Valve Orifice Area Research Articles

Auto-Pericardial Mitral Valve Implantation: A Pilot Study

Developing nations continue to grapple with rheumatic heart disease, particularly in the young. There is a need for an alternative to prosthetic mitral valve replacement in irreparable mitral valves, which avoids the need for anticoagulation and risks of thromboembolism. Twelve (12) patients with irreparable severe mitral valve disease underwent auto-pericardial mitral valve implantation from August 2020 to February 2021. The mitral valve leaflets were excised. Autologous pericardium treated with 0.5% glutaraldehyde for 8 minutes was fashioned into anterior and posterior mitral leaflets as per the dimensions on an indigenously designed template based on the studies by Ranganathan and Lam. The pericardial leaflets were sutured onto an appropriately sized mitral annuloplasty ring. The ring with the leaflets was implanted onto the mitral annulus. The leaflets were supported with neo-chordae prepared with Gore-Tex (W L Gore and Associates, Inc. Newark, DE, USA) and polyester sutures to mimic a repaired mitral valve in its structure and dynamics. The mean cross-clamp time was 138±21.7 minutes. None of the patients required re-exploration. On the third postoperative day, a mean mitral valve orifice area of 3±0.47 cm and mean mitral valve gradient of 2±1.04 were observed. None of the patients had any more than 1+ mitral regurgitation. None of them have required a re-intervention for mitral insufficiency to date. Auto-pericardial mitral valve re-implantation is a safe and effective procedure for severe, irreparable, mitral valve pathologies. However, the mid-term and long-term results need to be compared with conventional mitral valve replacement with a prosthetic valve in a randomised controlled trial.

Intravascular ultrasound for valve frame expansion and orifice area measurement as well as paravalvular leak assessment during transcatheter aortic valve replacement

Abstract Introduction Valve frame expansion (measured outer valve frame area/nominal valve dimension), but not oversizing (nominal valve dimension/annulus area, %) determines pattern of restored blood flow after transcatheter aortic valve replacement (TAVR). There is no online measure of frame expansion, and error in current echocardiographic assessment of effective orifice area (EOA) and paravalvular leak (PVL) are common. Purpose To evaluate large imaging field intravascular ultrasound (IVUS) during TAVR for measuring valve geometry [frame expansion, minimal geometric orifice area (min GOA), and mechanism of PVL] with transthoracic echo and angio-CT serving for comparative measures, along with the nominal EOA as established by Hahn et al. Methods After successful TAVR either a 10MHz Vision PV 0.035" (60mm imaging field) or 20MHz Vision PV 0.018" (24mm imaging field plus Chr omaFlo) IVUS catheter (Philips) was slowly pulled from the left ventricle outflow (LVOT) to the aorta with continuous imaging of the aortic root. Results There were 16 pts (80.8±7.1 yrs, 8 female) treated for de novo aortic stenosis (n=15) or failed bioprosthesis (n=1), 7 of whom were treated with balloon-expandable TAVR. PV 0.35" catheters were used in 8 pts (including valve-in-valve) and allowed complete geometry assessment of 26.6±2.7mm nominal prosthesis Ø (Figure 1A) whereas PV 0.018" allowed complete geometry assessment in only 4 of 8 pts with nominal prosthesis Ø of 26.1±2.8mm (Figure 1B). Actual % valve inflow expansion (IVUS outer frame/valve nominal dimension) was significantly smaller than % valve oversizing (80%±19% vs 125±19%, p=0.005). Min GOA was substantially bigger than corresponding nominal EOA and EOA calculated using the post-procedural LVOT diameter (272±84mm2 vs 174±25mm2 vs 181±59mm2, p=0.001 correspondingly). However, min GOA was similar to EOA calculated using baseline LVOT area (272±84mm2 vs 230±90mm2; r=0.713, p=0.009). IVUS and angio-CT measurements of outer prosthesis frame area were similar for inflow, coaptation site, and outflow (460±143mm2 vs 454±134mm2 and 455±134mm2 vs 447±114mm2 and 722±174mm2 vs 725±180; p≤0.001 for all paired correlations). Inflow expansion (IVUS outer frame/baseline CT annulus area) tended to be smaller among valves with ≥mild vs no PVL (95±14% vs 107±11%, p=0.156), with clear ChromaFlo signal seen in the space between the aortic annulus wall and outer-valve frame surface (Figure 1C). Conclusions Large imaging field IVUS during TAVR allows for peri-procedural assessment of actual valve geometry that differs substantially from nominal. IVUS offers online tomographic perspective and highest accuracy in anatomy evaluation corresponding with valve function. Funding Acknowledgement Type of funding sources: None. Figure 1

