Postoperative Transthoracic Echocardiography Research Articles

Bioprosthetic valve function in carcinoid heart disease

Abstract Background Carcinoid heart disease (CHD) is a complication of neuroendocrine tumours (NETs) with significant cardiovascular morbidity and mortality. It causes fibrotic damage to predominantly the right-sided valves with subsequent tricuspid valve (TV) and/or pulmonary valve (PV) regurgitation leading to right ventricular (RV) dilatation and dysfunction. The definitive treatment is valve replacement commonly using bioprosthetic valves. Case studies have suggested that bioprosthetic valve degeneration may occur due to ongoing carcinoid plaque deposition, but serial data is lacking. Purpose To assess the trajectory of prosthetic valve function on serial transthoracic echocardiography (TTE) in patients with CHD and determine the effect on long-term outcomes. Methods A retrospective multicentre observational cohort study including 81 patients who had valve replacement for CHD between 2005-2022. TTE data assessing prosthetic valve function (peak velocity, mean gradient, para/transvalvular regurgitation) and any associations with outcome were identified. Results Eighty-one patients (64±8 years, 56% male) were followed up for a median of 24 months (IQR: 8-48), during which there were 52 deaths, an estimated median survival of 32 months and 1-, 3- and 5-year survival rates of 69%, 48% and 38%, respectively. The post-operative TTE was carried out at a median of 10 days (IQR: 7-47) after surgery. Of the 71 patients with available post-operative TTEs, 48 had >1 TTE. No significant trends were seen in TV parameters over time. PV peak velocity and mean gradient increased significantly over time (p=<0.001). Increasing TV peak velocities were significantly associated with shorter survival (p=0.008) and those with increases of >5% per year had 5-year survival of 0% compared to 70% in those with decreasing by <5% per year. Increasing PV mean gradients were associated with longer survival (p=0.014), with 5-year survival 35%, 55%, and 91% for patients with increases of <0, 0-2 and ≥2 mmHg per year, respectively. This may reflect RV remodelling and improved RV function. There were 5 cases of prosthetic valve dysfunction, with only 1 needing re-intervention with transcatheter valve-in-valve procedure. A cause of death was available for 39 patients, 46% were due to NET causes and 31% due to cardiac causes. Conclusions Our data suggests that bioprosthetic valve degeneration in CHD is uncommon. TV function did not change over time and PV velocities although increased with time did not lead to significant valve dysfunction. The main cause of death was due to advancing NET disease. This raises the question as to whether transcatheter replacement may be a viable alternative in patients with CHD, who are facing a median survival of less than 3 years.

LONG-TERM OUTCOMES OF YOUNG PATIENTS AFTER SURGICAL CLOSURE OF VENTRICULAR SEPTAL DEFECT WITH EPOXY-TREATED XENO-PERICARDIAL “KEMPERIPLAS-NEO” PATCH

HighlightsVentricular septal defect is the most common congenital heart defect requiring open-heart surgery. The epoxy-treated patch made from xeno-pericardium used to correct this defect was assessed from the standpoint of efficacy, safety, thrombogenicity and degree of calcification AnnotationAim. To assess long-term outcomes of ventricular septal defect closure using epoxy-treated xeno-pericardial “KemPeriplas-Neo” patch in children.Methods. This retrospective study included 42 patients aged 16 months to 18 years, diagnosed with ventricular septal defect (VSD, membranous and muscular) and undergoing VSD closure. The study did not include patients with congenital heart defects (CHD) and congenital and acquired valvular heart diseases. In the long-term follow-up, VSD patch closure (including pseudoaneurysms, fibrosis, recanalization of VSD and recurrence, macrocalcification) was assessed using postoperative transthoracic echocardiography (TTE).Results. Mean age of patients at the time of surgery was 67.4 ± 53.4 months (range 16–216 months), and at the time of the study 178.2 ± 35.9 months (range 101–243 months). The mean follow-up period was 111.5 ± 18.5 months (range 70.0–147 months). According to TTE results, there were no complications after procedure. Valve function after surgical closure of VSD was satisfactory. Reoperations were not required, and there were no cases of acute stoke and myocardial infarction in the follow-up period. Moreover, there were no in-hospital deaths and no long-term fatal outcomes.Conclusion. The data obtained indicate the safety and effectiveness of conducting ventricular septal defect closure using epoxy-treated xeno-pericardial “KemPeriplas-Neo” patch. The VSD patch did not disturb the movement of the interventricular septum, and it did not negatively affect the adjacent areas, including the aorta. However, it is necessary to increase the number of patients and conduct a comparative analysis with other types of patches (synthetic, glutaraldehyde–treated) for a more detailed study of the VSD patch efficacy.

