Mitral Valvular Disease Research Articles

Prognostic value of cardiopulmonary exercise testing in valvular heart disease

Abstract Introduction Cardiopulmonary exercise testing (CEPT) is not routinely used for the assessment of valvular heart disease (VHD) patients. The cutoff values of percentage of predicted peak VO2 and ventilatory efficiency parameters that carry out a bad prognosis have been predominantly validated in heart failure. The aim of this study was to analyze the prognostic value of CPET parameters in a broad population of VHD patients. Methods 163 patients (51% female) with moderate or severe VHD who underwent a CEPT (n=197) at their physician's discretion from 2017 until 2019 were included. We calculated the net reclassification index of CPET, compared to the classical clinical or echocardiographic parameters, regarding the need for surgical indication. Also, the predictive value of CPET for death and symptom development during follow-up was estimated using regression analysis. Results At inclusion, all patients were asymptomatic or with minimal equivocal symptoms. Aortic valvular lesions were the most common (47%), followed by mitral valvular disease (44%). There was a predominance of severe valvular heart disease (71%) and most of the CEPTs were performed on a treadmill (74%). The percentage of predicted peak VO2 was 76±18% and at anaerobic threshold was 61±18%. The mean follow-up time was 15±10 months. There were 5 deaths (3%) and 24 patients became symptomatic. The net reclassification index of CPET over either clinical or echocardiographic parameters was 46%. The CEPT parameters that predicted increased risk of death were VE/VCO2 slope (p=0.009), % of predicted peak VO2 (p=0.049) and Eq CO2 at anaerobic threshold (p=0.047). None of the CEPT parameters was predictive of symptom development during follow-up, however, in the subgroup of patients who became clearly symptomatic, the ventilatory efficiency parameters were similar to the cut off values that confer bad prognosis (see Table in Figure). Conclusion In our series, CPET added prognostic mortality value to patients with VHD. The cut off values used for patients with HF can also be applied in a VHD population. In addition, CEPT clearly improved the clinical decision for surgical referral. Nevertheless, these results need to be validated in a broader population. Funding Acknowledgement Type of funding sources: None.

Burden of Valvular Heart Disease in Patients with Fabry Disease

Fabry disease (FD) is an X-linked lysosomal storage disorder in which glycosphingolipids accumulate in tissues, causing multisystem disease. FD is associated with mild tricuspid, aortic, and mitral valvular heart disease (VHD).1-3 The burden of VHD in the aging FD population treated with modern medical therapy, including enzyme replacement therapy (ERT), substrate reduction therapy, and aggressive control of cardiovascular comorbidities, is unknown. We describe the burden of VHD in a multicenter cohort of patients with FD with access to contemporary FD therapy.

