Mitral Valvuloplasty Research Articles

Two-dimensional-Wilkins and real-time transesophageal three-dimensional scoring systems: Which one is preferred to mitral valve morphological assessment?

To quantify valvular morphological assessment, some two-dimensional (2D) and three-dimensional (3D) scoring systems have been developed to target the patients for balloon mitral valvuloplasty; however, each scoring system has some potential limitations. To achieve the best scoring system with the most features and the least restrictions, it is necessary to check the degree of overlap of these systems. Also the factors related to the accuracy of these systems should be studied. We aimed to determine the correlation between the 2D Wilkins and real-time transesophageal three-dimensional (RT3D-TEE) scoring systems. This cross-sectional study was performed on 156 patients with moderate to severe mitral stenosis who were candidates for percutaneous balloon valvuloplasty. To morphologic assessment of mitral valve, patients were examined by 2D-transthoracic echocardiography and RT3D-TEE techniques on the same day. A strong association was found between total Wilkins and total RT3D-TEE scores (r = 0.809, p < 0.001). The mean mitral valve area assessed by the 2D and 3D was 1.07 ± 0.25 and 1.03 ± 0.26, respectively, indicating a mean difference of 0.037 cm2 (p = 0.001). We found a strong correlation between the values of mitral valve area assessed by 2D and 3D techniques (r = 0.846, p < 0.001). There is a high correlation between the two scoring systems in terms of evaluating dominant morphological features. Partially, mitral valve area overestimation in the 2D-transthoracic echocardiography and its inability to assess commissural involvement as well as its dependence on patient age were exceptions in this study.

Treatment of an Unyielding Central Vein Stenosis using Valvuloplasty Balloon in a Young Female Presenting with Ineffective Hemodialysis

Abstract Percutaneous balloon venoplasty is widely employed for the management of central vein stenosis (CVS), a condition frequently encountered in patients on maintenance hemodialysis (MHD). The hypertrophied and fibrotic venous stenotic lesions often pose a challenge for interventionists, due to resistance to dilatation and high-elastic recoil. We report here successful utilization of mitral valvuloplasty balloon for percutaneous treatment of an unyielding brachiocephalic vein stenosis. Repeated failure of conventionally used peripheral balloon dilatation catheter prompted the use of a mitral valvuloplasty balloon that could exert higher radial pressure while preventing melon-seeding and hence successfully achieve stenosis dilatation. The mitral valvuloplasty balloon can be effectively and safely used for lesions resistant to repeated dilatations by conventional peripheral balloons. Rheological stress on central veins from ipsilateral arteriovenous fistula (AVF) may result in development of stenotic lesions, even in the absence of prior venous catheterization of the affected vein; therefore, in the presence of relevant symptoms, this diagnosis should not be excluded on the basis of absence of prior direct trauma at the stenosis site.

Rheumatic heart disease in pregnancy and neonatal outcomes: A systematic review and meta-analysis.

PurposeAssociations between rheumatic heart disease (RHD) in pregnancy and fetal outcomes are relatively unknown. This study aimed to review rates and predictors of major adverse fetal outcomes of RHD in pregnancy.MethodsMedline (Ovid), Pubmed, EMcare, Scopus, CINAHL, Informit, and WHOICTRP databases were searched for studies that reported rates of adverse perinatal events in women with RHD during pregnancy. Outcomes included preterm birth, intra-uterine growth restriction (IUGR), low-birth weight (LBW), perinatal death and percutaneous balloon mitral valvuloplasty intervention. Meta-analysis of fetal events by the New-York Heart Association (NYHA) heart failure classification, and the Mitral-valve Area (MVA) severity score was performed with unadjusted random effects models and heterogeneity of risk ratios (RR) was assessed with the I2 statistic. Quality of evidence was evaluated using the GRADE approach. The study was registered in PROSPERO (CRD42020161529).FindingsThe search identified 5949 non-duplicate records of which 136 full-text articles were assessed for eligibility and 22 studies included, 11 studies were eligible for meta-analyses. In 3928 pregnancies, high rates of preterm birth (9.35%-42.97%), LBW (12.98%-39.70%), IUGR (6.76%-22.40%) and perinatal death (0.00%-9.41%) were reported. NYHA III/IV pre-pregnancy was associated with higher rates of preterm birth (5 studies, RR 2.86, 95%CI 1.54–5.33), and perinatal death (6 studies, RR 3.23, 1.92–5.44). Moderate /severe mitral stenosis (MS) was associated with higher rates of preterm birth (3 studies, RR 2.05, 95%CI 1.02–4.11) and IUGR (3 studies, RR 2.46, 95%CI 1.02–5.95).InterpretationRHD during pregnancy is associated with adverse fetal outcomes. Maternal NYHA III/IV and moderate/severe MS in particular may predict poor prognosis.

