Mitral Valve Replacement Research Articles

Impact of surgical technique on postoperative ventricular arrhythmias in arrhythmic mitral valve prolapse

Abstract Background Mitral valve prolapse (MVP) is associated with progressive mitral regurgitation (MR) requiring surgical correction. A subset of patients with MVP may also constitute an "arrhythmic" phenotype suffering from malignant ventricular arrhythmias (VAs). Purpose To assess the impact of surgical technique for correction of degenerative MR including repair using artificial chords, repair with resection and mitral valve replacement (MVR) on longitudinal risk of VAs in patients with arrhythmic MVP. Methods Patients who had undergone mitral valve surgery for MVP with moderate to severe degenerative MR between 2010-2022 at a university hospital in Sweden were retrospectively included. Patients with ischemic heart disease, primary cardiomyopathy, channelopathy, or endocarditis were excluded. To examine changes in VAs (defined as sustained- or non-sustained ventricular tachycardias) as assessed by continuous Holter monitoring before and after surgery, generalized estimating equation (GEE) models were performed to account for the correlations between repeated monitoring in each patient and for differences in the time of measurement. Results Of 599 patients undergoing mitral valve surgery, 423 (71%) underwent repair using artificial chords, 62 (10%) repair with resection and 114 (19%) MVR. For those presenting with symptoms such as palpitations, presyncope, and/or syncope, Holter monitoring was conducted before (n=171; 29%) and/or after mitral valve surgery (n=184; 31%) (Figure 1). The distribution of VAs before and after surgery, stratified by surgical technique, is illustrated in Figure 2. In GEE models, repair using artificial chords was associated with increased postoperative VAs compared with the other surgical techniques (OR 2.14; 95% CI 1.19-3.83; p=0.01), repair with resection with reduced postoperative VAs compared with the other surgical techniques (OR 0.15; 95% CI 0.04-0.61; p=0.01), and no change in postoperative VAs was observed for MVR compared with the other surgical techniques (OR 0.724; 95% CI 0.39-1.35; p=0.31). The results remained similar after adjustment for age, sex, myxomatous disease/fibroelastic deficiency or bileaflet prolapse. Conclusion In patients with symptoms of palpitations, presyncope and/or syncope before or after mitral valve surgery, repair using artificial chords was associated with an increased risk of postoperative VAs. Prospective studies including continuous monitoring before and after surgery are needed to confirm these findings.

Identification of left ventricular flow features in healthy and pathological conditions

Abstract Background In the presence of mitral valve diseases or following surgical interventions, the hemodynamics in the left ventricle (LV) are significantly altered [1]. These maladaptive intraventricular hemodynamic alterations can stimulate a cascade of events leading to progressive adverse LV remodeling and eventual heart failure [2]. Qualitative and quantitative evaluation of LV flow features may provide a potential for sensitive risk stratification of clinical cardiac function [3]. Purpose The purpose of this study is to identifying LV flow features using in vitro experiments under both normal and pathological conditions, including mitral regurgitation (MR), mitral valve replacement with bioprosthetic/mechanical valve, and transcatheter mitral valve edge-to-edge repair (TEER). Methods We utilized a biohybrid approach to construct the in vitro experimental platform, where the native mitral valve (including chordae tendineae and papillary muscles) and aortic valve from porcine were combined with a 3D-printed silicon LV (figure 1). To ensure comparability across different conditions, we maintained consistency by utilizing the same native valve and 3D-printed LV. For pathological conditions, we cut the chordae tendineae in A2 zone to induce the severe degenerative MR, and TEER was performed on this prolapsed valve by placing two clips in A2-P2 zone. Then, the anterior leaflet of valve was cut, and a bioprosthetic valve and mechanical valve were sutured to mitral annulus to simulate surgical valve replacement, respectively. Left ventricular flow fields were measured using four-dimensional particle image velocimetry (4D-PIV) technique, with vector interval of 0.9 mm in all the spatial directions and temporal resolution of 10 ms. Results Significant differences in mean flow field were observed among healthy and pathological conditions (figure 2). Firstly, the vortex orientation was clockwise in healthy, MR, bioprosthetic valve replacement, and TEER conditions, which could accompany the redirection of blood flows towards the aortic valve. However, the replacement with a mechanical valve resulted in an alteration in vortex orientation from clockwise to counterclockwise. Secondly, the position of the center of the vortex changed in pathological conditions, with the center of the vortex closest to the apex and the left ventricle outflow tract in the healthy condition. Thirdly, the maximum Reynolds shear stress (RSS), which may be responsible for thrombus formation, significantly increased after TEER procedure and bioprosthetic valve replacement. Conclusions This study demonstrates significant changes in LV hemodynamics across different conditions. The flow features, including vortex orientations, vortex positions and the RSS, may potentially become crucial considerations for the optimization of artificial valves and mitral valve repair devices.Figure 1 Figure 2

