Previous Mitral Valve Research Articles

Transcatheter Mitral Valve Repair for Failed Surgical Mitral Valve Repair: A Systematic Review and Meta-Analysis.

To assess the outcomes of transcatheter mitral valve repair (TMVr) for failed previous surgical mitral valve repair (MVr). We searched Pubmed, Embase, and Cochrane Library databases for studies that reported the outcomes of TMVr for failed initial surgical MVr. Data were extracted by 2 independent investigators and subjected to meta-analysis. The 95% confidence interval (CI) was calculated for preoperative demographics, peri-operative outcomes, and follow-up outcomes using binary and continuous data from single-arm studies. Eight single-arm studies were included, with a total of 212 patients, and mean follow-up ranged from 1.0 to 15.9 months. The pooled rate of residual procedural mitral regurgitation mild was 76% (95% CI: 67%~84%; = 0%; 7 studies, 199 patients). During follow-up, mitral regurgitation mild was found in 68% of patients (95% CI: 52%~82%; = 57%; 6 studies, 147 patients). Follow-up survival was 94% (95% CI: 88%~98%; = 0%; 7 studies, 196 patients). 83% patients (95% CI: 75%~89%; = 47%; 6 studies, 148 patients) were in NYHA class I or II. TMVr for failed surgical MVr was safe and effective, which should be recommended in selected patients if technically feasible.

Prosthesis choice for tricuspid valve replacement: Comparison of clinical and echocardiographic outcomes

ObjectivesThere is limited evidence evaluating valve function and right heart remodeling after tricuspid valve replacement (TVR), as well as whether the choice of prosthesis has an impact on these outcomes. MethodsWe reviewed 1043 consecutive adult patients who underwent first-time TVR; 33% had previous aortic and/or mitral valve operations. Severe tricuspid valve regurgitation (TR) was the indication for surgery in 94% patients. A mechanical valve was used in 149 (14%) patients and a bioprosthetic valve in 894 (86%). Concomitant major cardiac procedures were performed in 57% of patients. ResultsThe median age of the cohort was 68.8 (range, 25-94) years, and 57% were female. Overall survival at 5 and 10 years was 50% and 31%, respectively. Adjusted survival and cumulative incidence of reoperation after TVR were similar in patients with bioprosthetic and mechanical valves. Overall, right ventricular (RV) function and dilation improved postoperatively with the estimated proportion of patients with moderate or greater RV systolic dysfunction/dilatation decreasing by around 20% at 3 years follow-up. After adjusting for preoperative degree of dysfunction/dilatation, valve type had no effect on late improvement in RV function and dilation. Bioprosthetic TVR was associated with greater rates of recurrence of moderate or greater TR over late follow-up. Overall, a slight decline in tricuspid valve gradients was observed over time. ConclusionsMechanical and bioprosthetic valves provide comparable survival, incidence of reoperation, and recovery of RV systolic function and size after TVR. Bioprosthetic valves develop significant TR over time, and mechanical valves may have an advantage for younger patients and those needing anticoagulation.

Mechanism and outcomes of atrial tachycardia ablation in patients with mitral valve surgery

Abstract Funding Acknowledgements Type of funding sources: None. Background Atrial tachycardia (AT) is a common rhythm disorder after mitral valve surgery which may comprise both atria. Most of atrial arrhythmias are refractory to antiarrhythmic drugs and catheter ablation is usually required in cases with mitral valvular prosthesis. Purpose We aimed to evaluate the ablation outcomes of AT in patients with previous mitral valve (MV) surgery. Methods A total of 60 symptomatic patients with AT were enrolled. Activation mapping was performed during tachycardia in all patients as well as entrainment mapping when needed. Scar analysis was also performed when left atrial tachycardia detected. Results In 79 procedures, a total of 101 ATs were documented [35 (34.6%) ATs were right-sided, 65 (64.3%) ATs were left-sided and 1(0.9%) AT was biatrial]. Mean number of ATs per procedure was 1.4 ± 0.6. Macroreentry was the primary mechanism in right and left atrium (97% and 66.1%, respectively). Localization and mechanisms of ATs were demonstrated in Figure-1. Anterior wall [53.2%(17.9%-74.6%)], septum [53.7% (34.7%-80.0%)] and roof [40.1% (21.3%-72.5%)] were the left atrial sites with highest ratio of low voltage areas . The mean follow-up duration was 33.4 ± 17.7 months. Freedom from ATa after index procedure was 78.3% at 12 months and 65.9 % at 24 months. After multiple procedures, freedom from ATa was 80%, during the follow-up. Conclusion Left ATs are more common compared to the right ATs and macroreentry is the major mechanism in both right- & left ATs. RF ablation of ATs had favourable long-term outcomes in patients with MV surgery.