Short- and mid-term outcomes of percutaneous balloon mitral valvuloplasty under the guidance of ultrasound

Objective: To evaluate the safety, short- and mid-term outcomes of percutaneous balloon mitral valvuloplasty (PBMV) guided by the ultrasound. Methods: In this retrospective study, medical data of 15 patients [9 males and 6 females, with an age of (53±13) years] with PBMV under the guidance of ultrasound in Heart Center of Henan Provincial People's Hospital between December 2016 and January 2019 were collected and reviewed. The short-and mid-term outcomes were analyzed. Results: PBMV was successfully performed in all the patients. One patient underwent surgical valve replacement due to severe mitral regurgitation, and the other 14 patients were all followed up successfully. The average follow-up time was (13.8±4.6) months. Comparisons of preoperative and postoperative data showed significant differences in valve area [(1.84±0.43) cm2 vs (0.89±0.24) cm2], left atrial pressure [(11.9±4.5) mmHg (1 mmHg=0.133 kPa) vs (21.9±6.0) mmHg] and mean mitral valve pressure gradient [(10.9±3.2) mmHg vs (20.1±3.6) mmHg](all P<0.01), with no significant differences in mitral regurgitation area (P=0.67). Postoperative follow-up showed that there were no significant differences in mitral valve area, regurgitation area and N-terminal pro-B-type natriuretic peptide (NT-proBNP) between short-and mid-term postoperatively (all P>0.05). There was no secondary operation due to mitral stenosis in 14 patients, and 3 patients with moderate or severe tricuspid regurgitation showed significant improvement, with gradually recovered cardiac function, and there were no deaths in these patients. Conclusion: PBMV guided by the ultrasound is feasible and effective, and exhibits favorable short-and mid-term outcomes.

Left Ventricular Remodeling Following Balloon Mitral Valvuloplasty in Rheumatic Mitral Stenosis: Magnetic Resonance Imaging Study.

Background: Rheumatic heart disease affects primarily cardiac valves, it could involve the myocardium either primarily or secondary to heart valve affection. The influence of balloon mitral valvuloplasty (BMV) on left ventricular function has not been sufficiently studied.Aim: To determine the influence of balloon mitral valvuloplasty (BMV) on both global and regional left ventricular (LV) function.Methods: Thirty patients with isolated rheumatic mitral stenosis (MS) were studied. All patients had cardiac magnetic resonance imaging (CMR) before, 6 months and 1 year after successful BMV. LV volumes, ejection fraction (EF), regional and global LV deformation, and LV late gadolinium enhancement were evaluated.Results: At baseline, patients had median EF of 57 (range: 45–69) %, LVEDVI of 74 (44–111) ml/m2 and LVESVI of 31 (14–57) ml/m2 with absence of late gadolinium enhancement in all myocardial segments. Six months following BMV, there was a significant increase in LV peak systolic global longitudinal strain (GLS) (−16.4 vs. −13.8, p < 0.001) and global circumferential strain (GCS) (−17.8 vs. −15.6, p = 0.002). At 1 year, there was a trend towards decrease in LVESVI (29 ml/m2, p = 0.079) with a significant increase in LV EF (62%, p < 0.001). A further significant increase, compared to 6 months follow up studies, was noticed in GLS (−17.9 vs. −16.4, p = 0.008) and GCS (−19.4 vs. −17.8 p = 0.03).Conclusions: Successful BMV is associated with improvement in global and regional LV systolic strain which continues for up to 1 year after the procedure.

