Previous Mitral Valve Research Articles

High-density Mapping Facilitates Successful Ablation of Postincisional Right Atrial Flutter After Previous Mechanical Mitral Valve Replacement.

High-density Mapping Facilitates Successful Ablation of Postincisional Right Atrial Flutter After Previous Mechanical Mitral Valve Replacement.

Transcatheter aortic valve replacement in patients with previous mitral valve replacement. A systematic study.

IntroductionSevere aortic stenosis (AS) is an ever-growing healthcare problem in ageing populations. Transcatheter aortic valve implantation (TAVI) has revolutionized the treatment of AS. However, TAVI in patients who have undergone mitral valve replacement (MVR) is associated with increased risk of mitral valve damage. Limited data exist on TAVI in patients with AS who underwent MVR in the past.AimTo retrospectively assess the clinical characteristics, detailed echocardiographic and computed tomography measurements, procedural and in-hospital outcome as well as any valve intervention or major adverse cardiovascular events according to VARC-2 criteria at follow-up of patients with a history of MVR, who underwent TAVI.Material and methodsSeventeen patients with a history of mitral valve operation, in whom TAVI was performed between 2010 and 2018, were identified. Of these, 15 underwent previous MVR.ResultsOverall, TAVI resulted in a decrease of mean transaortic gradient by 38.3 ±14 mm Hg (p < 0.001) and a decrease of maximal transaortic gradient by 58.6 ±27.6 mm Hg (p < 0.001). A successful immediate result was obtained in 14 (93.3%) patients. One tamponade occurred during TAVI, which was successfully treated with pericardiocentesis. Post-procedurally, no significant changes in transmitral gradients or mitral regurgitations were observed. Two patients died after hospital discharge, one due to possible internal bleeding and the other due to infection.ConclusionsTAVI in patients after MVR is feasible. Meticulous preinterventional echocardiographic and computed tomography planning is essential. Although recommended in previous reports, TEE guidance may not necessarily be obligatory during the procedure.

P1705 Is mitral stenosis per se worthy of anticoagulation therapy?

Abstract We present the case of a 76-year-old man with hypertension and previous mitral valve repair (MVR) due to severe mitral valve regurgitation. He had never experienced atrial fibrillation (AF), and therefore he was not anticoagulated. He had been asymptomatic for 15 years, however, recently he reported the onset of dyspnoea and a transthoracic echocardiogram showed moderate to severe mitral valve stenosis (MVS) in the context of previous MVR. A transesophageal echocardiogram was then requested and it confirmed the degree of MVS (panel A Color flow on mitral valve, panel B CW Doppler), but, astonishingly, it also showed the presence of a giant thrombus in the roof of the left atrium (Panel C,D,F 2D TOE, Panel E 3D TOE). The maximal dimensions of the mass were 3.3 to 4.5 centimetres and, surprisingly, no thrombus was found in the left appendage, which nevertheless had low-flow. MVS is very often associated with severe left atrial dilation and with the onset of atrial fibrillation. However, when a patient has at least moderate MVS and he is in sinus rhythm, there is no robust evidence supporting the initiation of anticoagulants. Though, this case underlines the tight correlation between MVS and thrombus formation regardless of the detectable presence of AF. Moreover, in contrast to usual AF patients, in this particular case left appendage was not involved and the huge mass occupied most of the left atrium, showing that MVS provokes significant low-flow in the atrium too. Abstract P1705 Figure.

Transfemoral transcatheter aortic valve replacement in the presence of a mitral prosthesis.

In the current case series, we present our experience with the self-expanding CoreValve or Evolut R (Medtronic Inc.) in patients with severe symptomatic aortic valve stenosis and concomitant mitral valve prosthesis. Twelve patients with previous mitral valve prosthesis underwent transcatheter aortic valve replacement for severe symptomatic aortic valve stenosis and/or aortic valve regurgitation. All patients underwent evaluation with an echocardiogram, computed tomography and coronary angiogram. After the index intervention and before discharge all patients underwent transthoracic echocardiography. All outcomes were defined according to the Valve Academic Research Consortium-2 criteria. Eleven patients underwent transcatheter aortic valve replacement for severe symptomatic aortic valve stenosis and one patient for severe aortic valve regurgitation. There was immediate improvement of patients' hemodynamic status; no cases of procedural death, stroke, myocardial infarction, or urgent cardiac surgery occurred. There was no 30-day mortality and all patients improved, with 91.6% in functional New York Heart Association class I-II. The current study demonstrates that in patients with severe aortic valve stenosis or regurgitation and mitral valve prosthesis, the implantation of a self-expanding aortic valve via the transfemoral route is safe and feasible, with maintained long-term results.