SILENT GIANT LEFT ATRIUM

TOPIC: Cardiovascular Disease TYPE: Global Case Reports INTRODUCTION: Enlarged LA is a common finding in severe mitral stenosis(MS) and severe mitral regurgitation(MR). It can enlarge to giant proportions. The unusual finding in a thirty-year-old woman presenting with only mild dyspnea despite a hugely dilated LA prompted us to report this case CASE PRESENTATION: A thirty-year-old woman presented to the outdoor clinic with the complaint of dyspnea on exertion NYHA class I. Aside from mild shortness of breath during the past year, she had been asymptomatic all her life. The admission electrocardiogram showed atrial flutter with the variable block while her chest roentgenogram showed marked cardiac enlargement. The right heart border showed a double contour of atrial shadow (Fig.2). An echocardiogram showed a giant left atrium measuring 14.4 X 16.7 cm that encroached on the other cardiac chambers (Fig.3). Thickened mitral valves along with doming and restricted motion of anterior and posterior mitral leaflets were diagnostic of rheumatic heart disease(RHD) It was surprising to find a relatively asymptomatic patient despite the marked distortion of cardiac anatomy. DISCUSSION: Giant LA occurs due to many reasons but most commonly its result from long-standing rheumatic mitral valve regurgitation or mixed mitral valve disease with predominant regurgitation. Two factors implicated in its development are increased LA pressure and weakening of the LA wall by Rheumatic Pancarditis. When mitral valve disease persists for long, it leads to LA enlargement as a compensatory mechanism to ease the markedly increased LA pressure which could lead to pulmonary Congestion due to backpressure hemodynamic and hence protect from the development of pulmonary hypertension. These compensatory mechanisms help patients survive asymptomatically for a long time. Giant LA can lead to various complications including thromboembolism, pulmonary edema, pulmonary hypertension and it can compress the esophagus and airway causing Dysphagia. CONCLUSIONS: Progressive LA enlargement might be undetected and well-tolerated for a long time, even when it reaches massive proportions. When the LA enlarges to a gigantic size, a chest x-ray is insufficient to delineate the cause of cardiomegaly and even can be misleading. An echocardiographic study is the most useful method for evaluating these patients. Our case was unusual because the giant LA distorted the cardiac structures. This led to striking cardiomegaly on the chest x-ray, and it confused interpreting the cause of the enlarged cardiac silhouette. The echocardiogram was very helpful in demonstrating the severe MS and the giant LA. There is a poor correlation between the size of the left atrium and the severity of the MS. REFERENCE #1: Kawazoe K, Beppu S, Takahara Y, Nakajima N, Tanaka K, Ichinashi K, Fujita T, Manabe H: Surgical treatment of giant left atrium combined with mitral valvular disease. Plication procedure for reduction of compression to the left ventricle, bronchus, and pulmonary parenchyma. J Thorac Cardiovasc Surg 1983, 85: 885-892. REFERENCE #2: Hurst W: Memories of patients with a giant left atrium. Circulation2001, 104: 2630-2631. 10.1161/hc4701.100775 REFERENCE #3: Plaschkes J, Broman JB, Mercin G, Milwidsky H: Giant left atrium in rheumatic heart disease: a report of18 cases treated by mitral valve replacement. Ann Surg 1971, 174: 194-201. 10.1097/00000658-197108000-00004 DISCLOSURES: No relevant relationships by Vikash Jaiswal, source=Web Response no disclosure submitted for Akshyaya Pradhan; No relevant relationships by Prachi Sharma, source=Web Response No relevant relationships by Shweta Vohra, source=Web Response

Transcatheter mitral valve therapies: State of the art.

Mitral regurgitation (MR) is one of the most prevalent valvular pathologies in the developed world. There continues to be a growing population of aging patients with MR who may be too high risk for surgical management. The rapid adoption and remarkable success of transcatheter aortic valve replacement (TAVR) generated enthusiasm for transcatheter mitral valve therapies; however, the complex anatomy and pathophysiology of the mitral valve confers several unique challenges for a fully percutaneous approach. Nevertheless, several devices are under development and in various phases of preclinical or clinical testing, both for transcatheter mitral valve replacement and repair. MitraClip (Abbott Vascular), which has received FDA approval, is the most established percutaneous repair strategy and has been performed in over 80,000 patients as of 2019. The following article serves as a review of the available and upcoming devices for the various etiologies of mitral valvular disease, as well as the unique challenges and potential complications of transcatheter mitral valve intervention.

Huge Left Atrial Aneurysm: First Case Report in Bangladesh

The left atrial aneurysm (LAA) is an extremely rare congenital malformation of the heart. It can be caused by congenital dysplasia of atrial muscle. It may result secondarily from severe mitral valvular disease. This is the first ever case of left atrial aneurysm in an 8 months old child of Bangladesh who was treated successfully and now leading a normal life after surgical resection. Cardiovasc j 2021; 14(1): 70-72

Clinical Assessment of Mitral Valvular Diseases Requiring Its Prosthetic Replacement

