Previous Mitral Valve Research Articles

Delayed Ascending Aortic Pseudoaneurysm in an Adult Onset Still's Disease Patient with Previous Mitral Valve and Aortic Root Replacement

A 59-year-old female patient with adult onset Still's disease (AOSD) presented with hemoptysis and pseudoaneurysm from an aortic root vent cannulation site that was created 4 years earlier for combined mitral and aortic valve surgery. The pseudoaneurysm was successfully repaired and the patient remained well during a follow-up period of 20 months.

Urgent replacement of a mechanical mitral prosthesis in an anticoagulated patient with Bombay red blood cell phenotype

Bombay red blood cell phenotype is an extremely rare blood type for which patients can receive only autologous or Bombay phenotype red blood cells. We report a case of urgent repeat sternotomy for replacement of a mechanical mitral prosthesis in a patient with Bombay phenotype anticoagulated with warfarin, to emphasize the transfusion challenges in such patients. A male of Indian descent presented to hospital with New York Heart Association IV symptoms. His medical history revealed previous mitral valve replacement with a mechanical prosthesis in 2005 and Bombay phenotype blood. Preoperative transthoracic echocardiography demonstrated thrombus obstruction of the mitral prosthesis despite anticoagulation with warfarin. Right ventricular systolic pressure was >100 mmHg with 3+ tricuspid regurgitation. The patient's condition was temporized with diuretics, bronchodilators, and bi-level positive airway pressure ventilation while transfusion medicine and cardiac surgery were consulted for urgent surgery. The patient received vitamin K and prothrombin complex concentrate prior to repeat sternotomy and successful mitral prosthesis replacement. After cardiopulmonary bypass, heparinization was corrected with protamine and followed by a second dose of prothrombin complex concentrate and recombinant activated factor VIIa. Postoperatively, the patient received four units of packed red blood cells, two autologous units and two units of Bombay specific red blood cells. Right ventricular pressures stabilized at 40 mmHg following surgery. The patient recovered following several days of inotropic support with milrinone, diuretics, and bronchodilators. Patients with Bombay phenotype red blood cells present as type O, but they are unable to receive red blood cells from any phenotype other than Bombay phenotype. They are able to receive all other blood products, including fresh frozen plasma, cryoprecipitate, platelets, prothrombin complex concentrate, and recombinant activated factor VIIa. Coordination between Canadian Blood Services, transfusion medicine, surgery, and anesthesia is important in managing these patients.

Detection of cardiac tumour-surface thrombus: utilization of cardiac magnetic resonance imaging avascular tissue nulling sequence

A 71-year-old woman presented to her cardiologist with fatigue and progressive shortness of breath. She had undergone previous mitral valve replacement in 1989 and aortic valve replacement in 2008. Physical examination revealed audible mitral and aortic clicks and no other significant findings. Her electrocardiography and chest radiography showed no acute findings. A transesophageal echo performed for valve assessment revealed a friable mass arising from the interatrial septal wall of the left atrium ( Panel A ). At this point, the most likely differential diagnosis included tumour or thrombus. Following intravenous 0.2 mmol …

Transfemoral Aortic Valve Implantation in a Patient with Prior Mechanical Mitral Valve Replacement

Transfemoral aortic valve implantation has emerged as a promising alternative to surgical aortic valve replacement for high-risk patients with severe symptomatic aortic stenosis. In the setting of previous mechanical mitral valve replacement, the procedure represents a challenge due to the risk of interference and subsequent functional impairment of the mechanical prosthesis. The authors report a case of successful transfemoral implantation of a selfexpandable aortic bioprosthesis in a patient with a Björk-Shiley tilting-disk valve in mitral position demonstrating that the implantation is also feasible in this setting but requires careful preinterventional evaluation. Prior balloon aortic valvuloplasty with thorough observation of the mitral prosthesis during balloon inflation may be a helpful tool for indicating feasibility of this approach.

Successful Transapical Aortic Valve Replacement in a Patient With a Previous Mechanical Mitral Valve Replacement

In this case we illustrate our experience with transapical minimal invasive aortic valve replacement in a patient who previously underwent mitral valve replacement. The implantation did not interfere with the existing prosthesis and could even be used as a further landmark, helping height positioning of the aortic valve.