Transcatheter Aortic Valve Replacement After Prior Mitral Valve Surgery: Results From the Transcatheter Valve Therapy Registry

Due to perceived technical challenges, patients with previous surgical mitral valve repair or replacement (SMVR) have been excluded from most transcatheter aortic valve replacement (TAVR) trials. Our objective was to compare the 30-day and 1-year outcomes of TAVR for patients with and without prior SMVR. In a retrospective review of The Society of Thoracic Surgeons (STS) and American College of Cardiology (ACC) Transcatheter Valve Therapy (TVT) Registry, we compared 1097 patients with prior SMVR to 46,327 patients without prior SMVR who underwent TAVR between November 2011 and September 2015 at 394 US centers. Preoperative characteristics, procedural details, and clinical outcomes were analyzed. Patients with previous SMVR were younger, more often female, and had higher STS predicted risk of mortality (8.6% vs 6.8%, P < .001). However, there was no difference in 30-day mortality (4.6% vs 5.5%, P= .293), myocardial infarction, stroke, reintervention, new dialysis, or readmission. Moderate/severe paravalvular leak at discharge was also similar (5.8% vs 4.9%, P= .343). At 1 year, morbidity was similar with slightly higher mortality among patients with prior SMVR (20% vs 17.5%, P= .087) that was significant after adjustment (hazard ratio 1.18, P= .043). The type of prior SMVR (repair, bioprosthetic replacement, or mechanical replacement) had no impact on 30-day or 1-year survival. Patients with prior SMVR undergoing TAVR had similar 30-day outcomes, slightly higher 1-year mortality, and no increase in early paravalvular leak compared with patients who did not have previous SMVR. Prior SMVR should not preclude TAVR for appropriately selected patients.

Simultaneous Transseptal Mitral Valve-in-Valve and Trans-Bypass Aortic Valve Treatment Using Balloon-Expandable Valves

A 76 year-old man with previous mitral valve replacement (27-mm Magna Mitral Ease, Edwards Lifesciences, Irvine, California), abdominal endovascular aneurysm repair (EVAR) and iliobifemoral grafting for peripheral artery disease presented with heart failure secondary to mitral stenosis (mean

Multiple paravalvular leak closures

Introduction 70 year old man with paroxysmal atrial fibrillation and heart failure with preserved ejection fraction with previous bioprosthetic aortic and mitral valve replacement in 2003 and 2008 presented for fatigue and dyspnea. He was an unsuitable candidate for surgery due a EuroSCORE II of 7.27%. Preoperative TEE showed posterior mitral periprosthetic regurgitation (peak gradient 73.3 mmHg) for which he underwent a transcatheter closure using an Amplatzer Vascular Plug (AVP) 2 size 12 mm and 18 mm with improved regurgitation. Methods Arterial line was placed and general anesthesia induced. Using a 6 french and 14 french catheters, the left femoral artery and right femoral vein were accessed, respectively. The septum was crossed posteriorly in order to avoid the aortic valve. TEE demonstrated a 1.4cm by 0.6cm mitral leak – almost 1/3 the circumference of the biopresthesis, as well as a left atrial width of 5.8cm. After placement of device, TEE demonstrated coverage of 2/3 of the original paravalvular orifice with regurgitation decreased significantly, as well as S wave blunting on pulmonary vein flow. Results A month postoperatively, the patient returned with worsening fatigue, shortness of breath, and weakness. In addition to anemia, patient showed hemolysis. Hematology was consulted and they believed that his PVL was again the etiology. Thus, he underwent repeat attempt at closure of the mitral in addition to early closure of the aortic paravalvular leak. Of note, TEE showed previously closed leak measuring 9mm by 9mm. There were no immediate postoperative complications. Several days later however, the patient suffered decompensated heart failure leading to multisystem organ failure. Discussion Transcatheter leak closure results in significant decrease in regurgitation. Moreover, mortality rate within 30 days averages 1.4-2.0% and 3-year survival rate is 64.5%. When both aortic and mitral prosthesis are involved, it is generally accepted to close the most regurgitant lesion and return in about 6 months for closure of the second lesion. Followup TTE/TEE and labs with close attention to hemolysis is also warranted for possible recurrence.