Clinical Analysis of Redo Aortic Root Replacement after Cardiac Surgery

&#x0D; [Abstract] objectives To explore the etologies, surgical methods and outcomes of redo aortic root replacement after cardiac surgery. Methods Between February 2010 and February 2020, 41 patients who had at least one previous cardiac operation received aortic root replacement surgery in our hospita, including 27 males and 14 females with an average age of 49.5±10.2 years. Indications for reoperation include: aortic sinus dilation and ascending aortic aneurysm in 20 cases (48.8%), recurrent aortic dissection in 7 cases (17.0%), aortic pseudoaneurysm in 4 cases (9.8%), prosthetic valve endocarditis in 5 cases (12.2%) and 5 cases (12.2%) had paravalvular leakage. The redo operation was a midline thoracotomy, and Bentall operation was performed. In addition, 3 cases of mitral valve replacement surgery, 4 cases of mitral valvuloplasty, 8 cases of tricuspid valvuloplasty, 4 cases of coronary artery bypass graft surgery, 3 cases of Debakey I aortic dissection patients underwent Sun’s surgery simultaneously. Results The mean cardiopulmonary bypass time was 95~302 (168.1±41.2) min, and the mean aortic crossclamp time was 45~135 (84.5±22.3) min. Six patients (14.6%) died during the postoperative hospitalization. The main causes of death were heart failure in 3 patients and septic shock in 3 patients.The follow-up time was 3~62 (30.3±15.5) months. During the follow-up period, 3 cases died, including 1 case died of septic shock and 2 cases died of cerebral hemorrhage. Conclusions Redo aortic root replacement is difficult to deal with, and the risk is high. Preoperative evaluation is required, appropriate surgical approach, adequate myocardial protection, and a complete surgical plan are essential to ensure the success of the operation.

Atypical Takotsubo Cardiomyopathy With Persistent Left Ventricular Aneurysm After Cardiac Surgery

A 57-year-old man was admitted to the hospital because of severe mitral regurgitation. Minimally invasive mitral valvuloplasty was performed. Six months after surgery, he presented with discomfort. Urgent coronary angiography showed a normal coronary artery and large left ventricular aneurysm. After atypical Takotsubo cardiomyopathy was diagnosed, his clinical symptoms and heart function were improved with medication for his persistent left ventricular aneurysm. After 24 hours, Hotler showed a lethal ventricular arrhythmia. Surgical treatment was recommended and refused. After four years of observation, he died of asystole. Takotsubo cardiomyopathy is considered a severe complication after surgery. The prognosis is very poor if it has catastrophic complications.

Unusual Mechanism and Unusual Combination of Two Common Diseases

Balloon mitral valvuloplasty (BMV) is an accepted treatment for certain subsets of patients of mitral stenosis. Prior to BMV, a full clinical and echocardiographic evaluation is done. This 36-years old lady of severe mitral stenosis had two BMV's including a three-dimensional transesophageal echocardiography at leading cardiac centers. However, an important echocardiographic finding was missed which would have altered the course of management. These details are discussed.

Outcome of Rheumatic Heart Disease and Percutaneous Balloon Mitral Valvotomy

Abstract Background: Rheumatic heart disease (RHD) is still a leading cause of valvular heart disease in India. Balloon mitral valvotomy (BMV) is simple and safe procedure to improve the quality of life in patients with severe mitral stenosis. Aim: (1) To evaluate outcome of RHD patients in tertiary care hospital in developing country like India in twenty first century. (2) To evaluate safety and efficacy of BMV. Materials and Methods: We performed retrospective analysis of 500 patients with RHD undergoing echocardiography in a tertiary care hospital in Maharashtra, India. 15% (74 patients) of them underwent balloon mitral valvuloplasty between June 2012 and November 2019 and 37.6% (188 patients) were treated with valve replacements. Results: Successful BMV was performed in 72 patients. The rate of complication was 2.7%. No mortality was noted. One hundred and eighty-eight patients underwent Valve replacements. Conclusions: Balloon mitral valvuloplasty is a technically difficult procedure and demands considerable expertise in transseptal catheterization. Percutaneous balloon mitral valvotomy is a safe and effective treatment for symptomatic severe Mitral stenosis in experienced centers.