Percutaneous edge-to-edge therapy with PASCAL or MitraClip: a multicenter propensity score matched comparison

Abstract Background The MitraClip is the worldwide established transcatheter edge-to-edge repair system with over 100,000 treated patients. The recently approved PASCAL repair system is well adopted in the field of percutaneous mitral regurgitation (MR) treatment with growing acceptance both in mitral and tricuspid valves. The aim of this retrospective multicenter study was to compare the Edwards' PASCAL System with the Abbott MitraClip System in terms of procedural results and short-term outcome. Methods We retrospectively evaluated patient data of three high volume German centers that performed percutaneous edge to edge procedures either with the MitraClip or the PASCAL repair system. Primary endpoint was the amount of MR reduction. Secondary endpoints were residual MR at discharge, technical success, device success and 30-day mortality. Results Between 2018 and 2020 a total of 412 procedures were performed in the three centers. 216 cases were performed with the MitraClip compared to 196 procedures done with the PASCAL repair system. Patients were male in 55.6% of the cases (50.5% in the MitraClip cohort compared to 61.2% in the PASCAL cohort, p=0.028), mean Logistic Euro-Score II was 4.42 (3.58 in the MitraClip and 3.23 in the PASCAL cohort, p=0.038) and reduced LVEF beyond 45% was seen in 42.6% of the cases (49.5% in the MitraClip compared to 35.3% in the PASCAL cohort, p=0.004). Severe MR at baseline was seen in 98.5% in the MitraClip cohort compared to 98.6% in the PASCAL cohort, p=0.909). Mean number of implanted devices was 1.41±0.56 in the MitraClip cohort and 1.37±0.55 in the PASCAL cohort (p=0.401). Procedures were successfully conducted with both edge-to-edge systems (device success rate 93.2% in the MitraClip cohort and 94.0% in the PASCAL cohort, p=0.775), leading to comparably good results (final MR ≤2 in 94.4% with the MitraClip compared to 95.9% with the PASCAL system, p=0.448) and very good results (final MR ≤1 in 72.6% in the MitraClip compared to 79.5% in the PASCAL cohort, p=0.102). After propensity score matching for adjustment of major differences among the two treatment strategies (including age, gender, MR etiology, EROA, Severe MR (III and IV), reduced LVEF and Mitral Valve orifice area) the achieved mean MR reduction remains comparable (2.29±0.82 with the MitraClip compared to 2.46±0.82 with the PASCAL system, p=0.191). In multivariate regression analysis STS Score independently correlates with a very good final result while device choice did not show a significant impact in this cohort. Conclusion In this retrospective multicenter study both the MitraClip and PASCAL system performed excellent with comparable procedural success rates. Achieved final average reduction of MR Grade was 2.29±0.82 with the MitraClip and 2.46±0.82 with the PASCAL system. Funding Acknowledgement Type of funding sources: None.

Early Assessment of Left Atrial Appendicular Velocities in Patients Undergoing Balloon Mitral Valvuloplasty

Introduction: Peripheral embolism is a major complication in patients with mitral stenosis. Several studies have suggested a relation between a decrease in left atrial appendage (LAA) function and more frequent thromboembolic events of cardiac origin. This study was conducted to assess LAA function before and after percutaneous transvenous mitral commissurotomy (PTMC) using transesophageal echocardiography and to determine factors related to improvement in LAA function. Methods: Fifty consecutively admitted patients with significant mitral stenosis undergoing PTMC were included in the study. All patients underwent transthoracic and transesophageal echocardiographic examination, including the study of LAA velocities, before and 48 h after PTMC. Results: PTMC resulted in a twofold increase in the mitral valve area and no severe mitral regurgitation occurred. The mean mitral valve orifice area increased from 0.9 ± 0.3 cm2 to 1.84 ± 0.22 cm2. There was a decrease in the mean left atrial pressure from 26 ± 8.6 to 12 ± 2.8 mmHg. PTMC also resulted in a significant improvement in the LAA flow velocities, with the anterograde component of the flow increasing from 19.56 ± 9.48 cm/s to 33.10 ± 14.01 cm/s. There was also a significant resolution of the spontaneous echo contrast in the left atrium. Conclusion: There is a significant improvement in the LAA velocities following PTMC and a significant decrease in the spontaneous echo contrast, potentially leading to a lower risk of embolism.