P81 SIMULTANEOUS TRANS–APICAL AORTIC AND MITRAL VALVE IMPLANTATION IN A PATIENT WITH A DEGENERATED MITRAL BIOPROSTHESIS AND SEVERE AORTIC STENOSIS

Abstract Transcatheter Valve–in–Valve implantation has shown promising results in high–risk patients suffering from structural valve deterioration (SVD) of a previously implanted heart valve bioprosthesis. This is a case of a 82–year–old man, with history of multiple previous mitral valve replacement, admitted to the hospital for heart failure. During diagnostic work out he was diagnosed with a severe aortic stenosis and structural degeneration of a mitral valve bioprostheses Epic 29mm, St Jude Medical, (Inc, St Paul, Minn, USA). The heart team defined the patient at high surgical risk profile and was therefore scheduled for a simultaneous mitral and aortic transcatheter valve implantation. Through a double trans–apical approach (Figure A and B), the patient underwent two balloon expandable valves (Sapien 3, Edwards Lifesciences, Irvine, CA, USA) deployment in native aortic (Figure C) and mitral bioprosthesis (Figure D), respectively. Final angiography showed lack of aortic (Figure E) and left atrial (Figure E) regurgitation. The procedure was uneventful as well as the following hospital stay. Post–procedural transesophageal echocardiography confirmed the absence of paravalvular leakage nor aortic or mitral regurgitation. The patient was discharged at home on day 7. Simultaneous transapical transcatheter aortic and mitral valve replacement is technically feasible with the current available technology and can be a possible alternative in patients with high surgical risk.

Clinical experience of surgical repair left ventricular rupture after mitral valve replacement

Background: Left ventricular rupture after mitral valve replacement is very rare but often leads to death. This study aimed to report one center experience.
 Methods: Retrospective case series from 2001 to 2021 at the Heart Institute.
 Results: There had 18 cases of left ventricular rupture after mitral valve replacement (0.2%). 94% of patients were female, the mean age at surgery was 57. Rheumatic mitral stenosis (11) or mitral disease (6) occurred in the majority of cases. 6/18 has posterior annulus calcification; 3/18 cases had reoperation after previous mitral valve replacement. The median valve size was 27 (25-29mm). Type I rupture 03; type II: 1 and type III: 14. Time of left ventricular rupture occurrence: early in 5; late in 2 and intermediate in 11 cases. The mortality rate was 61% (11/18). Regarding the repair technique, 8 cases of external repairs, without opening the heart and 10 cases of combined internal and external repairs, reinforced with bio-glue. 100% had supported by extracorporeal circulation and 15/18 cases had inserted intra-aortic balloon counterpulsation.
 Conclusion: preserve the posterior valve as much as possible, gentle resection of the diseased valve, and no need for radical decalcification of the posterior annulus are measures to prevent left ventricular rupture. The combined technique of internal and external repairs with bio-glue coating has shown a good hemostatic and high success rate.

Ultrasonic Emulsification of Severe Mitral Annular Calcification During Mitral Valve Replacement

PurposeSevere mitral annular calcification (MAC) increases surgical complexity and is independently associated with increased operative mortality for mitral valve replacement (MVR). Recently we adopted ultrasonic emulsification/aspiration for annular decalcification to address these risks and describe our early experience with this new technology. DescriptionExcluding previous mitral valve surgery or endocarditis, 179 patients with MAC underwent MVR at a single institution between January 2015 and March 2020. Of these, 15 consecutive patients with severe MAC (≥50% of the annulus) underwent annular decalcification with ultrasonic emulsification/aspiration as an adjunct treatment during MVR from April 2019 to March 2020. EvaluationMean patient age was 68 ± 12 years, and 72% (n = 128) were female. Mean preoperative left ventricular ejection fraction was 60% ± 11%, and mean mitral valve gradient was 9.1 ± 4.4 mm Hg. Concomitant procedures included antiarrhythmia (n = 52), aortic valve replacement (n = 32), and coronary artery bypass grafting (n = 20). There were no operative deaths or strokes in the group undergoing ultrasonic emulsification and aspiration. ConclusionsThe use of ultrasonic emulsification and aspiration in severe MAC patients may help mitigate the risks of MVR and facilitate operative success in this challenging, high-risk population.