Clinical and echocardiographic trends in percutaneous balloon mitral valvuloplasty

BackgroundThe prevalence of Rheumatic Mitral Stenosis (MS) has significantly changed over the last decades. We intend to examine patient demographics, Echocardiographic characteristics, procedural success rates, and complications throughout 30-years.MethodsWe conducted a single-center descriptive observational study. The study population consists of patients undergone percutaneous balloon mitral valvuloplasty (PBMV) at Emek Medical Center in Israel from January 1990 to May 2019.ResultsFour hundred seventeen patients underwent PBMV during the study period and were eligible for the study. Age did not change significantly over time (p = 0.09). The prevalence of Male and patients who were smoking and had multiple comorbidities such as hypertension, dyslipidemia, ischemic heart disease, and chronic kidney disease became increases over time (p = 0.02, p = 0.02, p = 0.001, p = 0.01, p = 0.02, and p = 0.001, respectively). Wilkins score and all its components increased over time, and the total score was higher in females (p = 0.01). Seventy-nine (18.9%) patients had complications. The rate of complications did not change over decades. Patients with Wilkins score > 8, post-procedural MR of ≥2, and post-procedural MVA < 1.5 had the highest risk for the need of Mitral valve replacement (MVR) surgery in 2 years following PBMV (3.64, 4.03, 2.44, respectively, CI 95%, p < .0001 for all). The median time in these patients was 630 days compared to 4–5 years in the entire population. Patients with Post-procedural MR of ≥2 and post-procedural MVA < 1.5 had ten times risk for developing heart failure (HR 9.07 and 10.06, respectively, CI 95%, P < .0001).ConclusionOur research reveals trends over time in patients’ characteristics and echocardiographic features. Our study population consists of more male patients with multiple comorbidities and more complex and calcified valvular structures in the last decade. Wilkins score > 8, post-procedural MR of ≥2, and post-procedural MVA < 1.5 cm2 were in-depended predictors for the time for surgery and heart failure hospitalization.

A new over-the-wire percutaneous mitral balloon valvuloplasty technique.

To develop and evaluate a new over-the-wire technique for mitral valvuloplasty that is both technically easier and less costly. Rheumatic heart disease (RHD) and resultant mitral stenosis (MS) carries a significant burden of disease worldwide. The prevalence is however concentrated in lower income countries where the current gold standard for percutaneous mitral valvuloplasty (PMBV)-the Inoue technique, is not always available due to cost and technical complexity. The development of an over-the-wire technique involving a steerable catheter to aid crossing of the valve and a dedicated TAVI wire is described. The procedure evolved over the initial eight cases and the final standardized procedure was performed in 16 cases. Clinical, echocardiographic and procedural outcomes are described in 16 consecutive cases performed at a single center. The procedure was performed with 88% procedural success and only one technical failure during the development phase. 2/24 patients had moderate mitral regurgitation (MR) afterwards but one had unfavorable anatomy and the other had pre-procedural moderate MR. The average procedural duration was 66 min, which was shortened significantly over time. No procedural deaths or conversion to open surgery at 1 year. Procedural cost was 44% lower than the Inoue technique. We present favorable results of a new PMBV technique that is cheaper and technically easier in our opinion.

A new device to treat mitral valve regurgitation: a proof of concept in bench test study

Mitral valve repair is typically performed by implanting a ring-like device at the valve annulus to reshape the annulus and to improve leaflet coaptation. In most cases, some additional procedures are needed, including leaflet resection and artificial chordae implantation. However, artificial chordae implantation could be technically challenging and postoperative left ventricular remodeling could increase the risk of recurrent mitral regurgitation. We propose an innovative annular device made of chromo-cobalt, finalized not only to reshape the annulus but also to enable anchoring of leaflets to a fixed intraventricular structure. Durability evaluation of the device was tested by applying eight radial force vectors equally spaced along the ring and related fatigue analysis. To evaluate the efficacy of the mitral valvuloplasty using the tested ring, the device was implanted in five adult swine hearts. Functional analysis of the ring was performed by measuring left ventricular pressure and fluid volume loss, following implantation in normal and dysfunctional mitral valve leaflets. Both fatigue and functional analysis showed satisfactory and promising results in terms of durability and efficacy of mitral valve repair. Because of its favorable durability and functional characteristics this device appears promising and provides good results in terms of valve competence, thus avoiding both manipulations of papillary muscles and interference in left ventricular hemodynamics. However, an in vivo test is mandatory to fully understand the impact of the device on subvalvular apparatus.

Blood cyst of the mitral valve – is it common? Case report

Abstract Cardiac blood cysts are benign tumors, usually congenital malformations, found on the endocardium, particularly along the closing lines of the heart valves. Blood cysts of the heart are commonly reported at postmortem findings in infants and they are very rare in adults. We report a case of a 39 year old patient, who was incidentally discovered during echocardiography having a blood cyst attached to the ventricular face of the anterior mitral valve and to the mitral chordae. During surgery, the cystic mass was resected. Mitral valvuloplasty was successfully performed and the patient had an uneventful recovery. Blood cysts are rarely reported, thus there is no consensus or guidelines for the optimal management of the asymptomatic cases. Although our patient was asymptomatic and the cyst did not interfere with the cardiac function, together with the heart team, we chose the surgical resection of the cardiac mass in order to prevent possible complications.