Usefulness of Computed Tomography to Predict Mitral Stenosis After Transcatheter Mitral Valve Edge-to-Edge Repair

Multidetector computed tomography (MDCT) can provide valuable information for preprocedural planning of transcatheter mitral valve interventions. However, no data exists on pre-MDCT parameters predicting high transmitral pressure gradient (TMPG) post-MitraClip procedure. We analyzed the preprocedural MDCTs of 156 consecutive patients with mitral regurgitation undergoing MitraClip implantation at our institution. The mean TMPG was assessed by periprocedural transesophageal and pre-discharge transthoracic echocardiography. MDCT-derived mitral annulus area (MAA), anterior-posterior (AP) and medial-lateral (ML) mitral annulus diameters, and mitral valve orifice area (MVOA) were smaller in patients with mean TMPG ≥5 mmHg than those with mean TMPG <5 mmHg after 1-or 2-clip implantation. Small MAA, AP and ML diameters, and MVOA were moderately correlated with high TMPG post-MitraClip, in which MAA and MVOA had the highest degree of correlation after 1-clip (r=-0.46 both), whereas MAA and ML had the strongest degree of correlation after 2-clip (r=-0.39 both) and at discharge (r=-0.38 both). From the receiver-operating-characteristic curve analyses, no significant differences in the area under the curve were observed among these MDCT parameters for low TMPG after MitraClip implantation, except for those between MAA and AP diameter at discharge (p=0.026). For optimal cutoff values, MAA ≥1100 and ≥1300 mm2 had positive predictive values of 89% and 91%, while both MAA ≥750 and ≥900 mm2 had negative predictive values of 100%, for mean TMPG <5 mmHg after 1-and 2-clip implantation, respectively. In conclusion, in patients undergoing the MitraClip procedure, preprocedural MDCT parameters are useful to predict postprocedural mitral stenosis.

Telocytes-derived extracellular vesicles alleviate aortic valve calcification by carrying miR-30b.

AimsCalcific aortic valve disease (CAVD) is frequent in the elderly. Telocytes (TCs) are implicated in intercellular communication by releasing extracellular vesicles (EVs). This study investigated the role of TC‐EVs in aortic valve calcification.Methods and resultsTCs were obtained and identified using enzymolysis method and flow cytometry. EVs were isolated from TCs using differential high‐speed centrifugation method and identified using transmission electron microscope, western blot, and qNano analysis. The mouse model of CAVD was established. The changes of aortic valve activity‐related indicators were analysed by ultrasound, and the expressions of TC markers CD34 and vimentin in mouse valve tissues were detected using RT‐qPCR and western blot. The model mice were injected with TC‐derived EVs. The expressions of Runx2, osteocalcin, and caspase‐3 were detected using RT‐qPCR and western blot. The calcification model of valvular interstitial cells (VICs) was established. TC‐EVs were co‐cultured with calcified VICs, and calcium deposition was detected using alizarin red S staining. miR‐30b expression in calcified valvular tissues and cells was detected after EV treatment. miR‐30b expression in TCs was knocked down and then EVs were extracted and co‐cultured with calcified VICs. The target of miR‐30b was predicted through bioinformatics website and verified using dual‐luciferase assay. The levels of Wnt/β‐catenin pathway‐related proteins were detected. ApoE−/− mice fed with a high‐fat diet showed decreased aortic valve orifice area, increased aortic transvalvular pressure difference and velocity, reduced left ventricular ejection fraction, decreased CD34 and vimentin, and increased caspase‐3, Runx2, and osteocalcin. The levels of apoptosis‐ and osteogenesis‐ related proteins were inhibited after EV treatment. TC‐EVs reduced calcium deposition and osteogenic proteins in calcified VICs. EVs could be absorbed by VICs. miR‐30b expression was promoted in calcified valvular tissues and cells after EV treatment. Knockdown of miR‐30b weakened the inhibitory effects of TC‐EVs on calcium deposition and osteogenic proteins. miR‐30b targeted Runx2. EV treatment inhibited the Wnt/β‐catenin pathway, and knockdown of miR‐30b in TCs attenuated the inhibitory effect of TC‐EVs on the Wnt/β‐catenin pathway.ConclusionTC‐EVs played a protective role in aortic valve calcification via the miR‐30b/Runx2/Wnt/β‐catenin axis.

Implications of Atrial Fibrillation on the Mechanisms of Mitral Regurgitation and Response to MitraClip in the COAPT Trial.