Transcatheter Self-expandable Aortic Valve (Portico) Implantation in a Patient with Previous Mitral Valve Replacement: A Case Report

Transcatheter aortic valve implantation (TAVI) has shown favorable outcomes in patients with severe symptomatic aortic valve stenosis who are at high surgical risk or who are unsuitable candidates for open-heart surgery. However, concerns exist over treating patients who have undergone previous mitral valve surgery due to the potential interference between the mitral prosthetic valve or ring and the TAVI device. In this case report, we present a case in which a patient with symptomatic severe aortic stenosis and previous mechanical mitral valve replacement was successfully treated with TAVI using a Portico valve, which is under-researched.

Prosthetic valve endocarditis: A challenging complication of prosthetic valves.

This study aims to evaluate the surgical outcomes of prosthetic valve endocarditis. A total of 21 patients (6 males, 15 females; mean age 58.9±12.6 years; range, 33 to 79 years) who were surgically treated for prosthetic valve endocarditis between January 2013 and January 2018 were retrospectively analyzed. Surgical indications included persistent fever for more than seven days after antibiotherapy, congestive heart failure refractory to medical treatment, vegetations larger than 1 cm on echocardiography, the presence of fungal endocarditis, severe valvular leak and valvular dysfunction, and staphylococcal prosthetic valve endocarditis. Five patients had previous aortic valve replacement and three of the aortic prostheses were re-replaced. Two patients had coexisting native mitral valve endocarditis and double valve replacement was done. Thirteen patients had previous mitral valve replacement and 12 of the mitral prostheses were re-replaced. One patient had coexisting native aortic valve endocarditis and double valve re-replacement was done. Three patients had previous aortic valve replacement + mitral valve replacement. Mitral valve endocarditis was diagnosed in two patients and these patients had only mitral valve re-replacement. The other patient had double valve endocarditis, and double valve replacement was done. The mean time from the first operation to the development of endocarditis was 7.3±5.7 years. Of five lost patients, two died from multiple organ failure, one from low cardiac output, one from pneumonia, and one from respiratory failure. Radical resection of the infected tissues is critical to achieve favorable surgical outcomes. Single valve replacement of the infected valve may be preferred in patients having previous double valve replacement. Mechanical valves or bioprostheses can be used for re-replacement procedures.

Outcome of Patients Undergoing Transcatheter Implantation of Aortic Valve With Previous Mitral Valve Prosthesis (OPTIMAL) Study

BackgroundTranscatheter aortic valve replacement (TAVR) is the gold standard for severe valvular aortic stenosis in patients at high/prohibitive surgical risk. This procedure has also been used in patients with previous mitral valve (MV) prostheses, with contrasting outcomes reported. The aim of this study is to describe procedural and early outcomes of patients with previous MV prostheses undergoing TAVR. MethodsThis is a retrospective registry of 154 patients with previous MV prostheses who underwent TAVR across high-volume medical centres at a mean of 11.7 ± 8.4 years after mitral surgery. ResultsMean mitroaortic distance at computed tomography was 9.7 ± 4.8 mm. Procedural success was achieved in 150 (97.4%) patients, with reduction of aortic gradients (42.6 ± 14.2 to 10.0 ± 7.0 mm Hg; P < 0.001). Device success was achieved in 133 (86.3%) patients. MV prosthesis interference by the TAVR device was observed in 2 patients; in both, the mitroaortic distance was <5 mm, with 1 complicated by TAVR prosthesis embolization. Periprocedural complications included 4 (2.6%) cerebrovascular accidents, 10 (6.6%) major vascular complications, 22 (14.4%) severe bleedings, 1 (0.7%) myocardial infarction, and 5 (3.2%) in-hospital deaths (all cases cardiovascular or procedure related). At a median follow-up of 13.5 (interquartile range 1.0 to 36.0) months, 26 (16.9%) deaths occurred; 15 (9.7%) were cardiac related. Late fatal mitral prosthesis thromboses occurred in 2 patients. We recorded a case of fatal hemorrhagic stroke; hospital readmission was observed in 25 (16.2%) patients due to worsening heart failure. ConclusionsTAVR in patients with previous mitral prostheses appears to be safe and feasible, with good hemodynamic results at 30-day and at longer-term follow-up.