Trends in Patient Characteristics and Cardiothoracic Surgeries over 14 Years (2010–2023): A Single Center Experience

Background: as transcatheter technologies have advanced, the patient population that is referred to open heart surgeries has shifted. This study’s objective was to evaluate recent trends in the characteristics of patients undergo surgical valvular interventions and coronary revascularizations (CABG) in our center over a period of 14 years. Methods: this is a retrospective analysis of ecological trends in the age, sex, and risk profile (Charlson comorbidity index—CCI) of patients who, from January 2010 to December 2023, underwent CABG, aortic valve replacement (AVR), or mitral valve repair or replacement (with or without tricuspid valve intervention). The data were extracted from electronic clinical files using MD-Clone software. Results: for the CABG procedures, the respective data for 2010 and 2023 were: mean ages 68.0 and 64.6 years; 79.7% and 83.1% males; and mean CCI scores 3.16 and 2.51. The p-values for the cumulative differences over the study period were 0.001, 0.005, and 0.013, respectively. The respective data for isolated AVR were mean ages of 69.2 and 62.9 years; 64.1% and 59.1% males; mean CCI 3.64 and 2.32; p-values: <0.001, 0.229, and 0.019. The respective data for mitral valve procedures were mean ages of 63.6 and 59.8 years, 71.4% and 65.5% males; mean CCI 2.90 and 1.79; p-values: 0.84, 0.422, and 0.318. Conclusions: over a 14-year period, changes were evident in the age, sex distribution, and CCI for operations performed in our center. These changes most likely resulted from accumulated data regarding the advantages and detriments of treatment strategies, mostly of CABG vs. percutaneous coronary intervention; major advancements in transcatheter technologies, mostly in transcatheter AVR; and clinical guidelines facilitating a more collaborative decision-making, open-minded, and personalized approach.

One-year outcomes of transcatheter mitral valve replacement in patients with severe mitral regurgitation

Abstract Background Mitral valve regurgitation (MR) is a prevalent valvular heart disease, and a subset of patients face challenges in undergoing surgical treatment. Transcatheter mitral valve replacement (TMVR) has emerged as a viable option for selected patients with severe MR deemed unsuitable for traditional valve surgery. Purpose This study aims to evaluate the feasibility, safety, durability, and clinical outcomes of a novel transapical mitral valve system (MitraFix valve) in treating moderate to severe MR patients. Methods The early feasibility study of the MitraFix TMVR transapical system is a multicenter, prospective, nonrandomized study. All patients underwent evaluation by a multidisciplinary heart team and were deemed suitable for mitral valve intervention. Clinical events were adjudicated by an independent clinical events committee. Results From June 2021 to July 2022, 10 patients (mean age: 71.2 ± 7.4 years, 40% male) were enrolled. The mean Society of Thoracic Surgeons(STS) predicted risk of mortality was 7.5 ± 2.7%. All implants were successful, with a mean operational time of 45.2 ± 25.9 min. One patient was converted to open cardiac surgery after successfully implanting the valve due to persistent apical bleeding. At 1-year follow-up, all-cause mortality was 20%, with a cardiovascular mortality at 10.0%. Among survival patients, 87.5% of surviving patients had MR ≤1+ and 75% patients were in NYHA functional class I or II at 1 year. The overall KCCQ score significantly increased from 55.8 (42.9, 72.9) points at baseline to 77.5 (73.7, 88.6) points at 1-year follow up (P = 0.012). Left ventricular ejection fraction showed no significant change from basline (51.5%) to 1 year (50.0%) (P=0.799). No evidence of mitral stenosis or left ventricular outflow tract (LVOT) obstruction was observed. Conclusions The MitraFix TMVR transapical system demonstrated excellent valve function, low mortality, sustained MR elimination and clinical improvement up to one year in this study. Further studies, encompassing a larger cohort of patients and an extended follow-up duration, are needed to confirm these findings.Change in MR and NYHA functional classChange in Quality-of-Life Assessment

Initial experience with a 5G cellular network and robotic arm-based remote echocardiographic system in an all-comers setting