Postoperative transthoracic echocardiography showed smooth blood flow within the reimplanted left coronary artery without stenosis.

Postoperative transthoracic echocardiography showed smooth blood flow within the reimplanted left coronary artery without stenosis.

Preoperative mitral valve annulus area size is an important factor in avoiding functional mitral stenosis after mitral valve repair.

Functional mitral stenosis (FMS) following mitral valve (MV) repair for degenerative mitral regurgitation (DMR) is known as a poor prognostic factor. The parameters for avoiding postoperative FMS in MV repair for DMR have not been established. Two-hundred-and-twenty patients (mean age 61.1 ± 13.3years, 144 males) who underwent MV repair for DMR were analyzed. MV annulus area was measured pre- and postoperatively using three-dimensional transesophageal echocardiography (TEE). Trans-mitral pressure gradient (TMPG) was evaluated by postoperative transthoracic echocardiography and FMS was defined as a mean TMPG ≥ 5mmHg. FMS was present in 14 patients (6.4%). Pre- versus postoperative MV annulus area change ratio was greater in the FMS group than in the non-FMS group (62.5 ± 7.2% vs. 48 ± 11.2%, p < 0.0001). On multivariate logistic regression analysis, MV annulus area change ratio was an independent predictor of FMS (odds ratio 1.19, 95% confidence interval 1.09-1.33, p < 0.0001), while receiver operating characteristics analysis showed that the optimal threshold for MV annulus area change ratio to predict FMS was 56.2% (area under the curve, 0.87; p < 0.0001). The preoperative MV annulus area on TEE can be used to determine the postoperative MV annulus area to avoid FMS after MV repair.

Corrected partial anomalous pulmonary vein connection associated with lung resection: a case report

IntroductionPartial anomalous pulmonary venous connection (PAPVC) is a potential cause of right-sided heart failure. Notably, a risk of sudden circulatory failure exists during lung surgery. Only a few reports of PAPVC complicated by lung cancer requiring lobectomy exist. Here, we report a case of left lower lung lobectomy complicated by an anomalous connection of the left upper pulmonary vein requiring revascularization.Case presentationA 66-year-old man was found with an abnormal mass shadow in the left lower lung field on chest radiography. Bronchoscopy revealed lung adenocarcinoma. Preoperative contrast-enhanced computed tomography showed that the left upper pulmonary vein did not perfuse the left atrium but was connected to the left brachiocephalic vein. Preoperative transthoracic echocardiography revealed right atrial and ventricular enlargement. The clinical diagnosis was stage IB (T2aN0M0). We decided to perform a left lower lobectomy and correct the PAPVC to maintain oxygenation after the lobectomy. The PAPVC was ligated, and the stump of the left upper pulmonary vein was anastomosed to the left atrial appendage without cardiopulmonary bypass. Postoperative contrast-enhanced computed tomography revealed intact reconstructed vessels. Postoperative transthoracic echocardiography showed no right ventricular overload. The patient’s postoperative clinical course following the surgical procedure was uneventful. Furthermore, the patient was followed up without any complications.ConclusionsThis rare case of successful surgical correction can inform clinicians of similar cases.

Transmitral Pressure Gradients in Patients With Degenerative Mitral Regurgitation After Robotic Mitral Valve Repair With Leaflet Preservation Techniques.