Minimally Invasive Mitral Valve Replacement Using the Valve-in-valve Technique

A 90-year-old woman with two previous mitral valve replacements, presented with pulmonary edema due to mitral regurgitation from degeneration of her bioprosthetic mitral valve. A minimally invasive approach was used to replace the bioprosthetic mitral valve. During surgery, the bioprosthetic valve was noted to be too adherent to the endocardium of the left atrium, making removal of the prosthesis not only difficult, but also potentially harmful. The new bioprosthetic valve was instead placed using a valve-in-valve approach.

The Coronary Sinus: A Versatile Option for Pacemaker Implantation during Minimally Invasive Valve Surgery

A 66-year-old patient with previous mitral valve replacement underwent redo surgery for severe secondary tricuspid valve regurgitation. The patient presented with right heart failure and was pacemaker-dependent prior to surgery. Tricuspid valve replacement and implantation of a cardiac pacemaker lead through the coronary sinus were performed. The operative procedure and current literature are discussed.

Unusual complication of a migrant pacemaker lead

We describe the case of a 74-year-old male with a history of rheumatic valvular heart disease and previous aortic and mitral valve replacements. A single-chamber pacemaker was implanted in 1994. Four years later, the electrode was found to be malfunctioning. A new right ventricular electrode was implanted and the original electrode was capped. Routine follow-up in 2008 showed that the capture threshold had increased. Further investigations showed that the original electrode had fractured into three segments. One of the fragments had migrated into the left pulmonary artery. A year later the patient had not suffered from any complications although the fragment had migrated further in to the lung. …

Transcatheter membranous ventricular septal defect closure through a mechanical aortic prosthesis using the Amplatzer membranous ventricular septal defect occluder

An iatrogenic ventricular septal defect (VSD) after aortic valve replacement is rare, but represents a significant complication. Repeat surgery to repair such a defect carries a high surgical risk. The transcatheter approach (either transvascular or transapical) could be considered as an alternative to open chest surgery. We describe the successful transcatheter closure of an iatrogenic VSD with an Amplatzer membranous VSD occluder in a patient with previous combined mitral and aortic mechanical valve replacements. The device was implanted through a CarboMedics mechanical valve in the aortic position.

Logistic risk model predicting postoperative respiratory failure in patients undergoing valve surgery

Previous studies have been unable to identify independent valve-related risk factors for postoperative respiratory failure (RF) in patients undergoing valve surgery. This study was designed to determine the incidence and predictors of RF in these patients. We also aimed to create a model based on these risk factors that could serve as a tool for the prediction of this complication. We analyzed prospectively collected data of 2808 patients (mean age 63+/-15 years, 43% female) who underwent valve surgery from January 1998 to December 2006. Isolated valve surgery was performed in 2007 (72%) patients whereas 801 (28%) received concomitant coronary artery bypass grafting (CABG) procedures. The main outcome investigated was RF (ventilation >72 h). Other postoperative parameters included in the analysis were hospital mortality, morbidity, length of hospital stay, discharge and late survival. Respiratory failure occurred in 12.2% (n=342) of patients. The incidence of RF varied according to the procedures (single valve: 7.4-15.8%; multiple valves: 21.7-23.4%). The addition of CABG significantly increased the rate of RF (isolated valves: 10.8%, combined valve/CABG 15.7%, p<0.001). Multivariate analysis revealed preoperative renal failure, ejection fraction <30%, age >70 years, active endocarditis, emergent procedures, reoperation, diabetes, congestive heart failure, previous myocardial infarction, female gender, double aortic and mitral valve procedures, and cardiopulmonary bypass time >180 min as independent predictors of RF. Hospital mortality among patients with RF was 22.2% (n=76) versus 2.7% (n=66) in the control group (p<0.001). A logistic equation including the coefficients of the regression analysis was generated to calculate an individual patient's risk for the development of RF. Predictive accuracy of the model and validation was measured (ROC area under the curve: 0.751). Long-term survival of discharged patients with RF was significantly decreased compared to those without RF. Respiratory failure is a common complication particularly in patients undergoing complex valve operations such as endocarditis or multiple valve procedures. The independent predictors of RF including valve-related factors allowed us to create a predictive model with great accuracy. The poor long-term survival of patients with RF underlines the need to direct more resources towards prevention and treatment of this complication.