Abstract Background Echocardiography is the test-of-choice for the initial evaluation of many cardiac diseases and requires expertise that is often limited in rural area. Robotic arm-assisted remote echocardigram has been attampted for teleconsultation but was limited to heart failure patients(ref), primarily due to the network delay in telecommunication and the subsequent incoordination in robotic arm control. Purpose We aim to assess the feasibility and diagnostic accuracy of a 5G cellular network and robotic arm-based remote echocardiographic system in an all-comers setting. Methods 51 pts were enrolled from the outpatient cardiology clinic of our institute. All pts underwent standard comprehensive echocardiography on a 5G cellular network and robotic arm-based remote echocardiographic system (the robotic part was deployed at our hospital and the control part was located at another campus 20 kilometers away) (Figure 1)and a conventional echocardiographic platform (at our hospital) successively. The order in which patients were examined on the remote and conventional instruments was randomly determined. There was no interval between the two examinations, and examinations of the same patient were performed by experienced but different cardiologists, who were blinded to each other’s diagnosis. The doctor who used the remote system was also randomly allocated and had not been previously specifically trained. The exams were real-time and diagnoses were made right after the exams. Results Of the 51 pts, the image quality was sufficient for diagnosis in 50 patients (48% female, 40±18 years). 1 pt was excluded because some key views could not be obtained using the remote system (98% of exams successful). 17 pts had positive findings, including 10 with a primary diagnosis of valvulopathy (1 Barlow's syndrome, 1 bicuspid aortic valve and 8 less-than-moderate regurgitation), 2 cardiac surgery follow-ups (1 case of aortic valve replacement and septal myectomy, and 1 case of mitral valve replacement and tricuspid annuloplasty), and 2 hypertrophic cardiomyopathy (including 1 case of obstruction at papillary muscle level), 2 with abnormal left ventricular wall motion(including 1 case of apical mural thrombus) (Figure 2), and 1 with congenital heart disease (secumdum atrial septal defect). The main diagnosis was consistent in 98% of cases (papillary muscle level obstruction was missed in one case), using conventional echocardiographic findings as the standard. Time for image acquision using remote echocardiography was significantly longer than conventional one (24 minutes 36 seconds ± 4 minutes 52 seconds vs. 16 minutes 15 seconds ± 1 minute 54 seconds, p<0.0001, paired t-test). Conclusions Comprehensive echocardiographic exam with a 5G cellular network and robotic arm-based remote system is feasible with relatively good diagnostic accuracy.Figure 1Figure 2

Establishment and validation of a prediction model for the outcome of rheumatic mitral valve repair surgery based on transthoracic echocardiography

Abstract Background The outcome of mitral valve repair over replacement in degenerative diseases has been recognized, but the patient selection of mitral valve repair in rheumatic diseases are still controversial. At present, there is a lack of comprehensive evaluation methods for rheumatic mitral valve disease, which cannot guide the selection of patients before surgery. Purpose The aim of this study was to establish a comprehensive evaluation method and innovative indicators for rheumatic mitral valve disease using transthoracic echocardiography, and to establish a model for predicting the outcome of rheumatic mitral valve repair. Methods This prospective, multicenter, observational cohort study included 167 patients who underwent rheumatic mitral valve surgery in 4 centers from 2022 to 2023. Each enrolled patient underwent a comprehensive transthoracic echocardiography evaluation and measured 94 ultrasound indicators, mainly covering leaflets, annulus, subvalvular apparatus, and atrial and ventricular function. The main endpoint event was the failure of mitral valve repair (including switching to replacement after repair, and moderate to severe stenosis or regurgitation during follow-up after repair). Patients were randomly assigned to the modeling and validation groups at a ratio of 7:3. In the modeling group, LASSO regression was used for variable selection, and logistic regression was used for modeling. A nomogram was drawn and a webpage rating calculator was created. In the validation group, model comparisons were conducted using the C-statistic and Net Reclassification Index (NRI). Results 112 patients (67.1%) underwent mitral valve repair with satisfactory results, 47 patients (28.1%) ultimately underwent mitral valve replacement, and 8 patients (4.8%) found moderate to severe mitral stenosis or regurgitation during follow-up after repair. Three indicators, including mitral valve orifice area, leaflet calcification score, and anterior leaflet-annulus angle, were selected through LASSO regression. No collinearity was found between the three indicators, and they were ultimately included in the logistic regression model. The C statistics in the modeling group and validation group were 0.846 and 0.958, respectively, indicating that the constructed model has satisfactory predictive ability. Compared to the Wilkins score, the proportion of correctly classified items increased by 19.8%, significantly better than the Wilkins score. Finally, a nomogram was drawn based on the model, and a web rating calculator was created to guide clinical decision-making. Conclusion This study explored a comprehensive evaluation method and innovative indicators for rheumatic mitral valve disease by transthoracic echocardiography, established and validated a model for predicting the outcome of repair surgery, and had certain guiding significance for doctors to choose suitable patients for rheumatic mitral valve repair.Validation of the predictive modelNomogram

Transcatheter mitral replacement: what are the outcomes of un-eligible patients compared to treated?