The assessment of mitral valve disease: a guideline from the British Society of Echocardiography

Mitral valve disease is common. Mitral regurgitation is the second most frequent indication for valve surgery in Europe and despite the decline of rheumatic fever in Western societies, mitral stenosis of any aetiology is a regular finding in all echo departments. Mitral valve disease is, therefore, one of the most common pathologies encountered by echocardiographers, as both a primary indication for echocardiography and a secondary finding when investigating other cardiovascular disease processes. Transthoracic, transoesophageal and exercise stress echocardiography play a crucial role in the assessment of mitral valve disease and are essential to identifying the aetiology, mechanism and severity of disease, and for helping to determine the appropriate timing and method of intervention. This guideline from the British Society of Echocardiography (BSE) describes the assessment of mitral regurgitation and mitral stenosis, and replaces previous BSE guidelines that describe the echocardiographic assessment of mitral anatomy prior to mitral valve repair surgery and percutaneous mitral valvuloplasty. It provides a comprehensive description of the imaging techniques (and their limitations) employed in the assessment of mitral valve disease. It describes a step-wise approach to identifying: aetiology and mechanism, disease severity, reparability and secondary effects on chamber geometry, function and pressures. Advanced echocardiographic techniques are described for both transthoracic and transoesophageal modalities, including TOE and exercise testing.

Outcomes of Percutaneous Balloon Mitral Valvuloplasty in Significant Mitral Stenosis with Moderate Mitral Regurgitation - Single Center Study

Outcomes of Percutaneous Balloon Mitral Valvuloplasty in Significant Mitral Stenosis with Moderate Mitral Regurgitation - Single Center Study

Mechanism of Atypical Atrial Flutter With Alternating Tachycardia Cycle Lengths

A 67-year-old man diagnosed with non-ischaemic cardiomyopathy previously underwent radiofrequency catheter ablation for papillary muscle ventricular tachycardia and typical atrial flutter 4 years ago. Incessant atrial flutter was observed after recent mitral and tricuspid valvuloplasty for severe regurgitation (Figure 1).

Validation of New Real-Time Three-Dimensional Transesophageal Echocardiographic Scoring System in Prediction of Immediate and Long-term Outcome After Percutaneous Balloon Mitral Valvuloplasty