Objectives: The patient’s clinical assessment having mitral valvular diseases requiring its prostheticreplacement was done in the current study. Methods: The study included 45 selected cases of the mitralvalvular lesion that underwent prosthetic replacement of mitral valve admitted in the cardiothoracic surgerydepartment at a tertiary care centre. A detailed history of each patient was taken, and subsequent managementand follow up was done. The pre-operative clinical features of the patients were presented in terms offrequencies. Results: The patient’s peak age group was 31 to 40 years, comprising 42.22%. There was a femalepredominance with 28 (62.22%) patients. Dyspnea was the presenting feature in all 45 (100%) patients.Valvular lesions of the patients were diagnosed with Mitral stenosis, Mitral regurgitation and combinedvalvular lesion. In the present study, valvular lesions were predominantly associated with Rheumatic fever’shistory in 24 (53.33%) patients. Calcification was noted either in valve leaflet or annulus in 12 (26.66%)cases. Calcification was confirmed by pre-operative echocardiography and during the perioperative period.It is equally noted in mitral stenosis cases and combined valvular lesion. The maximum 33 (73.33%) patientsbelonged to the NYHA Class III, followed by Class IV. The associated other valvular lesions mainly were in7 (15.55%) cases that belonged to mild aortic regurgitation. 36 (80%) cases were diagnosed with left atrialenlargement followed by right ventricular enlargement for 23 (51,11%) patients. Left atrial hypertrophywas the most common feature for 39 (86.66%) cases. Conclusion: During the pre-operative period, clinicalassessment is critical to determine the extent of illness and type of valvular diseases. The results of this studyare comparable to other similar published clinical observations.

Clinical picture, diagnosis and treatment of mitral valvular diseases

Heart defects are pathological changes in the heart, during which the defects of the valve apparatus or its walls are observed, leading to heart failure. There are two large groups of heart defects: congenital and acquired. The diseases are chronic, slowly progressing; therapy only alleviates their course, but does not eliminate the cause of their occurrence; full recovery is possible only with surgical intervention. This article is devoted to the issues of classification, etiology, pathogenesis, clinical symptoms, approaches to the diagnosis and treatment of mitral valvular diseases.

A Rare Cause of Hemiparesis: Intracranial Mycotic Aneurysm—A Case Report, and Review of the Literature

Background: The intracranial mycotic aneurysm is known to be a rare complication of infective endocarditis and it is more clinically challenging to get this diagnosis right when it happened to be in a patient without a past medical history of heart diseases. We report a documented case of mycotic aneurysm revealed by isolated left hemiparesis and our management with the collaboration of the cardiology department. Case Description: A 48-year-old male patient with a history of teeth loss, a chronic smoker presented with sudden heaviness in the left upper and lower limbs. No fever. Physical examination revealed a left hemiparesis of 3/5 on the muscle tone scale without the stiffness of the neck. The CT-Scan and the MRI conclude of subarachnoid and cerebral hemorrhage with right temporal hematoma being most probably a vascular malformation. The cerebral arteriography concluded of a right Sylvian mycotic distal aneurysm in the M4 segment. Transesophageal echocardiography was performed and concluded of infectious endocarditis with mitral and aortic valvular disease grade II. Positive blood culture for staphylococcus coagulase-negative. The patient was managed with antibiotic therapy and clinically stable after 28 days. He was then transferred to the cardiology department for follow-up. Six (6) months later a CT-angiography was done for a check-up and shows no further changes in the aneurysm. The patient underwent surgery, two (2) months later, for clipping the aneurysm because the aneurysm did not regress in size. The aneurysm was then excluded with an eventless post-operative period, confirmed by controlled cerebral arteriography. The patient was discharged five (5) days later and he is doing well. Conclusion: Mycotic aneurysm is a rare consequence of infective endocarditis. The distal sites of the middle cerebral artery are commonly found, and conservative treatment with a long course of antibiotics like amoxicillin 12 g/24h for 6 weeks or direct surgical clipping or excision can manage it.