Abstract Background/Introduction Transcatheter mitral valve replacement (TMVR) is emerging in recent years as a promising tool to treat mitral regurgitation, however its applicability in the real world remains limited. Purpose The aim of the study is to assess the real-world screening success rate of TMVR in native anatomy and the 1-year outcomes of both accepted and refused patients as well as clinical results. Methods Retrospective analysis was performed on all patients screened for TMVR at our Valve Center, eligible for 1-year follow-up. In-hospital data of all patients admitted to our Department are prospectively collected. Follow-up was done through outpatient visits and/or telephone calls. Results Out of 3400 patients referred to mitral treatment at our department between January 2016-January 2022, 92 were submitted to screening for TMVR. Among these, 48 patients (49%) were accepted and treated with TMVR while 44 (44.8%) were refused (RG). The main reasons for rejection were anatomy unfeasibility in 25 patients (59%) and frailty in 5(11%). Main reasons for anatomy unfeasibility were risk LVOT obstruction (n=15; 60%), annular dimension (n=8; 33%) and ventricular dimension (n=2; 8,3%).Major baseline characteristics between groups were similar including age (85 vs 84), STS (12 vs 13), ejection fraction and LVEDD. However, refused patients had higher filtration rate than TMVR (80 vs 45 ml/min respectively (p=0.001)).All patients accepted were treated with TMVR: 7 patients received Tiara and 24 Tendyne. Procedure success in the TMVR group was 96% (46/48). Patients refused from TMVR were treated with Mitraclip in 5(11%) cases, 37(84%) were left in medical therapy and 2 (4,5%) underwent surgery. 1-year overall survival 65.2±51.3 vs 54.8±36.5 in TMVR and refused group respectively (p=0.002)(Figure 1). 6 deaths (2 cardiac, 33%) occurred in the TMVR compared to 37 (32 cardiac, 86%) in the refused group. Freedom from Cardiac death was 98±19% TMVR vs 75±65% (p<0.001)(Figure 2). NYHA class improved in 98% of cases in TMVR group but worsened in 80% in refused group, (p<0.001). TMVR screening failure is associated with increased cardiac death (HR 12 [1,51;95], p<0,019) and death for any causes (HR 17,5 [6,02;51], p<0,001). Conclusion(s) In the present experience, approximately 50% of patients screened for TMVR were accepted. The most frequent reasons for screening failure were anatomical issues. With a baseline similar clinical profile, treatment with TMVR provided significant 1-year survival and symptoms improvement compared to those of patients refused, whose prognosis is indeed remarkably poor. These data underline the importance of proper patient selection for TMVR to achieve good outcomes but also the need for technological improvement of devices to expand the proportion of patients who can be treated. Given the small numbers currently available, more data are needed to confirm the present findings, which must be considered hypothesis-generating.Figure 1Figure 2

Chronic infection and severe mitral regurgitation: first of all, do not harm.

techniques of mitral valve repair has improved in the last decades. Percutaneous approach is now a reliable and safe therapy in those patients with high surgical risk. However, the presence of an implanted prothesis increases the risk of endocarditis. we describe a case of a 75-year-old man with medical history of recurrent cellulitis due to chronic lymphedema, who had percutaneous edge-to-edge mitral valve treatment. After three months he developed fever without any specific symptoms. Emocolture were positive for Staphilococcus lugdunensis. Transesophageal echocardiogram demonstrated a huge vegetation at the level of Edwards Pascal device. Patients was then referred to cardiac surgery for mitral valve replacement with bioprothesis. in patients needing a prothesis implantation the management and treatment of chronic infection is of paramount importance to reduce the risk of prothesis infection procedure. Endocarditis after percutaneous edge-to-edge mitral valve treatment represents a rare but a life-threatening condition.

Transcatheter closure of the Gerbode type ventricular septal defect after redo mitral valve replacement

Gerbode defect is an uncommon ventricular septal defect (VSD) resulting in a left ventricle to right atrium shunt. Although typically congenital, acquired defects have been reported following infective endocarditis, cardiac surgery, trauma, or acute myocardial infarction. This condition causes left-to-right intracardiac shunt and potential hemodynamic instability. This complex anatomy poses therapeutic challenges, and optimal management is often unclear. We present a case of acquired Gerbode defect following a redo mitral valve replacement surgery in a 71-year-old man who developed severe dyspnea and pulmonary hypertension. Treatment was successfully performed with percutaneous transcatheter VSD closure using an Amplatzer device. This case highlights the importance of considering Gerbode defects in postoperative patients and demonstrates the efficacy of transcatheter closure in reducing symptoms and avoiding high-risk redo cardiac surgery. Transcatheter repair offers shorter recovery times, reduces pain, and avoids repeat sternotomy, making it a valuable and minimally invasive alternative for patients with acquired Gerbode defects. Keywords: Gerbode defect, left ventricle to right atrium shunt, redo mitral valve replacement, transcatheter closure