The hemodynamic effects of mitral valve repair (MVr) with respect to transmitral pressure gradients (TMPGs) have not been described well in patients undergoing leaflet preservation techniques. In a population of patients undergoing robotic MVr with leaflet preservation, we investigate the expected change of the postrepair intraoperative TMPG in the postoperative follow-up period. We retrospectively studied 144 adult patients who underwent robotic MVr. Demographic, clinical, procedural, and echocardiographic data were collected and analyzed. We found a slight increase in the mean TMPG from the intraoperative postrepair to the immediate postoperative period (intraoperative 3.3 ± 1.4mmHg vs. first postoperative transthoracic echocardiography [TTE] follow-up 3.6 ± 1.9mmHg, p = 0.016) with a gradual decline in the long-term follow-up (mean TMPG at last follow-up TTE 2.4+2.1mmHg). When dichotomizing the patient population using a cutoff of 3mmHg for the intraoperative mean TMPG, patients with an intraoperative mean TMPG > 3mmHg had higher mean TMPG gradients at first TTE (4.5 ± 2.4 vs. 3.1 ± 1.3mmHg, p<0.001) as well as at last TTE (3.0± 2.2 vs. 2.1 ± 2.0mmHg, p = 0.01) when compared with patients with an intraoperative mean TMPG ≤ 3mmHg. There was no difference in clinical outcomes. Although the hemodynamic effect of MVr seems to be small, patients with an intraoperative TMPG > 3mmHg have a higher mean TMPG at follow-up. The hemodynamic effect does not seem to have an impact on clinical outcome.

Long-term outcomes of mitral valve repair in children.

Mitral Valve Disease in children presents unique challenges due to the wide range of associated pathologies and the complexities of pediatric cardiac anatomy. Mitral valve repair in this demographic is preferred over replacement due to the drawbacks associated with prosthetic valves in young patients, such as the need for long-term anticoagulation and issues with prosthetic size and growth. This retrospective study reviewed pediatric patients under 18 years who underwent mitral valve repair between January 2002 and December 2023. Exclusion criteria included patients with atrioventricular septal defects or single-ventricle physiology. Surgical outcomes were assessed using preoperative and postoperative transthoracic echocardiography, with follow-up data analyzed via Kaplan-Meier survival estimates. The study included 47 patients with a median age of 4 years. Surgical techniques varied based on the specific mitral valve pathology. The overall early mortality was 6.3%, and the one and ten-year survival rates were 93.6 ± 3.6% and 91.4 ± 4.1%, respectively. Most patients showed improved or stable postoperative cardiac function during a median follow-up of 105 months. Notably, the rate of freedom from re-operation at ten years was 85.1 ± 6.9%, highlighting the durability of the surgical interventions. Mitral valve repair in children demonstrates favorable long-term outcomes with low mortality and reoperation rates, particularly when performed at an older age to accommodate growth and avoid the complexities of smaller, more delicate cardiac structures. These findings suggest that mitral valve repair should be considered a viable and effective option for managing pediatric MVD, with a personalized approach essential for optimizing outcomes.

Impact of bridging veno-venous extracorporeal membrane oxygenation to COVID-19 lung transplantation.

Veno-venous extracorporeal membrane oxygenation (VV-ECMO) therapy is being increasingly used as respiratory support for patients with severe coronavirus disease 2019 (COVID-19)-associated acute respiratory distress syndrome (ARDS). However, the long-term outcome of VV-ECMO as a bridge to lung transplantation in COVID-19-associated ARDS remains unclear, hence the purpose of this study aimed to evaluate its long-term outcome, safety, and feasibility. This was a retrospective cohort study from an institutional lung transplantation database between June 2020 and June 2022. Data on demographics, pre-transplantation laboratory values, postoperative outcomes, preoperative and postoperative transthoracic echocardiography findings, and survival rates were collected. Chi-square, Mann-Whitney U, Student's t, Kaplan-Meier, and Wilcoxon signed-rank tests were used for analysis. Twenty-five patients with COVID-19-associated ARDS underwent lung transplant surgery with VV-ECMO bridge. Unfortunately, six patients with COVID-19-associated ARDS using VV-ECMO died while waiting for transplantation during the same study period. Patients with VV-ECMO bridge were a more severe cohort than 16 patients without VV-ECMO bridge (lung allocation score: 88.1 vs. 74.9, P<0.001). These patients had longer intensive care unit and hospital stays (P=0.03 and P=0.02, respectively) and a higher incidence of complications after lung transplantation. The one-year survival rate of patients with VV-ECMO bridge was lower than that of patients without (78.3% vs. 100.0%, P=0.06), but comparable to that of patients with other lung transplant indications (84.2%, P=0.95). Echocardiography showed a decrease in the right ventricular systolic pressure (P=0.01), confirming that lung transplantation improved right heart function. Our findings suggest that VV-ECMO can be used to safely bridge patients with COVID-19 associated ARDS with right heart failure.