David procedure for aortic root aneurysm in the background of Marfan syndrome patient with severe kyphoscoliosis and previous mitral valve replacement

Cardiac complication is one of the diseases that usually develop in Marfan syndrome patient such as mitral valve regurgitation and aortic root aneurysm. Apart from that, other congenital anomalies also tend to occur in this group of patients such as pectus excavatum and scoliosis. We report a case of successful high-risk surgery involving a Marfan syndrome patient who had underlying severe kyphoscoliosis and previous mitral valve replacement that underwent redo sternotomy and valve sparing aortic root repair (David procedure). The surgery was challenging due to the need to perform redo-sternotomy on severe pectus patient, performing valve sparing aortic root repair, and complicated with injury to right coronary artery require modified Cabrol modification for implantation of the coronary artery. The available literature about redo sternotomy on severe pectus excavatum for aortic root repair is limited, hence this paper aims to highlight the successful of performing the procedure, and the complication that might occur during the procedure.

Case Study: Pneumococcal Prosthetic Valve Endocarditis with Mitral Annular Abscess Fistulised in the Left Atrium: An Uncommon Germ with Dramatic End

Background: Streptococcus pneumoniae is an infrequent cause of infectious endocarditis. Several case series have underscored the aggressive course of Streptocoque Pneumiae with acute clinical presentation, rapid valvular destruction, and high mortality despite appropriate antibiotic therapy. Case summary: We present a 74-year-old woman with previous aortic and mitral valve replacement 12 years ago, presented with a 5 days history of persistent fever and a red, hot, and swollen right knee. Atrial fibrillation was demonstrated on a 12-lead electrocardiogram. The initial echocardiography did not show any sign of endocarditis but in front of the clinical symptomatology the patient was put under probabilistic antibiotic therapy. in the meantime blood culture grew Streptocoque Pneumiae and then the antibiotic treatment was adapted. The sudden deterioration of the patient brought us back to control the heart by a transthoracic echocardiography, which revealed a mitral annular abscess fistulizing to the left atrium. the patient expired 30 days after admission from presumed severe sepsis and cardiogenic choc. Conclusion: Pneumococcal endocarditis in prosthetic valve is associated with very high mortality, especially when complicated by paravalvular abscess and other comorbidities. This case highlights the need for a carefull considered approach for fast and efficient care.

Thinking Outside the 'Cage'.

A patient with persistent chest pain and previous mitral valve replacement had no recurrence of pain once target international normalized ratio was reached.

Long-term outcomes of a totally thoracoscopic approach for reoperative mitral valve replacement: a propensity score matched analysis.

BackgroundThis study aimed to summarize the perioperative and long-term outcomes of patients with previous mitral valve surgery (MVS) undergoing reoperative mitral valve replacement (MVR).MethodsData for all reoperative mitral valve replacements (re-MVRs) with or without concomitant tricuspid surgery were analyzed from Guangdong Provincial People’s Hospital between January 2013 and December 2019. Propensity score matching resulted in 30 matched pairs with improved balance after matching in baseline covariates. Perioperative data and long‐term clinical outcomes were analyzed.ResultsResults are based on the matched cohorts between the two groups. The in-hospital mortality was 3.3% (two deaths) in the entire cohort and was not significantly different between the median sternotomy (MS) group and the totally thoracoscopic (TT) group. Most patients in the TT group had their tracheal intubation removed within 24 hours of surgery. The TT group had a diminished requirement for blood transfusion and a reduced 4-day postoperative chest tube drainage amount. The incidence of early major complications, including all-cause death and reoperation due to bleeding, was lower in the TT group. No significant differences were observed in the 7-year survival probability between the two groups.ConclusionsThe encouraging results regarding the perioperative and long-term outcomes of patients who underwent a TT re-MVR show that this approach is particularly beneficial for patients requiring reoperation.