Wide Variation in Mitral Valve Repair Rates Among U.S. Surgeons: Analysis of Medicare Claims Data

Mitral valve repair is the preferred treatment for primary mitral regurgitation, offering significant short- and long-term advantages over valve replacement. This study was designed to evaluate the contemporary national mitral valve surgery practice patterns, focusing on the impact of surgeon-specific factors, such as operative volume and years of practice, on repair rates. A retrospective analysis was conducted using 100% Medicare fee-for-service claims data over a 3-year period (January 2020 to December 2022). Mitral valve procedures were identified using specific CPT codes. We excluded patients with active infective endocarditis, mitral stenosis, or a history of prior mitral valve repair or replacement. Multivariable binomial regression was used to assess the impact of surgeon-specific factors on repair rates. We identified 2,072 surgeons in 770 hospitals who performed 12,339 mitral valve operations, with an overall repair rate of 68.8%. The median number of mitral valve operations performed per surgeon during the three-year study period was 3 (IQR 2 - 7), and the median number of mitral valve repairs was 2 (IQR 1 - 5). A subset of 312 surgeons (15%) performed more than 10 mitral valve procedures each and over half (57%) of all repairs nationally. This subgroup's median repair rate was 77%, with significant variability within the group: 17% of surgeons had a repair rate below 50%, 59% had a repair rate between 50 - 90%, and 24% had a repair rate above 90%. Multivariable regression analysis indicated significant associations between repair rates and surgeon-specific factors, including surgical volume, years of practice, and region of practice. Each additional procedure was associated with a 1.5% average increase in repair rate likelihood (95% CI 1.2 - 1.8%, p < 0.001), and each additional year of practice was associated with a 1.4% average increase (95% CI 0.8 - 2%, p < 0.001). Regional differences were notable: surgeons in the South demonstrating lower repair rates (median 71%, IQR 55% - 85%) compared to those in the Northeast (median 78%, IQR 68% - 91%, p = 0.02) and Midwest (median 86%, IQR 63% - 92%, p = 0.04). This study has identified significant variability in mitral valve repair rates among surgeons treating Medicare beneficiaries. Notably, even among the surgeons responsible for most of these procedures, the variability in repair rates is pronounced. These findings suggest substantial opportunities to improve outcomes for patients undergoing mitral valve operations in North America.

A Technique Avoiding Cardioplegia Delivery Complications: A Case Using Systemic Hyperkalemia Cardiopulmonary Bypass Combined with Circulatory Arrest

We conducted a high-risk redo mitral valve replacement through a right mini-thoracotomy without rib spreading (redo-MICS MVR) under systemic hyperkalemia combined with circulatory arrest to circumvent complications associated with cardioplegia delivery. The patient, a 75-year-old man, had a predicted mortality rate of 20%. Initial antegrade cardioplegia successfully induced cardiac arrest, which was administered every 30 minutes. However, upon infusion of the second dose of cardioplegia, the aortic root pressure was approximately 20 mmHg. Despite multiple attempts to re-cross clamp, the aortic root pressure did not improve. Consequently, retrograde cardioplegia was considered, but due to significant adhesion of the inferior vena cava, this approach was abandoned. Thus, the procedure was altered to utilize systemic hyperkalemia without aortic cross-clamping. Given the preoperative transesophageal echocardiography (TEE) diagnosis of mild aortic regurgitation, maintaining a clear surgical field was challenging, necessitating the combination of redo-MVR with circulatory arrest. This case exemplifies the successful management of cardioplegia delivery complications using systemic hyperkalemia and circulatory arrest, resulting in a favorable postoperative recovery for the patient.

The Role of Global Longitudinal Strain in Predicting Left Ventricular Reverse Remodeling After Mitral Valve Replacement Surgery in Patients With Primary Mitral Regurgitation.

This study aimed to identify the utility of global longitudinal strain (GLS) as a reliable parameter that can accurately forecast left ventricle reverse remodeling (LVRR) in patients undergoing valve replacement surgery for severe chronic primary mitral regurgitation (MR), thereby aiding in assessing mortality and morbidity risk. This retrospective observational study involved severe primary MR patients who underwent valve replacement surgery between 2018 and 2023. Pre- and postsurgery echocardiography data were collected, with GLS measurements utilized to assess left ventricular function. Various echocardiography parameters, including MR severity and LV dimensions, were analyzed. Bivariate and multivariate analyses were performed to explore relationships between GLS and LVRR. This study enrolled 103 patients (54.4% male; mean age 45.4 ± 13.6 years). Statistical analyses revealed GLS to be an independent predictor of LVRR, with a threshold of -16.25% showing 89% sensitivity and 50% specificity. Each 1% increase in GLS corresponded to a 1.14-fold (odds ratio [OR]: 1.14; 95% confidence interval [CI]: 1.01-1.31; p<0.05) increased likelihood of LVRR. These findings highlight GLS's potential as a prognostic marker for postsurgical outcomes in severe MR patients.