Evaluation of Intraoperative Saline Injection Leak Test Without Transesophageal Echocardiography as a Reliable Method During Heart Valve Repair

Background: Valvular heart diseases (VHD) pose a significant global health challenge, leading to numerous cardiac surgeries. The quality of valve repair is typically assessed using transesophageal echocardiography (TEE) and saline injection tests intraoperatively. However, TEE is not universally available, particularly in resource-limited settings. Objectives: This study aimed to evaluate the effectiveness of saline injection tests as the sole method for assessing cardiac valve repair quality. Methods: This retrospective cohort study included patients who underwent cardiac valve surgery without intraoperative TEE assessment. Preoperative transthoracic echocardiography (TTE) was performed on all patients. A consistent team performed all valve repairs, and the quality of these repairs was assessed intraoperatively using the saline injection test. Postoperative TTE was also conducted to evaluate valve function and compare it with preoperative measurements. Results: The study comprised 16 patients (mean age: 63.8 ± 10.6), predominantly male. Mitral valve (MV) repair was performed on 11 patients, with nine showing improved function (P-value: 0.006). Seven patients underwent tricuspid valve repair (TVr), all of whom exhibited improved function (P-value: 0.01). Four patients received aortic valve repair, with three showing improved function (P-value: 0.10). Additionally, significant improvements were observed in left ventricular end-diastolic diameter (LVEDd), left ventricular end-diastolic volume (LVEDV), inter-ventricular septal diameter, posterior wall thickness (PWT), tricuspid annular plane systolic excursion (TAPSE), right ventricular peak systolic myocardial velocity (RVSm), pulmonary artery pressure, tricuspid regurgitation (TR) gradient, and right atrium area. Conclusions: The saline injection test can be a valuable tool for assessing the quality of mitral and tricuspid valve repairs, particularly when TEE is unavailable. However, its reliability for aortic valve repair remains uncertain.

Outcomes of maze procedure and mitral valve surgery in atrial functional mitral regurgitation: a retrospective study

BackgroundAtrial functional mitral regurgitation (AFMR) is a newly discovered condition associated with longstanding atrial fibrillation. This retrospective study aimed to analyze the outcomes of the maze procedure and mitral regurgitation (MR) surgery in AFMR and atrial fibrillation in comparison with those in degenerative MR (DMR).MethodsPatients who underwent mitral valve repair/replacement with a maze procedure at a hospital (July 2012–August 2021) were included. We excluded patients aged below 18 years undergoing concomitant coronary artery bypass grafting or atrial septal defect repair and those with MR etiology other than ARMR or DMR.ResultsWe included 35 patients with AFMR and 50 patients with DMR. Patient characteristics and postoperative outcomes were not significantly different between the two groups. Long-term outcomes revealed no significant differences in the ratio of cardiac mortality, stroke, or hospital readmission. However, after the maze procedure, the sinus rhythm restoration rate was significantly lower (62% vs. 28.5%, p < 0.001), a junctional rhythm state (p < 0.001) and permanent pacemaker insertion for sick sinus syndrome (SSS) (p = 0.03) were significantly more common in AFMR than DMR. On postoperative transthoracic echocardiography (TTE), the pulmonary artery systolic pressure was significantly less decreased in the AFMR group than in the DMR group compared with that on preoperative TTE (p = 0.04).ConclusionsAFMR showed excellent mitral valve surgery outcomes, similar to DMR, but had a significantly higher risk of pacemaker insertion for SSS after the maze procedure.