Clinical outcomes after implantation of a sutureless aortic bioprosthesis with concomitant mitral valve surgery: the SURE-AVR registry

BackgroundEarly treatment of aortic valve stenosis is recommended in eligible symptomatic patients with severe aortic valve stenosis who would otherwise have a poor prognosis. The sutureless aortic valve bioprosthesis offers an alternative to standard aortic valve replacement with a sutured valve, but limited data are available in patients who have undergone multiple valve procedures involving the new, sutureless technology. We sought to investigate outcomes in high operative risk patients with previous or concomitant valve surgery who were implanted with a sutureless valve.MethodsSURE-AVR is an ongoing, prospective, multinational registry of patients undergoing aortic valve replacement. In-hospital and post-discharge outcomes up to 5 years were collected.ResultsThe study population comprised 78 patients (mean ± SD: age 73.6 ± 7.6 years, logistic EuroSCORE 18.0 ± 17.5) enrolled at 13 sites who presented for concomitant or previous mitral valve repair (n = 45) or replacement (n = 33), with or without additional concomitant procedures, and were implanted with a sutureless valve. Mean ± SD overall aortic cross-clamp time was 109 ± 41 min and cardiopulmonary bypass time was 152 ± 49 min. Mean ± SD aortic pressure gradients decreased from 37.6 ± 17.7 mmHg preoperatively to 13.0 ± 5.7 mmHg at hospital discharge, and peak aortic pressure gradient from 61.5 ± 28.7 to 23.4 ± 10.6 mmHg. Early events included 1 death, 1 transient ischaemic attack, and 1 bleed (all 1.3%); a permanent pacemaker implantation was required in 6 patients (7.7%), and 2 reoperations (not valve related) (2.6%) took place. Over a median follow-up of 55.5 months (Q1 13.4, Q3 68.6), 12 patients died (6 cardiovascular and 6 non-cardiovascular, both 2.1% per patient-year). Five-year survival was 81.3%. Late paravalvular leak occurred in 2 patients (0.7% per patient-year) and permanent pacemaker implantation was required in 3 patients (0.1% per patient-year). There was no apparent rise in mean or peak aortic pressure gradient over the study.ConclusionsThese results suggest that the sutureless implant is a technically feasible procedure during mitral surgery and is associated with good clinical outcomes.

P35 Innominate Vein to Right Atrial Appendage Bypass for Superior Vena Cava Syndrome – Technique and Pitfalls

We present a complicated case of a 43-year-old female with an occluded right internal jugular vein and distal superior vena cava (SVC) with a high grade stenosis of the innominate vein resulting from multiple long term venous lines in the treatment of her haemolytic uraemic syndrome. The patient had a background of previous mitral valve replacement for infective endocarditis in 2016 and subsequent to the development of SVC syndrome she required 3-weekly balloon angioplasties of her innominate vein for relief.

One-shot transcatheter double valve replacement: six-month follow-up-a case report.

BackgroundTranscatheter aortic valve replacement (TAVR) in combination with a valve-in-valve (V-i-V) transcatheter mitral valve replacement (TMVR) is a rare procedure in comparison to surgical therapy especially in young patients. We report on a young patient at high surgical risk, receiving a double valve implantation with two S3 transcatheter heart valves.Case summaryA 59-year-old female patient with two previous mitral valve replacements due to endocarditis and re-endocarditis experienced a new onset of severe mitral valve stenosis in combination with progredient aortic stenosis. She was admitted to the hospital with severe dyspnoea and intermittent non-invasive ventilation [New York Heart Association (NYHA) III–IV]. An interventional transapical transcatheter double valve implantation was planned and carried out due to cardiac decompensation and high comorbidity preoperatively (STS score of 6.92). At 6-month follow-up, the patient presented herself in an improved condition with reduced symptoms (NYHA I–II), a good functional status of both valves and an advanced right and left ventricular function in the echocardiogram.DiscussionEven in younger patients at high risk, a combined native TAVR and V-i-V TMVR procedure can be performed. In this case, a transcatheter SAPIEN 3 valve was transapically implanted with good clinical mid-term outcome at 6 months.