Dear Editor,The guidelines recommend percutaneous mitral balloon commissurotomy (PMBC) as the first choice therapy for symptomatic patients with moderate or severe mitral stenosis (MS) with favorable valve morphology and for asymptomatic MS patients with pulmonary hypertension (1). Echocardiography is the main diagnostic imaging method for assessing mitral valve stenosis and evaluating the severity and hemodynamic consequences of MS as well as valve morphology and disease extension (2). The main predictor of successful BMV is mitral valve morphology. Therefore, the MV scoring system using echocardiography is very important. Several two-dimensional echocardiographic scoring systems have been proposed to evaluate MV morphology, the severity of which is related to immediate and long-term outcome (3). Most cardiologists use the Wilkins score for evaluation of MV anatomy. Although, none of the available 2DE scores have not been shown to be superior to any of the other scores (4). The evaluation of the MV Wilkins score depends on the assessment of four parameters, which include: leaflets mobility, thickness, calcification, and subvalvular involvement. Each parameter is given a score of 1-4 and by calculating its sum, the total score of 1-16/16 (mild involvement = 1-4/16, moderate involvement = 5-8/16, and severe involvement &gt; 8/16) is obtained (3). The ideal echocardiographic scoring system should have the following characteristics:Quantitative and qualitative evaluation of each component of the MV apparatus separately to determine the deformity in a specific portionThe inclusion of all the points that have been proven through a large study affects the BMV resultEasy to use and interpretable by most cardiologists at a reasonable timeHigh reliability and reproducibility (4)In recent years, real-time three-dimensional echocardiography technology has evolved rapidly. RT3DE provides detailed morphologic display and analysis of the mitral valve structure. Improving the RT3DE probe technology, especially transesophageal probes, highlights the need to introduce a RT3DE scoring system (5). Anwar et al. introduced the first scoring system using real-time three-dimensional transthoracic echocardiography (RT3D-TTE) in patients with mitral valve stenosis candidate BMV, and compared the new score with the Wilkins score in predicting outcome after BMV. In the new RT3DE score, each leaflet was divided into three scallops (anterolateral A1-P1, middle A2-P2, and posteromedial A3-P3) and each scallop was scored separately for thickness, calcification, and mobility, as follows: 0 for normal thickness and mobility, 1 for abnormal thickness and restricted mobility, and for scoring calcification: 0 for the absence of calcification, 1 for calcification of middle scallop (A2 or P2) and 2 if there is calcification of commissural scallops (A1, A3-P1, P3). For scoring subvalvular apparatus, the anterior and posterior chordae were scored at three levels as follows: proximal (valve level), middle, and distal (papillary muscle level). Each level was scored separately for thickness and separation in between as follows: 0 for normal thickness, 1 for abnormal thickness, also 0 in case of normal chordal separation (distance in between &gt;5 mm), 1 in case of partial separation (distance in between &lt;5 mm) and 2 in case of absence separation. From the sum of these points, a total score of 0-31/31 (mild MV involvement &lt;8, moderate MV involvement 8-13, and severe MV involvement &gt;14) is obtained (6). 3D-Anwar score is complex and time consuming. This is due to the many anatomical and morphological components to achieve an accurate assessment. The available 3D score is highly selective for optimal BMV result, which leads to more patients being referred for surgery (5). So we decided to introduce a three-dimensional transesophageal (3D-TEE) echocardiographic scoring system that meets the criteria of an ideal echocardiographic scoring system, and evaluate the validity of the new score in predicting the immediate and long-term outcome of patients after BMV. We also believe that many studies are needed to achieve an ideal RT3DE scoring system.

Myocardial expression of somatotropic axis, adrenergic signalling, and calcium handling genes in heart failure with preserved ejection fraction and heart failure with reduced ejection fraction.

AimsLimited data are available regarding cardiac expression of molecules involved in heart failure (HF) pathophysiology. The majority of the studies have focused on end‐stage HF with reduced ejection fraction (HFrEF) without comparison with healthy subjects, while no data are available with regard to HF with preserved ejection fraction (HFpEF). HFpEF is a condition whose multiple pathophysiological mechanisms are still not fully defined, with many proposed hypotheses remaining speculative due to limited access to human heart tissue. This study aimed at evaluating cardiac expression levels of key genes of interest in human biopsy samples from patients affected with HFrEF and HFpEF in order to possibly point out distinct phenotypes.Methods and resultsTotal RNA was extracted from left ventricular cardiac biopsies collected from stable patients with HFrEF (n = 6) and HFpEF (n = 7) and healthy subjects (n = 9) undergoing elective cardiac surgery for valvular replacement, mitral valvuloplasty, aortic surgery, or coronary artery bypass. Real‐time PCR was performed to evaluate the mRNA expression levels of genes involved in somatotropic axis regulation [IGF‐1, IGF‐1 receptor (IGF‐1R), and GH receptor (GHR)], in adrenergic signalling (GRK2, GRK5, ADRB1, and ADRB2), in myocardial calcium handling (SERCA2), and in TNF‐α. Patients with HFrEF and HFpEF showed reduced serum IGF‐1 circulating levels when compared with controls (102 ± 35.6, 138 ± 11.5, and 160 ± 13.2 ng/mL, P < 0.001, respectively). At myocardial level, HFrEF showed significant decreased GHR and increased IGF‐1R expressions when compared with HFpEF and controls (0.54 ± 0.27, 0.94 ± 0.25, and 0.84 ± 0.2, P < 0.05 and 1.52 ± 0.9, 1.06 ± 0.21, and 0.72 ± 0.12, P < 0.05, respectively), while no differences in the local expression of IGF‐1 mRNA were detected among the groups (0.80 ± 0.45, 0.97 ± 0.18, and 0.63 ± 0.23, P = 0.09, respectively). With regard to calcium handling and adrenergic signalling, HFrEF displayed significant decreased levels of SERCA2 (0.19 ± 0.39, 0.82 ± 0.15, and 0.87 ± 0.32, P < 0.01) and increased levels of GRK2 (3.45 ± 2.94, 0.93 ± 0.12, and 0.80 ± 0.14, P < 0.01) and GRK5 (1.32 ± 0.70, 0.71 ± 0.14, and 0.77 ± 0.15, P < 0.05), while no significant difference was found in ADRB1 (0.66 ± 0.4, 0.83 ± 0.3, and 0.86 ± 0.4) and ADRB2 mRNA expression (0.65 ± 0.3, 0.66 ± 0.2, and 0.68 ± 0.1) when compared with HFpEF and controls. Finally, no changes in the local expression of TNF‐α were detected among groups.ConclusionsHeart failure with reduced ejection fraction and HFpEF patients with stable clinical condition display a distinct molecular milieu of genes involved in somatotropic axis regulation, calcium handling, and adrenergic derangement at a myocardial level. The unique opportunity to compare these results with a control group, as reference population, may contribute to better understand HF pathophysiology and to identify novel potential therapeutic targets that could be modulated to improve ventricular function in patients with HF.