Lower Levels of Vitamin D Are Associated with Higher Vasoactive–Inotropic Scores in Major Cardiac Surgery

Background: The vasoactive–inotropic score (VIS) predicts unfavorable outcomes after cardiac surgery in both children and adults. In our adult population, we investigated whether preoperative levels of vitamin D can predict the VIS and whether both vitamin D and the VIS can predict adverse outcomes following major heart surgery. Methods: Between 1 October 2021 and 28 February 2022, 300 patients underwent major cardiac surgery at our institution. Eighty-three of them had their 25-OH vitamin D levels measured before surgery. For this cohort, we calculated the VIS based on doses of vasoactive and inotropic medications administered post-surgery. Utilizing receiver operating curves, the predictive accuracy of vitamin D levels and the VIS in predicting acute kidney injury was assessed. Results: The median age of the cohort was 66 (IQR 61–71) years, with 59% being male and a median BMI of 28.4 (IQR 25.2–31.6). The most common procedures were aortic valve replacement, mitral valve replacement, coronary artery bypass grafting, aortic valve and ascending aorta repair, and ASD correction. There was a significant difference in the postoperative VIS between patients with vitamin D deficiency, i.e., &lt;20 ng/mL, and patients with vitamin D values &gt; 20 ng/mL (3.5 vs. 1.3 p &lt; 0.04). We also found a significant correlation between the VIS and the days of hospitalization (r = 0.335; p = 0.002), the days of stay in the intensive care unit (r = 0.547; p &lt; 0.00001), and the mechanical ventilation time (r = 0.327; p = 0.025). Both vitamin D levels and the VIS predicted postoperative acute kidney injury (p &lt; 0.05). Conclusions: Vitamin D deficiency is correlated with the VIS in adults undergoing major cardiac surgery. Both vitamin D levels and the VIS can predict unfavorable postoperative outcomes.

Early structural valve deterioration following transcatheter aortic valve implantation in a patient with Scheie syndrome: a case report

BackgroundScheie syndrome, an attenuated subtype of mucopolysaccharidosis type I, is a rare storage disease that causes progressive glycosaminoglycans (GAGs) accumulation. Cardiovascular disorders determine the prognosis, and cardiac valve abnormalities are the most common cause. The patients are usually young so mechanical valve replacement is often performed, but because of the features of this disease, the surgical treatment is very risky. Recently, transcatheter aortic valve implantation (TAVI) has been reported as an alternative choice for aortic stenosis, but optimal choice is still unclear. Here, we introduce a patient that underwent TAVI and refer to the histological finding of a biological valve extracted in relation to GAGs accumulation.Case presentationA 54-year-old woman with Scheie syndrome underwent valve surgeries three times throughout her whole life. At age 41, she received a mitral valve replacement with a mechanical valve for mitral stenosis. She promptly developed severe diastolic dysfunction and low output syndrome after the release of aortic clamping, thus requiring temporary mechanical circulatory support4. At age 51, she suffered from heart failure due to severe aortic stenosis and underwent TAVI because conventional aortic valve replacement (AVR) was deemed too risky. Three years later, her heart failure relapsed, and an echocardiogram unexpectedly revealed thickened bioprosthetic valve leaflets and a significant pressure gradient across the valve, consistent with early structural valve deterioration. AVR was performed via median sternotomy with a mechanical valve. As with the first operation, she presented refractory heart failure requiring mechanical circulatory support and was meticulously managed. However, she steadily showed worsening of multiple organ systems and died 9 days after the operation. Pathological autopsy and histological examination revealed accumulation of tissue with GAGs on the leaflets of the bioprosthetic valve of TAVI, which may have been the cause of early structural valve deterioration.ConclusionFor patients with Scheie syndrome, a biological valve can be compromised by the accumulation of GAGs, thereby causing early SVD. These findings may support valve selection for these high-risk patients.

Mid-term outcomes of valve replacement surgery with or without coronary artery bypass grafting in patients with overweight and obesity: A cohort study.