Atrial fibrillation (AF), mitral regurgitation (MR), and left ventricular (LV) ejection fraction have a complex interplay. We evaluated the role of AF in patients with heart failure and moderate-to-severe or severe secondary MR enrolled in the randomized COAPT trial (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation) and its impact on mechanisms and outcomes with the MitraClip. Patients in the COAPT trial were stratified by the presence (n=327) or absence (n=287) of a history of AF and by assignment to treatment group. Clinical, echocardiographic, and outcome measures were assessed. The primary outcome was the composite rate of death or heart failure hospitalization at 24 months. Patients with history of AF were older and more often male. They had a higher LV ejection fraction, larger left atrial volumes and mitral valve orifice areas, smaller LV volumes, and similar MR severity. Patients with AF compared with those without a history of AF had a higher unadjusted (hazard ratio [HR], 1.32 [95% CI, 1.06–1.64], P=0.01) and adjusted (HR, 1.30 [1.03–1.64], P=0.03) 2-year rate of the primary outcome. Treatment with the MitraClip compared with guideline-directed medical therapy alone reduced death or heart failure hospitalization in both those with (HR, 0.61 [0.46–0.82]) and without (HR, 0.46 [0.33–0.66]) a history of AF (Pint=0.18). Treatment with the MitraClip was associated with a lower risk of stroke in patients with a history of AF (HR, 0.18 [0.04–0.86]) but not in those without a history of AF (HR, 1.64 [0.58–4.62]; Pint=0.02). In the COAPT trial, patients with a history of AF had larger left atrial and mitral valve orifice areas with higher LV ejection fraction and smaller LV volumes, suggesting an atrial mechanism contribution to functional MR. Despite the worse prognosis of heart failure patients with a history of AF, MR reduction with the MitraClip still afforded substantial clinical benefits. Treatment with MitraClip was associated with a lower risk of stroke in patients with a history of AF. URL: https://www.clinicaltrials.gov; Unique identifier: NCT01626079.

Automatic segmentation and tracking of biological prosthetic heart valves.

Purpose: Prosthetic heart valve designs must be rigorously tested using cardiovascular equipment. The valve orifice area over time constitutes a key quality metric which is typically assessed manually, thus a tedious and error-prone task. From a computer vision viewpoint, a major unsolved issue lies in the orifice being partly occluded by the leaflets' inner side or inaccurately depicted due to its transparency. Here, we address this issue, which allows us to focus on the accurate and automatic computation of valve orifice areas. Approach: We propose a segmentation approach based on the detection of the leaflets' free edges. Using video frames recorded with a high-speed digital camera during in vitro simulations, an initial estimation of the orifice area is first obtained via active contouring and thresholding and then refined to capture the leaflet free edges via a curve transformation mechanism. Results: Experiments on video data from pulsatile flow testing demonstrate the effectiveness of our approach: a root-mean-square error (RMSE) on the temporal extracted orifice areas between 0.8% and 1.2%, an average Jaccard similarity coefficient between 0.933 and 0.956, and an average Hausdorff distance between 7.2 and 11.9 pixels. Conclusions: Our approach significantly outperformed a state-of-the-art algorithm in terms of evaluation metrics related to valve design (RMSE) and computer vision (accuracy of the orifice shape). It can also cope with lower quality videos and is better at processing frames showing an almost closed valve, a crucial quality for assessing valve design malfunctions related to their improper closing.

Abstract 12568: Impact of Aortic Stenosis on Myofiber Stress: Translational Application of Left Ventricle-Aortic Coupling Simulations

Introduction: Grading aortic stenosis (AS) has traditionally relied on measuring hemodynamic parameters of transvalvular pressure gradient, ejection jet velocity, or estimating valve orifice area. Recent research has highlighted limitations of these criteria at effectively grading AS in presence of left ventricle (LV) dysfunction. We hypothesize that simulations coupling the aorta and LV will provide meaningful insight into myocardial biomechanical derangements that accompany AS. Reference data from the normal ventricle should first be obtained. Methods: A multi-domain cardiac model with representative anatomy and material properties was used to create AS simulations. Finite element analysis was performed with ABAQUS FEA®. An anisotropic hyperelastic model was assigned to the aorta and LV passive properties, while time-varying elastance function governed LV active response. Mild and severe AS were created by restricting the aortic valve orifice area. Results: Global LV myofiber end systolic (ES) stress (mean±SD) was 9.31±10.33 kPa at baseline (no AS), 13.13±10.29 kPa for mild AS, and 16.18±10.59 kPa with severe AS. Mean LV myofiber ES strains were -22.4±8.7%, -22.2±8.9%, and -21.9±9.2%, respectively. Mild and severe AS had significant stress elevation compared to baseline (mild AS vs base; p&lt;0.01, severe AS vs base; p&lt;0.001) and when compared to each other (p&lt;0.01). See Figure 1 . Ventricular regions that experienced greatest magnitude ES stress were (severe AS vs baseline) basal inferior (39.87±14.73 vs 30.02±12.08 kPa; p&lt;0.01), mid-anteroseptal (32.29±11.56 vs 24.79±12.00 kPa; p&lt;0.001), and apex (27.99±8.44 vs 23.52±10.19 kPa; p&lt;0.001). Conclusions: Isolated AS in a normal heart was simulated, and significantly elevated LV myofiber stress was quantified. This data serves as a comparison to future studies that will incorporate patient-specific ventricular geometries and material parameters, aiming to correlate LV biomechanics to AS severity.

