosis of septic shock were identified in the National Readmissions Database (NRD) between the years 2016-2017. Propensity matched retrospective cross sectional clinical outcomes were compared between patients with and without non-cardiac PHTN using appropriate statistical methods after nearest matching on a 2:1 ratio for several demographic, social and clinical variables. Patients with cardiogenic shock, aortic and mitral valvular heart disease, underlying systolic and combined heart failure (HF), and PHTN due to left heart disease were excluded from the primary analysis. Appropriate ICD-10 codes were used. Results: A total of 13,676 patients diagnosed with non-cardiac PHTN and septic shock were identified with a mean age of 68 years and 58.6% identified as females. Patients with PHTN had higher comorbidities, including hypertension, chronic pulmonary disease, renal failure, diabetes, CAD, and obesity. After matching, patients with septic shock and non-cardiac PHTN were noted to have a higher mortality (33.2% vs 31.3%, p &lt; 0.001), greater vasopressor use (7.9% vs 6.6%, p &lt; 0.001), higher rates of acute heart failure (1.1% vs 0.6%, p &lt; 0.001), longer hospital stay (14.0 days vs 12.7 days, p &lt; 0.001), and higher hospital costs ($196,411 vs $171,537), when compared to patients with septic shock and without PHTN. Rates of AKI were noted to be lower in patients with PHTN. Amongst stroke outcomes, minimal differences in ischemic strokes were noted. There were no MI outcomes observed. Discussion: PHTN is associated with worse mortality, morbidity, and resource utilization outcomes in patients admitted with septic shock, except AKI. These findings should be interpreted carefully given the administrative nature of the database, and the population cohort restricted to readmissions.

Prevalence of mitral annular calcification and its association with mitral valvular disease.

Mitral annular calcification (MAC) is increasingly observed in elderly population. The purpose of this study was to investigate incidence of MAC and its association with mitral valvular disease (MVD). A total of 13,483 consecutive patients who underwent echocardiography were enrolled. MAC was defined as an echo-dense, shelf-like structure with an irregular, lumpy appearance involving the mitral valve annulus, with acoustic shadowing. Prevalence of MAC and its association with significant mitral stenosis (MS) or mitral regurgitation (MR) were studied. Significant (≥moderate) MS was defined as mean transmitral valvular pressure gradient>5mm Hg and significant MR was defined as ≥moderate MR based on quantitative or semi-quantitative Doppler methods. MAC was present in 1881 of 13,483 patients (14%). Patients with MAC (MAC group) was older and more female gender than those without MAC (non-MAC group). Significant MS was present in 2.2% of MAC and in .6% of the non-MAC group (p<0.0001). Significant MR was present in 11.9% of MAC and in 5.0% of the non-MAC group (p<0.0001). Co-existence of MAC and aortic valve replacement (AVR) was associated with increased prevalence of MVD (MS:11.4%, MR:17.2%, respectively). MAC was present in 14% of the patients and was associated with significant MVD. Co-existence of MAC and AVR may increase the risk of MVD.