Current data evaluating outcomes of valve replacement surgery in patients with overweight/obesity is contradictory. There is a scarce study comparing outcomes of valve surgery considering the type of valve involved in the procedure. We followed outcomes in patients with overweight and obesity after valve replacement surgery with or without coronary artery bypass graft (CABG) and also patients with aortic valve replacement (AVR) and mitral valve replacement (MVR), separately to compare their mid-term prognosis in each group. Consecutive patients who had undergone cardiac valve surgery with or without CABG in Tehran Heart Center were enrolled. We enrolled 3158 patients. Median survival was 125.71 ± 82.20 weeks in patients with overweight/obesity. We found a significantly higher LVDd, LVDs and RVDd in patients with CABG (51.85 ± 7.31, 36.80 ± 8.81 and 30.04 ± 3.58, respectively) compared to the valve group (50.10 ± 6.35 mm, 35.08 ± 7.29 mm and 29.76 ± 4.07 mm, respectively). All-cause mortality is significantly higher in patients with AVR (5.7%) than those with MVR (3.3%). Patients with CABG are at higher risk of myocardial infarction (MI) compared to the ones without CABG (0.8% vs. 0.1%). No significant interaction was observed between the type of valve surgery (AVR/MVR) or valve surgery combinations (valve/valve + CABG) (p-values = .81 vs. .97, respectively). Post-operative outcomes in patients with overweight/obesity depend on several factors such as type of valve involved and presence of CABG. Risk management can lower the rate of mortality and morbidity in these patients.

The effect of pulmonary hypertension and right ventricular dysfunction on early mortality and morbidity in patients undergoing mitral valve replacement

IntroductionThe indications for concominant tricuspid valve surgery in patients undergoing mitral valve surgery for rheumatic reasons are limited. The aim of our study was to investigate the effects of severe pulmonary hypertension and low TAPSE values on early-term mortality and morbidity in patients undergoing mitral valve replacement.MethodsThe data of all patients who underwent mitral valve replacement between January 2013 and August 2020 were examined retrospectively. Patients were divided into 2 groups according to pulmonary artery pressure (PAP ≥ 50 and PAP < 50). The group with PAP > 50 was then divided into 2 subgroups according to TAPSE (1.5 ≥ or < 1.5) values. The early-term mortality and morbidity rates of these groups were compared.ResultsSeventy-nine patients who underwent mitral valve replacement were included in the study. Fifty-four (68%) of them were female, and 25 (32%) were male. During the preoperative period, the TAPSE was 16.8 ± 3.0 mm, and the PAP was 52.1 ± 14.1 mmHg. There were 53 patients with PAP > 50 and 26 patients with PAP < 50. In the PAP > 50 group, the rates of tricuspid regurgitation (p < 0.001), blood transfusion (p < 0.001), intensive care unit stay (p < 0.001), need for CPAP (p = 0.043), reintubation (p = 0.048), acute renal failure (p = 0.028), and mortality (p = 0.026) were found to be significantly different.ConclusionIn conclusion, we believe that in patients with mitral valve pathology, early referral for surgical intervention, before the pulmonary pressures significantly increase and right ventricular function deteriorates, can enhance survival outcomes.

Failure to Rescue Female Patients Undergoing High-Risk Surgery

Female patients have higher mortality rates after high-risk surgery than male patients. It is unknown whether this mortality gap is due to different rates of postoperative complications or if complications are addressed differently by sex, causing complications to lead to death-so-called failure to rescue. To evaluate sex differences in failure to rescue across high-risk surgical procedures. This retrospective cohort study was conducted using data from Medicare beneficiaries from October 2015 to February 2020 who underwent high-risk vascular or cardiac surgical procedures, including abdominal aortic aneurysm repair, coronary artery bypass grafting, aortic valve replacement, and mitral valve replacement or repair. Data analysis was performed from August 2023 to March 2024. The primary exposure was patient sex. The primary outcomes were risk-adjusted rates of complications, 30-day mortality, and failure to rescue, which was defined as a death occurring after a serious complication. Categorical variables are presented as frequencies and proportions and compared using χ2 analysis. Continuous variables were tested for normality and compared using a t test. A total of 863 305 Medicare beneficiaries were included in this study cohort, of whom 304 176 (35.2%) were female. Mean (SD) age was slightly higher in female patients (74.8 [9.3] years) than male patients (73.4 [8.5] years), and female patients had more comorbidities than male patients (≥2 Elixhauser comorbidities, female: 262 809 [86.4%] vs male: 465 231 [83.2%]). Female patients were more likely to receive care at large hospitals and hospitals with a higher surgical case volume. Overall, female and male patients had similar rates of complications (female: 14.98% vs male: 14.37%; adjusted relative risk [aRR], 1.04; 95% CI, 1.03-1.05; P < .001). However, female patients had higher rates of 30-day mortality (female: 4.22% vs male: 3.34%; aRR, 1.26; 95% CI, 1.23-1.29; P < .001) and higher rates of failure to rescue (female: 10.71% vs male: 8.58%; aRR, 1.25; 95% CI, 1.22-1.28; P < .001). A similar pattern was observed when stratified by each procedure. In this cohort study among Medicare beneficiaries undergoing high-risk surgery, male and female patients experienced similar rates of serious complications, but female patients with complications were more likely to die. In other words, clinicians fail to rescue female patients with complications after high-risk surgery more often than male patients. Improving the recognition and management of female patients' complications postoperatively may narrow the sex disparity after high-risk surgery.