Prognostic value of left atrial volume index in patients with rheumatic mitral stenosis.

BackgroundThe significance of left atrial volume index (LAVI) for predicting outcomes in patients with mitral stenosis (MS) has been unclear, even though rheumatic MS is known to be associated with left atrium enlargement and functional deterioration.HypothesisThe current study aimed to investigate the prognostic value of LAVI, based on the severity in patients with rheumatic MS.MethodsWe retrospectively reviewed 611 patients with pure rheumatic MS. The prognostic value of LAVI and the effect of MS severity on the prognostic value of LAVI for events were evaluated. The events were defined as a composite end‐point that included all‐cause death, heart failure admission, mitral valve replacement, percutaneous mitral valvuloplasty, and stroke.ResultsThere were 236 (38.6%) overall events during a median follow‐up of 8 months. The optimal LAVI cutoff for the prognostic threshold was 57 ml/m2. The MS severity had a significant effect on the prognostic value of LAVI. A LAVI >57 ml/m2 was a prognostic value for events in progressive MS (hazard ratio [HR]: 2.40, 95% confidence interval [CI]: 1.41–5.40, p = .004) and in patients with severe MS (HR: 1.70, 95% CI: 1.06–2.74, p = .029), but it was not prognostic in patients with very severe MS (HR: 1.02, 95% CI: 0.56–1.84, p = .955).ConclusionsThe prognostic value of LAVI varies and is dependent on the MS severity. A LAVI >57 mL/m2 was independently associated with poor outcomes in patients with progressive MS, while this association was minimized in patients with severe MS.

Medical Interventions for Chylothorax and their Impacts on Need for Surgical Intervention and Admission Characteristics: A Multicenter, Retrospective Insight.

The incidence of chylothorax is reported from 1-9% in pediatric patients undergoing congenital heart surgery. Effective evidenced-based practice is limited for the management of post-operative chylothorax in the pediatric cardiac intensive care unit. The study characterizes the population of pediatric patients with cardiac surgery and chylothorax who eventually require pleurodesis and/or thoracic duct ligation; it also establishes objective data on the impact of various medical interventions. Data were obtained from the Pediatric Health Information System database from 2004-2015. Inclusion criteria for admissions for this study were pediatric admissions, cardiac diagnosis, cardiac surgery, and chylothorax. These data were then divided into two groups: those that did and did not require surgical intervention for chylothorax. Other data points obtained included congenital heart malformation, age, gender, length of stay, billed charges, and inpatient mortality. A total of 3503 pediatric admissions with cardiac surgery and subsequent chylothorax were included. Of these, 236 (9.4%) required surgical intervention for the chylothorax. The following cardiac diagnoses, cardiac surgeries, and comorbidities were associated with increased odds of surgical intervention: d-transposition, arterial switch, mitral valvuloplasty, acute kidney injury, need for dialysis, cardiac arrest, and extracorporeal membrane oxygenation. Statistically significant medical interventions which did have an impact were specific steroids (hydrocortisone, dexamethasone, methylprednisolone) and specific diuretics (furosemide). These were significantly associated with decreased length of stay and costs. Dexamethasone, methylprednisolone, and furosemide were associated with decreased odds for surgical intervention. These analyses offer objective data regarding the effects of interventions for chylothorax in pediatric cardiac surgery admissions. Results from this study seem to indicate that most post-operative chylothoraxes should improve with furosemide, a low-fat diet, and steroids.