Uncommon presentations of type A quadricuspid aortic valve in the Septuagenarian

BackgroundQuadricuspid aortic valve (QAV) is a rare congenital anomaly characterized by the presence of four cusps instead of the usual three. It is estimated to occur in less than 0.05% of the population, with Type A (four equal-sized leaflets) accounting for roughly 30% of QAV subtypes. Based on limited clinical series, the usual presentation is progressive aortic valve regurgitation (AR) with symptoms occurring in the fourth to sixth decade of life. Severe aortic valve stenosis (AS) and acute AR are very uncommon.Case presentationWe describe two cases of Type A QAV in patients who remained asymptomatic until their seventies with very uncommon presentations: one with severe AS and one with acute, severe AR and flail leaflet. In Case A, a 72-year-old patient with history of moderate AS presents to clinic with progressive exertional dyspnea. During work-up for transcatheter vs. surgical replacement pre-operative computed tomography angiogram (CTA) reveals a quadricuspid aortic valve with severe AS, and the patient undergoes surgical aortic valve replacement. Pre-discharge transthoracic echocardiography (TTE) shows good prosthetic valve function with no gradient or regurgitation. In Case B, a 76-year-old patient is intubated upon arrival to the hospital for acute desaturation, found to have wide open AR on catheterization, and transferred for emergent intervention. Intraoperative TEE reveals QAV with flail leaflet and severe AR. Repair is considered but deferred ultimately due to emergent nature. Post-operative TTE demonstrates good prosthetic valve function with no regurgitation and normal biventricular function.ConclusionsQAV can present as progressive severe AS and acute AR, with symptoms first occurring in the seventh decade of life. The optimal treatment for QAV remains uncertain. Although aortic valve repair or transcatheter option may be feasible in some patients, aortic valve replacement remains a tenable option.

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

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

Prediction of left ventricular ejection fraction improvement in patients with ischemic cardiomyopathy after coronary artery bypass grafting based on cardiac magnetic resonance.

To investigate the risk factors of left ventricular ejection fraction (LVEF) improvement in patients with ischemic cardiomyopathy (ICM) after coronary artery bypass grafting (CABG), and to construct a model that predicts LVEF improvement. A retrospective analysis was performed on 106 ICM patients who received CABG and underwent cardiac magnetic resonance (CMR) at Beijing Anzhen Hospital, Capital Medical University from January 2017 to June 2022. Patients were divided into two groups with improved LVEF and no improved LVEF based on the results of postoperative 6-month transthoracic echocardiography. To analyze the risk factors affecting the LVEF non-improvement after CABG and establish a prediction model. There was LVEF non-improvement in 30.2% (32/106) of patients. Multivariate analysis showed that the number of transmural scar segments and left ventricular end-systolic volume index (LVESVI) were independent risk factors in LVEF non-improvement after CABG [odds ratio (OR) =2.398, 95% confidence interval (CI): 1.607-3.579, P<0.001; OR =1.036, 95% CI: 1.009-1.063, P=0.008]. The model is built and internally verified. ROC showed that the area under the curve (AUC) was 0.866 (95% CI: 0.792-0.940), calibration curve showed that the probability predicted by the model matched well with the clinical results, and decision curve analysis (DCA) showed that the model had good clinical applicability. During the mean follow-up time of 1.5 years, the incidence of major adverse cardiovascular and cerebrovascular events (MACCE) in the LVEF non-improvement group was higher (5.4% vs. 25.0%, P=0.009), and the NYHA grading was higher (P=0.016), when compared to the LVEF improvement group. The prediction model based on the number of transmural scar segments and LVESVI has good diagnostic efficacy. Our findings help to identify patients with improved LVEF and thus guide the selection of clinical treatment strategies.

Determinants of trans-prosthetic gradients after isolated surgical aortic valve replacement and effect on survival