Abstract 17363: Cardiac Output and Valve Orientation Affect Blood Flow Patterns Local to Bioprosthetic Pulmonary Valves in Tetralogy of Fallot

Introduction: Tetralogy of Fallot (ToF) typically requires surgical repair of the right ventricular outflow tract (RVOT) and subsequent placement of an artificial pulmonary valve. Bioprosthetic valve longevity is highly variable and there is currently little understanding of what hemodynamic factors may lead to early valve dysfunction. Hypothesis: We hypothesize that cardiac output and valve orientation impact the performance of bioprosthetic valves by affecting blood flow patterns in the RVOT. Methods: We analyzed hemodynamics in a 3D printed ToF anatomy model in a physiological flow loop. A 25mm surgical valve was implanted in the model at two orientations: native and rotated 180 degrees. Full 3D, three-component, phase-averaged velocity fields were obtained over the cardiac cycle using 4D flow MRI at cardiac outputs of 2, 3.5, and 5 L/min. We acquired images of valve leaflet motion at 1500Hz. The 4D flow MRI and high-speed camera experiments were run identically, allowing us to examine the relationship between flow fields and leaflet motion. Results: The full velocity fields from the MRI scans revealed key differences among cases in flow features including location of reverse flow regions, systolic jet shape, and asymmetry local to the valve. At 2 L/min, the forward flow through the jet was more asymmetric compared to the other cases and a strong vortex formed, indicating a region of recirculation. With the rotated valve orientation, the 2 L/min case also produced a unique pattern as flow was washed from the RVOT inner curve back toward the center of the valve (Fig 1). Leaflet behavior during systole varied with cardiac output as well, as higher frequency flutter was observed at 5 L/min and the effective valve orifice area was decreased by 8.5% at 2 L/min compared to 5 L/min. Conclusions: We observed key differences in flow patterns and leaflet motion due to cardiac output and valve orientation that could impact leaflet loading and fatigue and long-term valve function.

Abstract 13429: Echocardiographic Predictors of Mitral Transvalvular Gradients After Mitraclip Insertion

Introduction: The MitraClip procedure is a non-surgical alternative for patients with severe mitral regurgitation and high surgical risk. However, the MitraClip may lead to a reduction in the mitral valve orifice area (MVOA) and elevated transmitral mean gradients (TMG). The objectives of this study are to assess the value of baseline MVOA by different imaging methods and explore the value of MVOA indexed for left ventricular (LV) forward stroke volume (SV) to predict postprocedural TMG. Methods: Preprocedural echo images were retrospectively reviewed in 76 consecutive patients. MVOA from 2D transthoracic (MVOA TTE ), 2D transgastric (MVOA TG ) and 3D transesophageal (MVOA 3D ) echocardiography were measured and then indexed by the SV measured by Doppler in the LV outflow tract (MVOA/SV) . Postprocedural TMG was measured at one month and survival rate at one year. Results: Patients with postprocedural TMG &gt;5 mmHg (18/76, 24%) had significantly smaller preprocedural MVOA 3D (3.9±0.9 vs 5.2±1.3 cm 2 , p&lt;0.01) and MVOA TTE (4.9±1.1 vs 5.9±1.5 cm 2 , p=0.02). No significant difference was found for MVOA TG (5.5±1.4 vs 5.9±1.4 cm 2 , p=0.2). Best threshold values for MVOA 3D and MVOA TTE to predict postprocedural TMG &gt;5 mmHg were respectively 3.9 cm 2 (AUC=0.80, IC95%: 0.67-0.94, p&lt;0.01; sensitivity (Se) 62%, specificity (Sp) 87%) and 4,6 cm 2 (AUC=0.69, IC95%: 0.54-0.83, p=0.02; Se 50%, Sp 84%). MVOA/SV from each echocardiographic modality were smaller in patients with postprocedural TMG &gt;5 mmHg (3D: 80 [62-95] vs 113 [99-129] cm 2 /L; TTE: 92 [81-105] vs 130 [100-166] cm 2 /L; TG: 104 [83-123] vs 135 [104-166] cm 2 /L; p&lt;0.01 for all). MVOA/SV 3D was overall the best predictor of postprocedural TMG &gt;5 mmHg, with an optimal threshold of 96 cm 2 /L (AUC=0.86, IC95%: 0.76-0.97, p&lt;0.001; Se 84%, Sp 81%). Patients with MVOA 3D &lt;3.9 cm 2 and MVOA/SV 3D &lt;96 cm 2 /L tend to be at higher risk for mortality at one-year follow-up (69% vs 84%, p=0.14 and 67% vs 87%, p=0.11 respectively). Conclusion: Unlike preprocedural MVOAs assessed by 3D echocardiography, preprocedural MVOAs measured by 2D echocardiographic modalities were poor predictors of high TMG after MitraClip. Preprocedural MVOA 3D &lt;3.9 cm 2 and MVOA/SV 3D &lt;96 cm 2 /L were found to be the best cut-off values to predict postprocedural TMG &gt;5 mmHg.