Non-infectious thrombotic endocarditis associated with chronic rheumatic heart disease and disseminated tuberculosis.

ABSTRACTRheumatic heart disease is still common in developing countries and requires prompt intervention to prevent chronic complications. Vegetations in rheumatic heart disease might be due to acute episodes of rheumatic fever itself or due to either infective endocarditis (IE) or Non-infectious thrombotic endocarditis (NITE). Each form of vegetations has specific pathological characteristics on gross and microscopic examination. However, clinically IE and NITE may have overlapping signs and symptoms. A chance of misdiagnosis of NITE as culture-negative infective endocarditis is higher if the former present with infective symptoms like fever. NITE of valves can be due to underlying associated malignant neoplasm, particularly mucinous adenocarcinoma, pneumonia, cirrhosis, autoimmune disorders, and hypercoagulable state. The coexistence of tuberculosis, non-infectious thrombotic endocarditis and rheumatic valvular heart disease was rarely documented in medical literature. We describe a case of chronic rheumatic heart disease with vegetations in the posterior mitral valve leaflet, treated as culture-negative infective endocarditis, which, at autopsy, reveals the presence of Nonbacterial thrombotic endocarditis vegetation over calcified, fibrosed mitral valve leaflets and associated disseminated tuberculosis along with classic pathological sequela findings of chronic rheumatic mitral valvular heart disease in lungs and liver.

Imaging the mitral valve: a primer for the interventional surgeon.

Transcatheter mitral valve interventions (TMVI) have evolved over the past decade as alternatives to open surgical repair for the therapeutic management of patients with severe mitral regurgitation (MR). Concurrent with the development of these technologies, quality multi-modality cardiac imaging has become essential in patient selection and procedural guidance. The former involves assessments of the pathophysiologic mechanisms of regurgitation, valvular anatomy and morphology, as well as objective quantification of the severity of MR. Both transthoracic and transesophageal echocardiography (TEE) are crucial and serve as the gateway to diagnosis and management of mitral valvular disease. Along with multi-detector computed tomography (CT) and cardiac magnetic resonance imaging (CMR), echocardiography plays an important role for preprocedural planning and evaluation of the spatial relationships of the mitral valvular complex with the coronary sinus, circumflex coronary artery and left ventricular (LV) outflow tract. Procedures that target mitral leaflets (e.g., MitraClip, PASCAL) or annulus (e.g., Cardioband, Carillon), or provide chordal (e.g., NeoChord, Harpoon) or valvular replacement, tend to be guided by TEE and assisted by fluoroscopy. As newer devices become available and outcomes of TMVI improve, cardiac imaging will undoubtedly continue to play an essential role in the success of percutaneous mitral valve repair (MVr) and replacement. The interventional surgeon of the future must therefore have a thorough understanding of the various imaging modalities while synthesizing and integrating novel concepts (e.g., neo-LV outflow tract) as applicable to assessing valvular function and pathology.

Evaluation of Mitral and Aortic Valvular Disease and Left Ventricular Dysfunction in a Lebanese Population: Retrospective Single-Center Experience.

BackgroundRecently, new therapeutic approaches have revolutionized the management of left ventricular dysfunction (LVD) and valvular heart disease (VHD), which are a growing public health problem. In parallel, there are no available epidemiological data about LVD and VHD in developing countries, especially in the Mediterranean area. This retrospective study was conducted at a single center and aimed to evaluate the associations between mitral and aortic valvular disease and left ventricle systolic and diastolic dysfunction in the Lebanese population.Material/MethodsA retrospective study was conducted of 4520 consecutive patients aged >18 years who were referred to the Cardiovascular Department of Notre Dame de Secours-University Hospital in Jbeil-Lebanon for transthoracic echocardiography between December 2016 and December 2019. The study population was divided into different groups based on types of LVD and VHD. Left ventricle systolic dysfunction was defined as a left ventricle ejection fraction (EF) ≤40%. Statistical analysis was carried out using SPSS software version 20.ResultsVHD and systolic dysfunction were more common in men, whereas diastolic dysfunction was more common in women. Being older than age 65 years and smoking were significantly associated with heart failure with preserved EF, whereas female sex was a significant preventive factor against heart failure with reduced EF. Systemic hypertension was correlated with mitral stenosis and tricuspid regurgitation, whereas diabetes mellitus was associated with tricuspid regurgitation (TR). Smoking and older age also appeared to be associated with aortic stenosis.ConclusionsMitral valve disease (regurgitation and stenosis) was significantly correlated with systolic dysfunction, whereas aortic and mitral regurgitation were associated with diastolic dysfunction. Better monitoring of cardiovascular disease risk factors may lead to a reduced burden of LVD and VHD.