Mitral Valve Replacement Surgery in Redo Patients with Mix Blood Cardioplegia (MBC) Protection

Aim of Study : Redo patient undergoing valve surgery are always a challenge for both cardiac surgeon and anesthesiologists. Mix blood cardioplegia has had a profound impact on cardiac surgery. but there have been few studies on its use in mitral valve replacement, especially in redo patient. The purpose of this study was to determine whether mix blood cardioplegia offers any advantages in redo patient undergoing mitral valve replacement. Patients and Methods : 20 patient, who have had a previous mitral valve surgery and were scheduled for mitral valve replacement with or without tricuspid repair, were randomized retrospectively to one of two groups of 10 with different technique of myocardial protection: group A (10 patients) had cold crystalloid cardioplegia, and group B(10 patients) had mix blood cardioplegia, a technique modified on our clinic condition (made by mixing 400-500ml oxygenated blood from oxygenator and 10ml KCL 7.5%) . Systemic hypothermia was 28°C in Group A and between 32°C and 33°C in Group B. The results were primarily assessed on the basis of clinical outcome, such as hematocrit level intra and post CPB, maximum dose of inotropic support, spontaneous rhythm recovery after aortic cross clamping, length of intensive care unit stay and secondly on postoperative blood loss and blood requirements. Results : There were no preoperative or operative differences between the groups with regard to age, sex, diagnosis, rhythm, New York Heart Association functional class, left ventricular ejection fraction, estimated pulmonary artery systolic pressure, operation, or duration of the operation, CPB, or aortic cross clamping and the time when the patients underwent the first operation. There was one death in group A (10% mortality). The changes in hematocrit level differs significantly between the two groups on the post CPB period (p=0,02) There appeared to be a trend towards better spontaneous recovery of sinus rhythm after removal of the aortic cross clamp in group B compared with group A, the difference did reach statistical significance. (p=0.002). Patients on group A required more inotropic support than Group B (p=0.005). There were differences even on blood requirements postoperatively, more dominant these requirement were in group A (p=0.02). Discussion : Mix Blood Cardioplegia had beneficial effects in clinical outcome in redo patients undergoing mitral valve replacement surgery. This may be due to its better preservation of high-energy phosphates and endogenous amino acids, less anerobic metabolic activity on reperfusion, reduced release of cardiac troponin T, and improved post-ischemic functional recovery. Keywords: Miocardial protection, cardiopulmonary bypass CPB, Mix Blood Cardioplegia (MBC) DOI: 10.7176/ALST/82-04 Publication date: October 31 st 2020

Percutaneous Watchman FLX implantation in a patient with previous mitral valve surgery and large-sized left atrial appendage.

Percutaneous Watchman FLX implantation in a patient with previous mitral valve surgery and large-sized left atrial appendage.

Outcome of Patients Having Transcatheter Mitral Valve Implantation for the Treatment of Degenerated Mitral Bioprostheses

Transcatheter mitral valve implantation (TMVI) is at various levels of preclinical investigation and has proven to be more challenging than transcatheter aortic valve implantation due to more complex anatomy. The purpose of this study is to evaluate the short-term and long-term outcomes of high-risk patients who underwent TMVI for degenerated mitral bioprostheses. In this retrospective, observational study, we reviewed data on the first 26 patients with previous surgical mitral valve replacement or repair with annular ring that underwent TMVI using the balloon-expandable heart-valve system at our institution from 2014 to 2019. We reviewed pre/postprocedure echocardiographic data, in-hospital, 30-day data and 1-year outcomes. The indication for TMVI was mitral regurgitation (MR) in 9 patients, mitral stenosis in 9 patients and mixed mitral disease in 8 patients. There was a 100% device implantation success rate and a 96% in-hospital survival rate. Survival was 96% at 30 days and 85% at 1 year. Mean mitral gradient (MMG) improved postprocedure (13.3 mm Hg to 6.8 mm Hg, p <0.0001) and was sustained at 1 year (13.3 mm Hg to 7.2 mm Hg, p <0.0001). MR grade improved postprocedure (3+ to 1+, p <0.0001) and was sustained at 1 year (3+ to 0, p <0.0001). Additionally there was significant 30-day and 1-year improvements in patients' Kansas City Cardiomyopathy Questionnaire score after TMVI (47.8 to 75.7 to 84.0, p = <0.0001). In conclusion, our early experience with treatment of degenerated mitral bioprostheses using TMVI in high-risk patients resulted in significant short-term and sustained long-term improvements in mean mitral gradient, MR and heart failure symptoms.