Surgical rheumatic mitral valve repair compared with percutaneous balloon mitral valvuloplasty in mitral stenosis in current era: a propensity score matching study.

BackgroundMany comparative studies of percutaneous balloon mitral valvuloplasty (PBMV) and surgical mitral commissurotomy (SMC) in rheumatic mitral stenosis (MS) were done in the last few decades. With the development of valve repair techniques, various surgical rheumatic valve repair techniques have been applied in clinic, but there is a lack of comparison with PBMV. Our study was designed to compare the perioperative and mid-term outcomes of PBMV and mitral valve repair with “four-step” procedure in the treatment of rheumatic MS.MethodsPatients with MS were treated with PBMV or rheumatic mitral valve repair (rMVP) at Beijing Anzhen Hospital between January 1, 2013 and September 30, 2018 were selected. By using propensity score matching (PSM) method, we compared the changes in post-operation clinical outcomes between the two matched groups. Kaplan-Meier analyses was used for survival analysis and drawing the curve, and log-rank test were used to compare intergroup differences.ResultsA total of 252 cases were enrolled after selection, 74 cases in PBMV and 178 cases in rMVP. Seventy-four pairs were matched successfully after PSM. There were 53 females in PBMV and 54 in rMVP. The mean age of two groups was 46.95±12.50 and 47.55±11.91 years respectively. There was no significantly differences in mitral valve orifice area (MVOA) (1.05±0.32 vs. 0.97±0.24 cm2, P=0.12) and left ventricular ejection fraction (EF) (62.36%±5.17% vs. 62.52%±4.94%, P=0.76) between two groups preoperatively. Baseline characteristics were basically balanced after PSM. In each group, there was one case transferred to surgical mitral valve replacement due to the failure of valvuloplasty before discharge. All patients survived the interventions and no severe complications were found. MVOA were significantly increased in rMVP compared with PBMV postoperatively, as well as grading of MS and tricuspid regurgitation (TR) were significantly improved in rMVP. Three cases in PBMV were lost during the follow-up. Mitral replacement was performed in 11 patients and one of them died in PBMV, while none of patients underwent re-intervention in rMVP, but one patient died of pneumonia.ConclusionsFor selected patients with rheumatic MS in China, our study shows that there are comparable clinical outcomes in terms of operative, mid-term mortality and complications between PBMV and surgical rMVP with “four-step” procedure. Surgical rMVP shows more advantageous in the correction of valve stenosis and the management of concomitant tricuspid valve lesions and atrial fibrillation (AF).

Sutures on the Anterior Mitral Leaflet to Prevent Systolic Anterior Motion

Mitral valve systolic anterior motion and associated regurgitation remain a challenging problem in mitral valve plasty. A simple procedure to correct intraoperative systolic anterior motion using sutures applied between the tip of the anterior leaflet and the posterior annulus is presented. This technique reduces the movement of the anterior leaflet toward the septum while maintaining sufficient valve orifice area.

Double-lumen oropharyngeal cannula for sedation in percutaneous aortic valve implant with transesophageal echocardiography. Case report

Introduction The prevalence and severity of aortic valve disease increases in the elderly population. Transfemoral transcatheter aortic valve implantation (TAVI) has been gaining space as an alternative method even in mild cases to conventional open aortic valve replacement surgery. In many centers, conscious sedation as an alternative to general anesthesia to these procedures. Therefore, the use transesophageal echocardiography (TEE) is a concern when conscious sedation is performed. In this case report, we describe for the first time the use of a double-lumen oropharyngeal cannula to support sedation in a patient undergoing TAVI and TEE monitoring. Methods Case report: 72-year-old male patient, 58kg, 178 cm tall, physical status ASA 3, Euroescore II 1,81%, with severe aortic stenosis (Aortic valve orifice area = 0.5cm2, maximum and mean gradient = 58mmHg and 31mmHg, respectively) underwent elective percutaneous aortic valve implantation with transfemoral vascular access. After standard monitoring, sedation was started with intravenous infusion of dexmedetomidine and propofol titrated to effect. The cannula was inserted right after loss of consciousness, connecting one of its lines to the capnograph and the other one to the supplemental oxygen source with a continuous flow of 3L/min. Right after, TEE probe was passed through the cannula to the upper esophagus.(Figure 1) A: CO2 exhaled line monitoring; B: O2 line administration; C: Lumen used to keep a better patency of the airway during spontaneous ventilation; D: Lumen used to pass the TEE probe. Throughout the procedure, patient was maintained on spontaneous ventilation, maintaining BIS values below 60. Data collection includes: ETCO2, mean arterial pressure, heart rate, BIS values, SatO2 and arterial blood gases . The examiner was also questioned subjectively the comfort of handling the TEE probe during the exam (easy, moderate or difficult) and also checking for possible oral cavity trauma due use of the cannula during procedure. Results The procedure went without any complications. No soft tissue lesions were found The examiner considered the handling of the probe with the presence of the cannula easy. Discussion The oropharyngeal cannula was feasible to support sedation in this patient for TAVI with TEE monitoring. However, further studies with a larger number of patients and randomized trials comparing different techniques are still needed to confirm our results.