A Severe Case of Idiosyncratic Hepatotoxicity with Unfractionated Heparin.

The authors describe a case of clinically apparent idiosyncratic hepatotoxicity in association with unfractionated heparin (UFH). A 52-year-old woman with increasingly symptomatic rheumatic mitral valvular disease and severe pulmonary hypertension underwent elective minimally-invasive bioprosthetic mitral valve replacement. The patient received 42 000 units of UFH intraoperatively 10 days after receiving 3100 units during a left heart catheterization. Standard prophylactic doses of unfractionated heparin were started on POD 2 for prevention of venous thromboembolism. On the evening of postoperative day (POD) 3, the patient was lethargic, encephalopathic, and hypoglycemic with an acute liver injury and hyperlactatemia. Similar events occurred on POD 7 after clinical improvement from the initial injury and an unintentional rechallenge with UFH. Heparins are usually not suspected of idiosyncratic hepatotoxicity due to their widespread utilization and reports of milder episodes of hepatotoxicity. This case highlights the need to consider UFH in the differential of drug-induced liver injury, including severe cases.

Early outcomes of mitral valve replacement with a mechanical prosthesis for rheumatic mitral valve disease.

Objectives: To study the early outcomes of mitral valve replacement with a mechanical prosthesis is patients with rheumatic mitral valvular disease. Study Design: Retrospective Observational study. Setting: Punjab Institute of Cardiology, Lahore and Rawalpindi Institute of Cardiology, Rawalpindi. Period: From August 2014 to August 2017. Material & Methods: Consecutive patients who underwent mitral valve replacement for a rheumatic pathology were included in the study. Patients undergoing a redo surgery, those with concomitant aortic valve intervention, coronary artery bypass grafting and emergency procedures were excluded from the study. Results: Of the 104 patients included in the study, 58 (56.2%) were female patients. The mean age of the patients was 35 ± 12.36 years (median 33 years). Sixty (58.5%) had hypertension and 22 (21.28%) had diabetes. Mitral valve stenosis was the main pathology in 84 (81.25%). Severe pulmonary hypertension was recorded in 15 (15%) patients. The mean preoperative Tricuspid Valve Pressure Gradient (TVPG) was 55.33 ± 18.35 mmHg. The mean cross clamp time was 45.33 ± 12.32 minutes. The postoperative tricuspid valve pressure gradient came down to 31.5 ± 12.21 mmHg. No patients had acute renal injury, pulmonary complications or re-exploration for bleeding. Perioperative mortality was 4 (3.75%). Conclusion: Rheumatic valvular disease is still prevalent in our part of the world. Most of the patients with rheumatic heart disease will end up with replacement of the valve. Replacement with a mechanical prosthesis has favorable early outcomes.