Outcomes and predictors of cardiac events in medically treated patients with atrial functional mitral regurgitation

BackgroundLittle is known about the outcomes and predictors of adverse cardiac events in medically treated patients with atrial functional mitral regurgitation (FMR). MethodsWe screened 1405 consecutive patients with grade ≥ 3+ mitral regurgitation (MR) detected by echocardiography. After excluding patients with previous or early (within 3 months from diagnosis) mitral valve surgery, congenital heart disease, hypertrophic cardiomyopathy, severe aortic valve disease, or unknown etiology, the study population consisted of 319 patients with primary MR, 395 patients with FMR with left ventricular (LV) dysfunction, and 184 patients with atrial FMR. Atrial FMR was defined as FMR in patients without LV wall motion abnormality or dilatation. ResultsThe cumulative incidence of the composite of cardiac death and heart failure hospitalization at 3 years was 10.5% in primary MR, 37.5% in FMR with LV dysfunction, and 14.0% in atrial FMR (p < .001). In atrial FMR patients, LV end-diastolic volume index (hazard ratio [HR] 1.06, 95% confidence interval [CI] 1.02–1.10), severe MR (grade 4+) (HR 2.73, 95% CI 1.21–6.12), being symptomatic (NYHA ≥ 2) (HR 2.82, 95% CI 1.15–6.92), and having ≥1 comorbidities (HR 3.96, 95% CI 1.74–9.00) were independently associated with an increased risk for adverse cardiac events by a multivariable Cox regression analysis. ConclusionsOutcomes of medically treated patients with atrial FMR were better than those of FMR with LV dysfunction, but worse than those of primary MR. In atrial FMR patients, LV dilatation, severe MR, being symptomatic, and the presence of comorbidities were independently associated with an increased risk for adverse cardiac events.

Successful Repeat Transcatheter Mitral Valve Replacement After Late Prosthesis Failure

An 80-year-old woman on oral anticoagulation therapy, with previous mitral valve reconstruction, subsequent coronary artery bypass grafting with aortic and mitral valve (29-mm Mosaic, Medtronic, Dublin, Ireland) replacement, and 10 years later, transcatheter mitral valve replacement (TMVR) with a 26

The Clinical Importance of Functional Mitral Regurgitation and Atrial Fibrillation in Patients with Left Ventricular Assist Device

Functional mitral regurgitation (FMR) and atrial fibrillation (AF) are common in patients undergoing left ventricular assist device (LVAD) implantation. However, the impact of FMR and AF on clinical outcomes is uncertain. The aim of this study is to investigate the prognostic significance of FMR and AF in patients with LVAD. We retrospectively reviewed all patients who underwent LVAD implantation at our center between January 2010 and December 2017. We excluded patients who had previous or concomitant mitral valve procedure and patients who had insufficient quality of echocardiographic images. We defined significant FMR as MR color jet area / left atrial area > 0.2 and AF as persistent AF at LVAD implantation. 427 patient's charts were reviews (125 patients had previous or concomitant mitral valve procedure and 31 patients had insufficient quality of echocardiographic images). 271 were included in this analysis. Mean age of cohort was 57.1 +/-13.0 years, and 84% were male. Of all, 110 (41%) patients had significant FMR and 51 (19%) patients had persistent AF. Patients were divided into 4 groups: no AF and no significant FMR (Group1, n=136), no AF and significant FMR (Group 2, n=84), AF and no significant FMR(Group 3, n=25), and AF and significant FMR (Group 4, n=26). Forty-four (16%) patients died within 2years. Kaplan-Meier curve analysis demonstrated 2-year survival of 77% in Group 1, 87% in Group 2, 92% in Group 3, and 47% in Group 4 (P=0.0006). On the multivariate Cox proportional hazard model Group 4 was significant predictor of mortality [hazard ratio (HR), 2.62; 95% confidence interval (CI),1.27-5.41; P =0.009], independently of other parameters. Coexistence of significant FMR and AF is a poor prognostic marker in patients undergoing LVAD implantation.

Stent Frame Infolding of a 34-mm Evolut-R in a Patient With a Mechanical Mitral Valve

A 71-year-old woman with previous mechanical mitral valve implantation and tricuspid annuloplasty was admitted for transcatheter aortic valve replacement for symptomatic severe aortic stenosis. Multidetector computed tomography showed a large and elliptic aortic annulus with an estimated