ECHOCARDIOGRAPHIC PREDICTORS OF MITRAL TRANSVALVULAR GRADIENTS AFTER MITRACLIP INSERTION

The percutaneous MitraClip system is recognized as a valuable alternative to surgery in patients with symptomatic mitral regurgitation (MR) and prohibitive surgical risk. However, the MitraClip procedure may lead to a reduction in the mitral valve orifice area (MVOA) and increased transmitral mean gradients (TMG). Although preprocedural MVOA≤4 cm2 is considered a relative contraindication for the procedure; predictors of post-intervention TMG are not well known and TMG is also influenced by transvalvular flow. The objectives of this study are to assess the value of baseline MVOA by different imaging methods and explore the value of MVOA indexed for left ventricular forward stroke volume (SV) to predict post-intervention TMG.

Novel approach for automatic mid‐diastole frame detection in 2D echocardiography sequences for performing planimetry of the mitral valve orifice

The mitral valve orifice area is a reliable measure for evaluating mitral valve stenosis (MS) severity, which is obtained by the planimetry of the mid-diastole frame in the echocardiography sequences. Since the manual method for determining this frame is time-consuming and user-dependent, a novel automatic method has been proposed in this study. First, the region of interest (ROI) containing the mitral valve orifice region is detected using circular Hough transform and k-means algorithms. Then, the dimension reduction method is applied to the ROI of each frame to map it into a point in a 2D space. The performance of the local linear embedding (LLE), isometric mapping, kernel principal component analysis (PCA), and linear PCA algorithms has been evaluated in this study. Finally, a distance curve is obtained by calculating the Euclidean distance between consecutive points in 2D space, and the mid-diastole frame is determined by interpreting this curve. The proposed algorithm was validated using 2D echocardiography of the 20 MS patients. Finally, the LLE method showed the best result, and the average frame difference for 20 cases using the proposed method compared with the gold standard (the echo-cardiologist opinion) was 1.40.

Impact of Aortic Stenosis on Myofiber Stress: Translational Application of Left Ventricle-Aortic Coupling Simulation

The severity of aortic stenosis (AS) has traditionally been graded by measuring hemodynamic parameters of transvalvular pressure gradient, ejection jet velocity, or estimating valve orifice area. Recent research has highlighted limitations of these criteria at effectively grading AS in presence of left ventricle (LV) dysfunction. We hypothesized that simulations coupling the aorta and LV could provide meaningful insight into myocardial biomechanical derangements that accompany AS. A realistic finite element model of the human heart with a coupled lumped-parameter circulatory system was used to simulate AS. Finite element analysis was performed with Abaqus FEA. An anisotropic hyperelastic model was assigned to LV passive properties, and a time-varying elastance function governed the LV active response. Global LV myofiber peak systolic stress (mean ± standard deviation) was 9.31 ± 10.33 kPa at baseline, 13.13 ± 10.29 kPa for moderate AS, and 16.18 ± 10.59 kPa for severe AS. Mean LV myofiber peak systolic strains were −22.40 ± 8.73%, −22.24 ± 8.91%, and −21.97 ± 9.18%, respectively. Stress was significantly elevated compared to baseline for moderate (p < 0.01) and severe AS (p < 0.001), and when compared to each other (p < 0.01). Ventricular regions that experienced the greatest systolic stress were (severe AS vs. baseline) basal inferior (39.87 vs. 30.02 kPa; p < 0.01), mid-anteroseptal (32.29 vs. 24.79 kPa; p < 0.001), and apex (27.99 vs. 23.52 kPa; p < 0.001). This data serves as a reference for future studies that will incorporate patient-specific ventricular geometries and material parameters, aiming to correlate LV biomechanics to AS severity.