Correction of Postoperative Anemia in Patients undergoing Mitral Valve Replacement through Blood Saving Technology

The aim. To investigate anemia of chronic disease (ACD) in patients with mitral valvular disease, to provide preoperative correction in these patients and to determine the level of postoperative anemia after mitral valve replacement (MVR) through blood saving technology (BST) under artificial circulation (AC).Materials and methods. This is a study of 104 patients operated due to acquired mitral heart defects under AC. According to the baseline Hb, Ht, serum iron (SI) as well as the use of BST during MVR, all the patients were divided into 3 groups. Group A included 47 patients with normal Hb concentration, Ht and SI, who underwent the surgical intervention without BST with blood transfusion. Group B included 35 patients without ACD who were operated without blood transfusion with the use of BST. The group C included 22 patients with preoperative ACD with low Hb, Ht, and SI. A week before surgery the patients of group C underwent preoperative correction of SI and erythropoiesis stimulation using erythropoietin. The patients of group C were operated using BST. Preoperative correction of anemia and the use of blood and BST during surgery in groups A, B, C were compared. The effect of preoperative ACD correction and erythropoiesis stimulation on the level of postoperative anemia in patients operated due to mitral heart disease through BST in group C and with or without correction in group B was studied.Results. The presented research results show that in group A, in order to sufficiently stabilize the level of Hb and Ht during the operation, donated blood components (590.0 ± 83.0 ml of packed red blood cells and 563.0 ± 68.0 ml of fresh frozen plasma) were used. The use of BST in the group B reduced the level of Hb by 17.4%, Ht by 15.8%, thrombocyties by 20.5%, and the intervention could be performed without donated blood transfusion. Preoperative correction of SI and administration of erythropoietin in patients with ACD resulted in 8.6-fold increase in SI, 5.5-fold increase in ferritin and increase in Hb by 8.1% before the intervention. The use of BST and hematopoietic technology during MVR in patients of group C stabilized SI, Hb and platelets in the operative period, which facilitates operations under AC without transfusion of donated blood components.Conclusions.1. In patients of group A, donor blood components (590.0 ± 83.0 ml of packed red blood cells and 563.0 ± 68.0 ml of fresh frozen plasma) were used to stabilize Hb and Ht during MVR without the use of BST.2. ACD correction in patients of group C with mitral heart disease has led to a 8.6-fold increase in SI (p˂0.05), increase in transferrin saturation coefficient by 36.8% (p˂0.05), and 5.5-fold increase in ferritin activity (p˂0.05).3. The use of BST in patients of group B undergoing MVR reduces the level of Hb by 17.4% (* p˂0.05) and platelets by 20.5% (* p˂0.05).4. Preoperative correction of SI with iron (III) hydroxide and hemapoiesis stimulation by erythropoietin in patients of group C with MVR using BST reduces anemia by 10.7% and thrombocytopenia by 5%.

Analysis of Red Blood Cell Parameters in Dogs with Various Stages of Degenerative Mitral Valve Disease.

IntroductionAlthough peripheral blood analysis has become increasingly automated, microscopy is the only available method for the diagnosis of anisocytosis and poikilocytosis. The aims of the study were to compare RBC volume data obtained with two different analysers and by manual assessment of smears and to compare this data between dogs in various stages of heart failure secondary to degenerative mitral valvular (DMV) disease. The impact of diuretic administration on RBC morphology was also assessed.Material and MethodsSixty-eight dogs, 56 in different stages of DMV disease and 12 as healthy controls, were studied. Impedance and flow cytometry haematological analyses were performed for each animal. Additionally, two smears were prepared for manual analysis. RBC structure, staining, and size differences were recorded.ResultsThere were no significant differences between the blood morphological parameters assessed using haematological analysers nor between dogs receiving diuretic treatment and those not treated. Based on the manual smear, significantly higher erythrocyte anisocytosis was observed in the dogs with symptomatic DMV disease than in the control group.ConclusionHaematological analysers based on impedance and flow cytometry provide reliable and comparable morphological results in dogs with heart failure. However, microscopic assessment of blood smears is a more reliable tool to detect erythrocyte anisocytosis.