Abstract Background Surgical aortic valve replacement (sAVR) remains the primary therapeutic approach for severe symptomatic aortic stenosis. Patient-prosthetic mismatch (PPM) occurs when the implanted valve is too small for the patient and is characterized by a small orifice area and elevated trans-valvular pressure gradient identified on post-operative transthoracic echocardiography (TTE). PPM is thought to be associated with adverse clinical outcomes, especially when severe, however data is conflicting. Purpose We sought to determine the impact of patient- and prosthesis-related parameters on post-operative trans-valvular pressure gradient, as a surrogate of PPM, and identify its influence on survival in a large single centre study. Methods This was a retrospective study of patients who underwent isolated sAVR between June 2003 and February 2017 at our tertiary cardiothoracic centre. Patients were excluded if their clinical and surgical records were incomplete, they hadn’t attended post-operative follow up or they had undergone valve replacement with anything other than a conventional stented tissue or mechanical prosthesis. All patients underwent postoperative follow up at eight weeks, six months and annually thereafter in keeping with local guidelines. TTE was performed between six and 12 months after surgery. Peak trans-valvular gradient was calculated using the continuity equation based upon continuous wave doppler assessment through the aortic valve. The highest value obtained from multiple views was recorded. Independent predictors of post-operative gradient were determined using a cox-proportional hazards model. Survival analysis was evaluated by Kaplein-Meier curves and log-rank test. Results One thousand seven hundred and ninety patients underwent isolated SAVR during the study period, of which 604 patients satisfied the inclusion and exclusion criteria. Mean age was 69.5 (±11.4) years and 346 (59%) were male. Mean peak pressure gradient was 29.96 (±12.4) mmHg. Independent predictors of increased post-operative gradients were: smaller valve size, postoperative diuretic use, age, gender and operating surgeon (p&amp;lt;0.001) (Table 1). Seventy-two patients (12%) died during follow-up. Mean survival was 12.1 years. After adjusting for confounders, post-operative pressure gradient was identified as a significant predictor of mortality (HR 1.02, p=0.001), alongside age (HR 1.06, p=0.001) and diabetes mellitus (HR 2.18, p=0.007) (Figure 1). Conclusion In a large cohort of patients undergoing sAVR at a single centre in the UK, valve size was the biggest determinant of postoperative pressure gradient alongside sex, diabetes, diuretic use and operating surgeon. Postoperative pressure gradient was a significant predictor of all-cause mortality. Accordingly, implanting the largest possible valve size should be considered the single most effective way of reducing the post-operative gradient and long-term mortality in patients undergoing sAVR.Table 1:Multivariate linear regressionFigure 1:K-M curve

Abstract 13665: Clinical Outcomes and Predictors of Residual Pulmonary Hypertension in Patients Undergoing Transcatheter Aortic Valve Replacement

Background: Although transcatheter aortic valve replacement (TAVR) improves pulmonary hypertension (PH) secondary to aortic stenosis (AS), PH can remain after TAVR. We sought to investigate the outcomes and predictors of residual PH after TAVR. Methods: A total of 491 consecutive patients underwent TAVR between 2014 and 2023 at our institution. After excluding patients without baseline or postoperative transthoracic echocardiography, we stratified 483 patients according to baseline and postprocedural PH estimated by systolic pulmonary artery pressure &gt;36 mmHg as follows: no PH group (n=285), improved PH group (n=87), residual PH group (n=111). Outcome measures were the composite of cardiac death and heart failure (HF) hospitalization. Logistic regression analysis was used to identify the predictors of residual PH. Variables included in the model were age, atrial fibrillation (AF), left ventricular ejection fraction, left atrial dilatation, moderate/severe mitral regurgitation, moderate/severe tricuspid regurgitation (TR). Results: The mean age was 83.6±5.4 years, and 314 (65%) were female. Patients in residual PH group were more likely to have AF, higher left atrial volume index, moderate/severe MR, and moderate/severe TR, compared with patients in no PH group. Compared with no PH group, the cumulative incidence of the composite of cardiac death and HF hospitalization were comparable in improved PH group (6.1% vs. 10.5 at 2 years, P=0.3), but significantly higher in residual PH group (6.1% vs. 20.6% at 2 years, P=0.002) (Figure). Multivariable logistic regression analysis showed that AF (Odds ratio [OR] 1.91, 95% confidence interval [CI] 1.09-3.32), moderate/severe TR (OR 4.09, 95% CI 2.30-7.28) were independently associated with residual PH. Conclusions: Among patients undergoing TAVR, residual PH were associated with increased risk of adverse cardiac events. AF, moderate or severe TR were independent predictors of residual PH after TAVR.

Hemodynamics and diastolic function after native aortic valve preserving vs replacing surgery.