Hemodynamics of a stenosed aortic valve: Effects of the geometry of the sinuses and the positions of the coronary ostia

Aortic valve stenosis is one of the most prevalent cardiovascular disease among adults worldwide. Stenosis of the aortic valve changes the hemodynamic parameters inside the aortic root which perpetuates aortic valve calcification and has been associated with the development of coronary artery atherosclerosis. Invasive studies have revealed that the geometry of the sinuses, as well as the locations of the coronary artery ostia, impact coronary blood flow hemodynamics, which has been associated with the development of coronary artery disease. The aim of this study is to elucidate this observed phenomenon, in which geometrical variations inside the aortic root and malfunctioning of the aortic valve because of the calcification not only affect the progression of the calcification but also lead to initiation of coronary artery atherosclerosis. A 2D fluid structure interaction model of the aortic valve was developed and simulated in ANSYS Fluent based on available echocardiography images in the literature. The model incorporates fluid structure interaction and employs the k − ω Menter's Shear Stress Transport (SST) turbulence model for the turbulent flow downstream of the leaflets. The effects of various diameters of the sinuses 25, 20.8, and 17.6 mm and positions of the coronary artery ostia (proximal, middle, and distal) on aortic root hemodynamics were investigated and parameters including transvalvular pressure gradient, valve orifice diameters, maximum jet velocity along the valve orifice area, and wall shear stresses on leaflets calculated. Results demonstrate that a severely calcified valve with the proximal coronary artery ostia witnesses a much higher transvalvular pressure gradient (approximately 10 times larger) compared to that for a healthy case. Moreover, the presence of the proximal coronary artery ostia for valves with diameters of the sinus 25 and 20.8 mm results in the reduction of the coronary blood flow and increase of the probability of coronary artery atherosclerosis.

Impact of COAPT trial exclusion criteria in real-world patients undergoing transcatheter mitral valve repair

BackgroundThe generalizability of the COAPT trial results on the benefit of TMVR in patients with secondary mitral regurgitation is unclear. MethodsFunctional and long-term clinical outcome were examined in 122 consecutive patients with secondary mitral regurgitation and reduced ejection fraction undergoing TMVR. “COAPT-like” patients were defined according to principal COAPT inclusion/exclusion criteria if all of the following was fulfilled: symptomatic mitral regurgitation grade 3+ or more according to American guidelines; left ventricular ejection fraction ≥ 20%, left ventricular end-systolic dimension ≤ 70 mm, estimated pulmonary artery systolic pressure ≤ 70 mmHg, mitral valve orifice area ≥ 4 cm2, no prior mitral valve procedure, no right sided congestive heart failure, no COPD requiring home oxygen therapy and NYHA class less than IVb. Results51% of 122 patients (mean age 74 ± 10 years, 76% male) showed COAPT-like characteristics. COAPT-like patients showed a significantly lower hazard for the composite endpoint of mortality and heart failure hospitalization (HR 0.51, 95%CI 0.30–0.89, p = .017) during a mean follow-up of 16 ± 6 months, with an estimated 1-year event rate of 20% vs 43%, respectively. The improvement in functional outcomes 6 min walking distance (76 ± 136 m vs. 31 ± 90 m), Minnesota Living with Heart Failure Questionnaire (−6 ± 19 vs. −10 ± 23) and Short Form 36 physical component score (3.8 ± 10 vs. 5.5 ± 11) was similar in COAPT-like and the other patients. ConclusionIn this first real world cohort half of the patients undergoing TMVR showed COAPT-like characteristics and these patients showed a substantially better clinical outcome. The mid-term functional benefit was similar in COAPT-like and other patients.

Predictors of Complications During Percutaneous Multitrack Balloon Mitral Valvuloplasty

Introduction: Mitral Stenosis (MS) is characterized by a decrease in Mitral Valve (MV) orifice area leading to compromised left ventricular filling. The consequence is stagnation of blood proximal to the MV that results in elevated left atrial, pulmonary venous, and pulmonary artery pressure. Aim of the work: Trace the complication of mitral regurgitation during the procedure percutaneous Balloon Mitral Valvuloplasty (PMV) by using multitrack balloon. Subjects and methods: This interventional non-randomized cohort study was conducted on 121 patients who presented with moderate to severe MS and subjected to PMV using multitrack balloon technique and were divided into 2 groups, according to resultant mitral regurgitation: Group A: included patients with no or mild mitral regurgitation and Group B: included patients with severe mitral regurgitation. Results: Multivariate regression identified MV balloon sizing (OR 3.877, CI 95% 1.131-13.289, P value 0.031), MV commissural asymmetry (OR 67.48, CI 95% 5.759-790.72, P value 0.001). Conclusion: Mitral valve calcification, balloon sizing and MV asymmetry are significant factors that can predict the development of severe MR after balloon valvuloplasty.