Retrospective Study of the Outcome of Mitral Valve Replacement with or without Tricuspid Valve Repair in Ain Shams University

Abstract Background Rheumatic mitral valvular disease is more common than degenerative mitral valve disease. Mitral valve repair is not possible in large number of patients because of rheumatic cicatrized subvalvular mitral valve disease. The prosthetic mitral valve replacement is commonly performed in our center. Objective The aim of the study was to evaluate and assess the short outcome of Mitral Valve Replacement with or without Tricuspid Valve Repair. Patients and Methods This study was done in department of Cardiothoracic surgery, Faculty of Medicine at Ain Shams university, after approval of the local ethical committee from 2015 to 2016.The inclusion criteria includes All gender, All age, Primary Mitral valve replacement for severe Mitral valve disease of Rheumatic origin with or without Tricuspid Valve Repair and Primary Mitral valve replacement for severe Mitral valve disease of Degenerative origin with or without Tricuspid Valve Repair and the exclusion criteria includes concomitant coronary artery bypass graft surgery or other cardiac operations or infective endocarditis and Patients with chronic liver, kidney and parenchymal pulmonary disease. Results This study included one hundred and seventy- seven (177) patients; One hundred and thirty one (131) patients did Mitral Valve Replacement without Tricuspid valve Repair, Fourty six (46) patients did Mitral valve Replacement with Tricuspid valve Repair and the outcome was Mortality (3.9%), Reoperaion (5.08%), Stroke (0. 56%), Re-Intubation (1.13%) and Re-Admission to ICU (1.69%) Conclusion The Reoperation has a direct relation and effect on the Mortality,Prolonged bypass time independently predicts postoperative morbidity and mortality and Prolonged aortic cross-clamp time significantly correlates with major post-operative morbidity and mortality.

Thromboembolism and bleeding complications in anticoagulated patients with atrial fibrillation and native aortic or mitral valvular heart disease: a descriptive nationwide cohort study.

To describe the risks of thromboembolism and major bleeding complications in anticoagulated patients with atrial fibrillation (AF) and native aortic or mitral valvular heart disease using data reflecting clinical practice. Descriptive cohort study of anticoagulated patients with incident AF and native aortic or mitral valvular heart disease, identified in nationwide Danish registries from 2000 to 2018. A total of 10043 patients were included, of which 5190 (51.7%) patients had aortic stenosis, 1788 (17.8%) patients had aortic regurgitation, 327 (3.3%) patients had mitral stenosis, and 2738 (27.3%) patients had mitral regurgitation. At 1 year after AF diagnosis, the risk of thromboembolism was 4.6% in patients with mitral stenosis taking a vitamin K antagonist (VKA), and 2.6% in patients with aortic stenosis taking a VKA or non-vitamin K antagonist oral anticoagulant (NOAC). For patients with aortic or mitral regurgitation, the risks of thromboembolism ranged between 1.5%-1.8% in both treatment groups. For the endpoint of major bleeding, the risk was ∼5.5% in patients with aortic stenosis or mitral stenosis treated with a VKA, and 3.3-4.0% in patients with aortic or mitral regurgitation. For patients treated with a NOAC, the risk of major bleeding was 3.7% in patients with aortic stenosis and ∼2.5% in patients with aortic or mitral regurgitation. When using data reflecting contemporary clinical practice, our observations suggested that 1 year after a diagnosis of AF, anticoagulated patients with aortic or mitral valvular heart disease had dissimilar risk of thromboembolism and major bleeding complications. Specifically, patients with aortic stenosis or mitral stenosis were high-risk subgroups. This observation may guide clinicians regarding intensity of clinical follow-up.