Background Alterations in left ventricular (LV) diastolic function following native tissue-preserving aortic valve (AV) procedures have not been systematically investigated. Furthermore, no comparisons have been made between these changes and those observed after prosthetic AV replacement. Methods From October 2017 to August 2020, 74 patients aged <65 years were referred to our institution for elective AV surgery. Preoperative and postoperative (i.e., discharge, 3-months and 1-year follow-up) transthoracic echocardiography was analyzed. Results Native tissue-preserving surgery was performed in 55 patients (AV repair: n=42, Ross procedure: n=13). The remaining 19 patients underwent prosthetic AV replacement. Preoperatively and at discharge, transvalvular hemodynamics and LV diastolic function were comparable in both groups. At 1-year follow-up, native valve patients showed significantly lower mean transvalvular gradients (7±5 vs. 9±3 mmHg,p=0.046) and peak velocity (1.74±0.51 vs. 2.26±0.096 m/s,p=0.004) and significantly better septal e' (9.1±2.7 vs. 7.7±2.5 cm/s,p=0.043) and lateral e' (14.7±3.1 vs. 11.7±3.7 cm/s,p=0.001). From preoperatively to 1 year postoperatively, septal and lateral e' and E/e' improved markedly after native valve preservation (septal e': +0.7 cm/s,p=0.075; lateral e': +2.3 cm/s,p<0.001; E/e': -1.5,p=0.001) but not after AV replacement (septal e': +0.2 cm/s,p=0.809; lateral e': +0.8 cm/s,p=0.574; E/e': -1.2,p=0.347). Significant negative linear correlations between postoperative transvalvular gradients and absolute changes in lateral e' and E/e' were detected during follow-up. Conclusion Preservation of native tissue in AV surgery results in superior transvalvular hemodynamics compared to prosthetic AV replacement. This may induce faster LV reverse remodeling and may explain more pronounced improvement in LV diastolic function.

Postoperative transthoracic echocardiography showing mild aortic regurgitation and successful valve-sparing root replacement.

Postoperative transthoracic echocardiography showing mild aortic regurgitation and successful valve-sparing root replacement.

Progressive changes in residual gradient after aortic coarctation repair and its role in the prediction of reintervention: A longitudinal data analysis.

Repair of aortic coarctation through left thoracotomy is the standard treatment when anatomically feasible. Long-term outcomes are well studied, including the need for reintervention. However, the timely variation in residual gradients across the repaired segment is ill-defined. The aim of this work was to study the progressive changes of estimated peak gradient (ePG) acquired by transthoracic continuous-wave Doppler echocardiography across the aortic arch after repair and to assess the role of timing of assessment and values of ePG in prediction of reintervention. All eligible patients for this study who underwent aortic coarctation repair through left thoracotomy from 2001 to 2017 were reviewed. Details of the aortic arch dimensions and associated lesions were obtained by transthoracic echocardiography (TTE). The primary outcome was the ePG across the aortic arch after repair. Longitudinal data analyses with mixed effect modeling were used to determine independent predictors for ePGs. A total of 312 patients were included. Median age and weight were 30 days and 4 kg, respectively. Associated lesions included ventricular septal defect (VSD) (53%), bicuspid aortic valve (53%) and mitral stenosis (25%). Over 15-years follow-up the freedom from reintervention was 92.3%, while 24 out of the 312 patients underwent reintervention (7.7%). Longitudinal data analyses of serial 2566 TTE studies were done. The graphical display showed that the ePG across coarctation area in the first postoperative TTE was the most notable difference between those who underwent reintervention and those who did not. Further testing with proportional hazard and logistic regression modeling confirmed this finding. The area under receiver operating curve statistics showed that an ePG of 25 mmHg is an optimal cutoff value for the prediction of the reintervention. The ePG acquired in the first postoperative TTE is the most important predictor for reinterventions. The presence of VSD is associated with decreased ePGs. We propose that an ePG in the first postoperative TTE of 25 mmHg or more is a strong predictor for the need of reintervention.

Reverse Takotsubo Stress Cardiomyopathy During Liver Transplantation

Reverse Takotsubo Stress Cardiomyopathy During Liver Transplantation

Anaesthetic implications of right atrial myxoma in a premature infant.