Transcatheter Aortic Valve Replacement in the Presence of Mitral Prosthesis or Ring

ABSTRACT Background: Data concerning transcatheter aortic valve replacement (TAVR) in patients with prior mitral surgery is limited and preliminary reports seem encouraging. We sought to describe TAVR outcomes in the presence of mitral prosthesis. Methods: Clinical, imaging and angiographic records of patients with previous mitral valve surgery who underwent TAVR in three Israeli tertiary hospitals were analyzed. Amongst the patients, 28 received a balloon-expandable valve, nine received a self-expandable valve, and one received a mechanically-expandable valve. Aorto-mitral distance and angle were obtained from reconstructed multi-sliced CT images. Primary endpoint was a composite of procedural mortality, need for a second valve, complete AV block, significant paravalvular leak (PVL), and intensive care unit (ICU) admission > 5 days. Results: Thirty-eight patients (74% women) with a mean age of 76 ± 7 years underwent TAVR. Euroscore2 and Society of Thoracic Surgeons (STS) score were 12 ± 9% and 6 ± 5%, respectively. Mean aorto-mitral distance was 9 ± 1 mm and aorto-mitral angle was 117 ± 14°. Mean TAVR implantation depth was 6.1 ± 3 mm. The composite end-point occurred in 15.8% of patients (n = 6), driven by need for a second valve (n = 1), and by three patients that underwent valve snaring due to mitral valve impingement, complete aortic valve (AV) block, and PVL. The 90-day and 1-year mortality was 8% and 21%, respectively. A statistically significant association (HR = 11.2, 95%CI 2.8–45.5, p = 0.012) was found between low implantation depth (>8 mm) and the composite end-points. Conclusion: TAVR in the presence of mitral valve prosthesis adds to the complexity of the procedure and promotes higher procedural risk. Meticulous pre-procedural anatomic assessment and patient selection are mandatory. Implantation depth of less than 8 mm seems prudent.

Outcomes of Redo Valve Surgery in Indigenous Australians

Rheumatic heart disease often leads to valve surgery at a young age in our Indigenous population. Anticoagulation can be problematic and therefore repeat surgery to replace degenerated bioprosthetic valves is common. We sought to examine outcomes following redo valve surgery in this population. Data from our institutional database was reviewed from 1992 to 2017. During this period, 82 redo valve surgeries were performed in 73 patients identifying as Aboriginal and Torres Strait Islander. We compared this study group to Indigenous patients undergoing primary valve surgery (n=389) and non-Indigenous patients undergoing redo valve surgery (n=154). Redo patients had a median age of 29.5 years (IQR 24, 44), 59% were female, and they had significant comorbidities. The 30-day mortality in this cohort was 6% (EuroSCORE II 3.57), and they had significant morbidity. The median time to repeat surgery in those who had previous mitral valve surgery was 6.3 years, with no difference between mitral valve repair or replacement at the index procedure. Compared to non-Indigenous patients undergoing redo valve surgery, the Indigenous patients were significantly younger with higher left ventricular function but a greater proportion of pulmonary hypertension. There were no significant differences in short-term outcomes. Compared to Indigenous patients undergoing primary valve surgery, the Indigenous redo patients were significantly younger with more co-morbidities. There was no difference in 30-day mortality, but the redo patients did have significantly greater resource utilisation (increased hospital and intensive care unit (ICU) lengths of stay, ventilation and blood transfusion) and poorer long-term survival. Indigenous patients presenting for redo valve surgery represent a complex and comorbid group of patients, with outcomes worse than expected in a young population, albeit comparable within study groups. Time from original surgery was short at 6 years, and thus a strategy must be in place in terms of planning future surgeries in this cohort of predominantly young rheumatic heart disease patients.