Effectiveness of sildenafil in pulmonary hypertension secondary to mitral valve disease

Background and Aim: Pulmonary arterial hypertension almost always accompanies long-standing mitral valvular heart disease. The objective of this study is to study the effectiveness of sildenafil in reducing pulmonary hypertension in the peroperative and perioperative period. Materials and Methods: Fourteen patients were randomized into two groups test and control. Patients with mitral valvular disease with Pulmonary Artery Systolic Pressure (PASP) >50 were selected from the outpatient department and echo was done before the admission. Patients in the test group and control group were administered oral sildenafil 25 mg and placebo, respectively, three times a day in the preoperative period in the same fashion for 2 weeks. Preoperative echo was repeated thereafter. After induction of anesthesia and with all aseptic and antiseptic precautions, pulmonary artery catheter was inserted in the right internal jugular vein. PASP was calculated ½ hour after the induction of anesthesia. After operation, patients were monitored by transthoracic echo after 1 week. After discharge, patients were monitored by transthoracic echo at 1 month and at 3 months. Patients' data were analyzed using the statistical tools such as mean, Chi-square test for independence, and paired t-test. Results: There was a statistically significant reduction in PASP in the sildenafil group in the preoperative period (P

Circulating Stromelysin-1 (MMP-3): A potential predictor for atrial fibrillation in patients with mitral stenosis

The mitral valvular disease is strongly related to atrial fibrillation (AF). The impact of matrix metalloproteinases (MMPs) on structural atrial remodeling and sustainment of AF in patients with AF is unresolved. This study aimed to investigate serum metalloproteinases as markers of atrial remodeling in patients with mitral stenosis. Blood sample, clinical and echocardiographic parameters were evaluated in 73 patients with mitral stenosis: 37 with AF and 36 with sinus rhythm. The Plasma levels of MMP-3, MMP-2, MMP-9 and TIMP-1 were measured by ELISA sandwich assay. The concentration of MMP-3 ( P = 0.05) was significantly higher in patients with AF than in patients with sinus rhythm. After adjusting for age, gender, and treatment, the regression model indicates that the high MMP-3 appears to be a risk factor for AF (OR = 1.5, P = 0.001). ROC curve showed that plasma levels of MMP-3 can be predict atrial remodeling in patient with mitral stenosis at the cutoff value of > 9.05 ng/ml with an area under the curve (AUC = 0.618, P = 0.038). The combined analysis with the receiver-operating curve of matrix parameters shows a strong association with AF where we observed an increased area (0.706, P = 0.004). Elevated level of MMP-3 was related to the occurrence of AF. This suggests that MMP-3 could be a marker of atrial remodeling in patients with AF.

Rheumatic heart disease in Nigeria: A review

Rheumatic heart disease (RHD) is a major public health problem in resource-poor countries, especially in sub-Saharan Africa where about 1 million affected children between 5 and 14 years of age live with the disease. The aim of this paper is to review current knowledge on the clinical epidemiology of RHD in Nigeria, identify gaps, and suggest possible future directions. A systematic literature search was conducted using African Journal online (AJOL), Cinahl, Google Scholar, PubMed, and Web of Science. In PubMed, the following medical subject headings and free text terms were used: “Rheumatic heart disease” OR “Rheumatic “Valvular heart disease” OR “Rheumatic fever” AND “Nigeria”. The same text word search was used in Google scholar, AJOL, CINAHL, and Web of Science. A search date was limited to articles published from January 1950 to December, 2018. A total of 44 original studies were reviewed. Nineteen (45.2%) of the studies used clinical criteria for diagnosis of RHD, 19 (40.5%) used echocardiographic diagnosis, and 6 (14.3%) used autopsy or post mortem examination of the patients for the diagnosis of RHD. Five (11.9%) of the studies were conducted in children only, 9 (16.7%) were in both children and adults, and the remaining 31 (73.8%) were done in adults only. Only 6 (14.3%) of the studies reported complications seen in patients with RHD. Of the 6 studies that reported on complications, only 1 reported on recurrent of acute rheumatic fever. Mitral valvular disease was the most common lesion reported in all the studies. RHD still remains a major cardiovascular health problem in Nigeria. There is therefore a need for more recent clinical studies on the contemporary pattern of RHD in Nigeria. In addition, community based screening for RHD is needed to determine the true burden of the disease in Nigeria. Finally, primary and secondary preventive measures are needed to help reduce the burden of RHD in Nigeria.