Sir, Cardiac myxoma is a benign tumour and the most common primary cardiac tumour in adults; however, it is unusual in paediatric patients, with only 20% constituting right atrial myxomas (RAMs).[1] A 3-month-old male baby, weighing 1.7 kg, presented to our hospital with tachypnoea while feeding and failure to thrive. The baby was born prematurely after 29 weeks of gestation. On examination, the baby looked emaciated [Figure 1]. A pansystolic murmur was present at the left lower sternal border on auscultation. Transthoracic echocardiography (TTE) revealed a large, homogenous, pedunculated mass (19 mm × 10 mm) attached to the interatrial septum (IAS) and protruding into the tricuspid valve (TV) causing tricuspid regurgitation (TR) [Figure 2]. Blood investigations revealed haemoglobin of 9.8 g/dL and platelet count of 78000/mm3. Surgical removal of the RAM was planned because of the inability to gain weight.Figure 1: Intraoperative image showing an emaciated look of the child. Fr: FrenchFigure 2: Apical four-chamber view on TTE showing RA myxoma. RA: right atrium, RV: right ventricle, LA: left atrium, LV: left ventricleOn the day of surgery, the baby was shifted to the operating room, and a multiparameter monitor was attached. All preparations were done before induction of anaesthesia to go on emergent cardiopulmonary bypass (CPB) if required. General anaesthesia with endotracheal intubation was induced with intravenous midazolam 0.1 mg/kg, fentanyl 5 μg/kg and vecuronium 0.1 mg/kg through an already placed peripheral cannula. Induction agents were given slowly while constantly monitoring the haemodynamics. Right radial arterial cannulation was done, and central venous catheter (CVC) was inserted carefully in the right internal jugular vein. Anaesthesia was maintained with 1.5% (v/v %) isoflurane and intermittent boluses of fentanyl and vecuronium. After midline sternotomy and full heparinisation, CPB was instituted through aorto-bicaval cannulation. Superior vena cava (SVC) cannulation was done through a higher approach, and other manipulations near the right atrium (RA) were done gently to avoid embolisation of the tumour. Under deep hypothermic circulatory arrest (DHCA), the RA was opened, and the mass was excised completely. The baby was weaned off CPB with inotropic support of intravenous milrinone 0.5 μg/kg/min. After completion of the surgery, the patient was shifted to the paediatric intensive care unit and was extubated after 8 hours. Postoperative TTE showed an intact IAS with no TR or residual mass in RA. RAMs usually present with breathlessness, cyanosis, feeding difficulty, and constitutional symptoms like fever, fatigue, anaemia, thrombocytopenia, malnourishment, and weight loss because of the release of interleukin-6 by RAM.[2] RAM can obstruct the TV causing jugular venous distension, peripheral oedema, hepatic congestion, ascites, and syncope.[3] Our patient looked malnourished, weighed only 1.7 kg along with low haemoglobin and platelet count. Arrhythmias commonly occur due to conduction defects caused by myxoma. Anaesthetic considerations in RAMs include hypoxaemia, low cardiac output, and potential pulmonary emboli due to their mobile nature. Aggravation of the patient’s symptoms and hypotension can occur at certain positions due to intermittent obstruction of TV by a mobile RAM along with a change in the character of the murmur. Evaluation of these positions must be done preoperatively, and induction should be done with careful positioning, with the administration of titrated doses of anaesthetic drugs, which avoid myocardial depression while maintaining the preload and preparation to go on emergent CPB. Placing a CVC and SVC cannulation can be difficult in the presence of a tumour in the RA and may result in its fragmentation and dislodgement. Hence, utmost care should be taken to avoid entering the RA. Intraoperative transoesophageal echocardiography (TOE) monitoring helps in the detection and diagnosis of tumour fragmentation or dislodgement, and in assessing volume status as TR caused by RAM renders CVP measurement unreliable for evaluation of volume status.[4] However, in our case, TOE examination was not done because of non-availability of a neonatal probe. DHCA provides excellent surgical exposure for tumour removal, but the duration of circulatory arrest must be limited to prevent complications.[5] Perioperative care in premature neonates also includes preventing hypoglycaemia, hypoxia and hypothermia.[6] Anaesthetic concerns range from difficult airways, risk reduction for adverse events and adequate pain management.[7] Thus, neonates with RAMs require early diagnosis, meticulous anaesthetic management and multidisciplinary approach to perioperative care. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.