Transcatheter Mitral Valve Replacement After Transcatheter Electrosurgical Laceration of Alfieri STItCh (ELASTIC): First-in-Human Report

A 78-year-old woman was referred with refractory heart failure. She had previous surgical mitral valve repair with a 32 Carpentier-Edwards Physio ring (Edwards Lifesciences, Irvine, California) and a polypropylene Alfieri stitch. Echocardiography demonstrated restricted mitral valve leaflets, 2

Anomalous left coronary artery from the pulmonary artery (ALCAPA) diagnosed in adulthood: Varied clinical presentation, therapeutic approach and outcome

IntroductionThe diagnosis of ALCAPA syndrome is sporadic in adulthood, of the limited cases in the literature most are incidental or without symptoms. There is a broad spectrum of clinical manifestations of ALCAPA syndrome however, including sudden cardiac death. CasesWe present herewith a series of 12 consecutive patients with ALCAPA, all diagnosed in adulthood (between 18 and 73 years of age). Five patients developed symptoms (breathlessness) after the fourth decade of life, 3 were undiagnosed despite a history of previous mitral valve repair, one presented with heart failure, one with resuscitated cardiac arrest, whereas two patients were asymptomatic. We review in this paper, the clinical history, diagnostic approach and therapeutic choices of ALCAPA syndrome. ConclusionALCAPA syndrome is not confined to childhood, late diagnosis in adulthood has a varied clinical presentation. ALCAPA syndrome should be particularly considered as a potential, albeit uncommon cause of mitral regurgitation and/or dilated cardiomyopathy.

Clipping the Ring: Transcatheter Edge-to-Ring Mitral Valve Repair in a Patient With Prior Mitral Annuloplasty Ring

A 68-year-old man and observant Jehovah’s Witness was referred for transcatheter mitral valve repair for recurrent severe (4+) symptomatic (New York Heart Association functional class III) mitral regurgitation (MR) after previous surgical mitral valve repair. Two years before, he underwent

Imaging of a Detached Mitral Annuloplasty Ring by Intra-Operative 3D Transoesophageal Echocardiography: A Case Report

A 53 year old gentleman with previous tissue AVR and mitral valve repair in 2011 was admitted for redo AVR and MVR. On perioperative TOE we noted an echogenic structure projecting into the left atrium just above the anterior mitral valve leaflet. It was difficult to characterise on 2D TOE but 3D TOE views immediately revealed it was the mitral annuloplasty ring which had detached from the posterior annulus.

Mid-term results and risks of isolated tricuspid valve reoperation following left-sided valve surgery.

Tricuspid valve reoperation (TVR) following left-sided valve surgery (LSVS) is a high-risk procedure. This study was conducted to analyse the mid-term results and risks of isolated TVR following LSVS. From May 2007 to December 2016, 91 patients who underwent isolated TVR following LSVS were enrolled in this study. The patients comprised 23 men and 68 women with a mean age of 57.5 ± 8.0 years (range 33-75 years). The in-hospital mortality rate was 2.2% (2 of 91 patients). Fourteen (15.4%) procedures were performed through a median sternotomy, whereas 77 (84.6%) were performed through a right thoracotomy. One patient underwent tricuspid valve repair, while the others underwent valve replacement including 16 (17.6%) cases involving mechanical valves and 74 (81.3%) involving tissue valves. Eight (9.0%) deaths occurred during the follow-up at 9.21 ± 18.8 months (range 1-108 months), including 5 cardiac deaths. The Kaplan-Meier survival rates at 1 year and 5 years were 97.7% and 90.0%, respectively. Previous aortic and mitral valve replacement [odds ratio (OR) 0.161, P = 0.0015], preoperative central venous pressure (OR 1.202, P = 0.0353), pulmonary artery pressure (OR 1.075, P = 0.0134) and left ventricular end-systolic diameter (OR 1.13, P = 0.0155) were the risk factors for a longer intensive care duration. The valve type had no significant effect on the survival of patients who had undergone valve replacement. Isolated TVR is a safe and effective surgery for tricuspid valve lesions following LSVS, and right thoracotomy may be a reasonable choice.