Lingual artery thrombosis as a presentation of infective endocarditis in a pregnant patient; a case report

Abstract Background Infective endocarditis during pregnancy is a rare condition that compromises the health of both the mother and the fetus, presenting high rates of morbidity and mortality. The clinical manifestations of this disease are varied, with embolic phenomena being a frequent presentation. Case summary We report the case of a 37-year-old patient, at 29 weeks of pregnancy, with no known cardiovascular history, who presented with 48 hours of sudden mandibular and lingual pain. The study showed acute thrombosis of the right lingual artery and the rest of the right external carotid artery. In this context, searching for the origin of the embolism, acute mitral valve endocarditis was diagnosed, which was effectively treated with antibiotic therapy and biological mitral valve replacement, as well as early cesarean delivery. Discussion We report the first case where lingual artery thrombosis was the key diagnostic feature of infective endocarditis.

Mid- and long-term outcomes of percutaneous balloon mitral valvuloplasty guided solely by echocardiography

Objective: To evaluate the mid-and long-term clinical outcomes of percutaneous balloon mitral valvuloplasty (PBMV) guided solely by echocardiography. Methods: A total of 71 patients with moderate to severe mitral stenosis who underwent PBMV guided solely by echocardiography at Fuwai Hospital, Chinese Academy of Medical Sciences, from January 2016 to December 2022 were retrospectively included. The clinical data and follow-up information were collected and analyzed. Results: Finally, 71 patients (11 males and 60 females) aged (48.6±12.4) years, including 3 pregnant women were included. One patient required surgical intervention due to moderate to severe mitral regurgitation, resulting in a procedure success rate of 98.6% (70/71). The procedural duration was (84.1±40.2) minutes, with the balloon diameter of (26.5±1.1) mm and number of dilatations of 2.9±0.7. The mean mitral transvalvular pressure gradient decreased from (12.6±6.1) mmHg (1 mmHg=0.133 kPa) preoperatively to (5.4±2.4) mmHg postoperatively, while the mitral valve orifice area increased from (0.9±0.2) cm² to (1.7±0.3) cm² (both P<0.001). Before discharge, 16 patients developed new mild mitral regurgitation, five developed new moderate mitral regurgitation, and one patient had a small amount of pericardial effusion absorbed by herself. No severe complications such as death, pericardial tamponade, or thromboembolism occurred during the perioperative period. The average follow-up duration was 12-84 (49.7±21.4) months. At two years postoperatively, the mean mitral transvalvular pressure gradient was (6.2±2.5) mmHg, and the mitral valve orifice area was (1.6±0.3) cm². Eight patients underwent surgical mitral valve replacement at an median of [M(Q1, Q3)] 18 (5, 53) months postoperatively, and one patient died during the follow-up period due to non-cardiac reasons. Conclusion: The mid-and long-term outcomes of PBMV guided solely by echocardiography are favorable.

Best treatment option for secondary mitral regurgitation surgery: a network meta-analysis of randomized and non-randomized controlled studies

The objective of this study is to ascertain whether subvalvular papillary muscle repair in conjunction with restrictive mitral valve annuloplasty represents the most efficacious treatment for patients presenting with secondary ischemic mitral regurgitation, as compared to restrictive mitral valve annuloplasty alone and to mitral valve replacement. A network meta-analysis was conducted to investigate outcomes of randomized controlled trials, propensity-matched studies, and observational studies, comparing various treatments for secondary ischemic mitral regurgitation. The average follow-up duration for late mortality was 4.4 years. Coronary artery bypass grafting (CABG) without mitral valve surgery had a late mortality incidence of 3.7%. Restrictive mitral annuloplasty demonstrated a rate of 6.5%, while restrictive mitral annuloplasty + CABG resulted in a rate of 4.1%. Subvalvular papillary muscle repair plus restrictive mitral annuloplasty ± CABG and mitral valve replacement + CABG had rates of 4.4% and 5.1%. SUCRA analysis showed that CABG was the most effective treatment for reducing late mortality (70.0%). This was followed by subvalvular papillary muscle repair plus restrictive mitral annuloplasty with or without CABG (62.4%). The top strategy for decreasing early death, reoperation, and readmission to the hospital for heart failure is subvalvular papillary muscle repair plus restrictive mitral annuloplasty with or without CABG, based on SUCRA probabilities (84.6%, 85.54%, and 86.3%, respectively). Subvalvular papillary muscle repair plus restrictive mitral annuloplasty ± CABG has potential to reduce the risks associated with early mortality, reoperation, and re-hospitalization for heart failure. However, further research is required to substantiate these findings.