Abstract 20912: The Impact of Mitral Valve Disease on Atrial Fibrillation Ablation Outcome

Introduction: Mitral Valve Disease (MVD) is associated with atrial fibrillation (AF) and can worsen its prognosis. Left Atrial (LA) fibrosis is a known substrate for AF and its extent affects the management. Hypothesis: We hypothesize MVD increases LA fibrosis in AF patients and the chance of AF ablation failure. Secondly, even in patients with low levels of LA fibrosis that are optimal candidates for ablation, presence of MVD still worsens the outcome. Methods: Patients were categorized in two groups: 140 patients had coexisting MVD and AF, and 100 patients AF without MVD. MVD was defined as any dysfunctionality of mitral valve including mitral stenosis, mitral regurgitation, and history of previous mitral valve surgery . LA fibrosis was quantified by Late Gadolinium Enhancement MRI (LGE-MRI). Baseline characteristics were gathered through chart reviewing. Following ablation, patients were followed for median of 71 months for AF recurrence. Results: Patients were 76.4 ± 10.7 years of age in MVD+AF group and 64.2 ± 14.7 in AF group (p &lt; 0.0001). Extent of LA fibrosis was 18.1% ± 9.3 and 10.3% ± 5.3 in MVD+AF and AF group, respectively (p &lt; 0.0001). The result of our statistical model adjusted for possible cofounders showed that coexistence of MVD in AF patients result in presence of 6.4% more LA fibrosis (p &lt; 0.00001) and lowered the chance of remaining AF free after the ablation (recurrence-free ratio of 0.554 vs 0.757 in MVD+AF and AF group respectively, P &lt; 0.05) (Figure 1). In patients with LA fibrosis less than 20% who would be ideal AF ablation candidate, the presence of MVD decreased the chance to remain AF free (0.574 vs 0.775 in MVD+AF and AF respectively, p &lt; 0.05) (Figure 2). Conclusions: MVD increases LA fibrosis in AF patients and the chance of AF recurrence post-ablation.

Outcomes of surgery for infective endocarditis: a single-centre experience of 801 patients.

Infective endocarditis (IE) remains a life-threatening disease, despite the improvement in diagnostic and therapeutic measures. We reviewed our outcomes for all adults who underwent surgery for endocarditis at our centre. Between January 1995 and December 2013, 801 patients [586 men (73%)] underwent surgery for IE. Mean age was 60 ± 14.7 years. Native endocarditis (NE) was present in 372 patients (46%), and 379 (47%) patients had active IE. The mean follow-up period was 4.6 ± 4.75 years (maximum 20 years). Single-valve endocarditis was present in 551 (69%) patients (392 aortic and 159 mitral). Multivalve involvement was present in 250 (31%) patients. Preoperative stroke was present in 149 (19%) patients, while 62 (8%) patients were on dialysis prior to surgery. Valve repair was possible in 122 (15%) patients, while 679 (85%) patients underwent valve replacement. Mechanical valves were used in 312 (39%) patients. Aortic homografts were used in 84 (10%) patients. Early mortality occurred in 64 (8%) patients. Overall survival at 5, 10 and 20 years was 68%, 45% and 8.4%, respectively. Postoperative stroke occurred in 16 (2%) patients, while 59 (7%) patients required new dialysis postoperatively. Multivariate analysis revealed active IE (P = 0.002), preoperative dialysis (P = 0.007), previous coronary artery bypass grafting (P = 0.001), root abscess (P = 0.006) and tricuspid valve or multivalve involvement (P = 0.002) to be predictors of early mortality. The need for dialysis (P < 0.001), previous coronary artery bypass grafting (P < 0.001) and mitral valve (P = 0.002) and tricuspid valve/multivalve involvement (P < 0.001) were significant predictors of late mortality. Active IE is associated with high perioperative mortality especially with multivalve and aortic root involvement. Preoperative stroke has no impact on perioperative mortality. Long-term survival for those who survived the immediate postoperative period is satisfactory, and mechanical valves are associated with the best long-term survival.

Systematic review of transcatheter aortic valve replacement after previous mitral valve surgery

Systematic review of transcatheter aortic valve replacement after previous mitral valve surgery