Mitral Valve Replacements in Redo Patients with Previous Mitral Valve Procedures: Mid-Term Results and Risk Factors for Survival

We aimed to investigate the risk factors for hospital mortality, short (five years) and mid-term (10 years) survival in patients who underwent mitral valve replacements in redo patients with previous mitral valve procedures. Between September 1989 and December 2003, 62 redo patients have undergone mitral valve replacements due to subsequent mitral valve problems. Preoperative, operative, and postoperative data were analyzed retrospectively and evaluated for risk factors affecting hospital mortality, mid- and long-term survival. The hospital mortality was 6.4%. The one-, five-, and 10-year actuarial survival rates were 94%+/- 2%, 89%+/- 6%, and 81 +/- 9%. New York Heart Association (NYHA) functional class IV, low left ventricular ejection fraction (<35%), increased left ventricular end-diastolic diameter (LVEDD) > 50 mm, female gender, pulmonary edema, and urgent operations were found to be risk factors in short-term survival. NYHA functional class IV, low left ventricular ejection fraction, increased LVEDD, and increased left atrial diameter (LA > 60 mm) were risk factors in mid-term survival. Redo mitral valve surgery with mechanical prosthesis offers encouraging short- and mid-term survival. NYHA functional class IV, low left ventricular ejection fraction, and increased left ventricular diameters were especially associated with increased short- and mid-term mortality. Earlier surgical management before the development of severe heart failure and myocardial dysfunction would improve the results of redo mitral valve surgery.

Late posterior failure after mitral valve repair in degenerative disease

Little is known regarding the mechanisms, the feasibility and the long-term results of re-repair in 'posterior failure' of a previous mitral valve repair performed for severe degenerative mitral regurgitation. We report our 16-year experience in redo surgery for late posterior failure of mitral valve repair in degenerative disease. From 1991 to 2004, 13 consecutive patients (10 males; median age: 65 years) were reoperated for late posterior failure of mitral valve repair. All patients had grade > or =3+ mitral regurgitation. Repair was mainly performed using Carpentier's techniques. Repair failure was due to posterior leaflet prolapse, leaflet retraction or leaflet dehiscence in eight (62%), three (23%) and two (15%) patients, respectively. Repair was performed in nine patients (69%). There was no perioperative death. During follow-up (median: 105 months; range: 40-170 months) one late death occurred in the mitral valve replacement group. One (11%) patient underwent mechanical mitral valve replacement 125 months after re-repair. Congestive heart failure occurred in one patient in each group. At the latest follow-up, all but one patient in the mitral valve repair group were in NYHA functional class I or II and all were in sinus rhythm. Doppler echocardiographic studies of the re-repaired valves (n=8) showed no or trivial, grade 1+ and grade 2+ residual mitral regurgitation in 6 (75%), 1 and 1 patients, respectively. Mean transmitral gradient was 3 mmHg (2-8 mmHg) and left ventricular ejection fraction was 59% (43-77%). In case of late posterior failure of mitral valve repair for severe degenerative, re-repair is feasible in about 70% of the patients with encouraging results at 10 years.

Obstruction of Left Ventricular Outflow Tract After Mechanical Mitral Valve Replacement

We successfully operated on a patient with a rare complication of left ventricular outflow tract obstruction after mitral valve replacement. In a 57-year-old woman with previous mitral valve replacement, transthoracic echocardiography showed left ventricular outflow tract obstruction as a result of anterior displacement of the mitral prosthesis and local thickening of the interventricular septum. Cardiac surgery verified this rare lesion. During the operation, the anterior half of the prosthesis ring was cut away from hyperplastic tissue and sutured to the natural mitral annulus. Subaortic hyperplastic tissue was excised to enlarge the left ventricular outflow tract. The patient had an uneventful postoperative recovery, and left ventricular outflow tract obstruction disappeared on postoperative transthoracic echocardiography.

Candida prosthetic valve endocarditis: the complementary role of multidetector computed tomography and transoesophageal echocardiography in preoperative evaluation

A 72-year-old man with previous mitral valve replacement and single coronary bypass surgery was diagnosed with recurrent candida endocarditis by transoesophageal echocardiography and positive blood cultures. Preoperative electrocardiogram-gated multidetector CT (MDCT) was ordered to evaluate the patency and course of the mammary graft. In addition to verifying graft patency, MDCT demonstrated a mobile vegetation on the mitral prosthesis as well as a vegetation on the posterior left atrial wall which was not visible by transoesophageal echocardiography. Multidetector CT also revealed signs of osteomyelitis in the thoracic spine. Repeated surgery confirmed these findings and mitral valve replacement with resection of the left atrial vegetation were performed. This case illustrates the complementary role of MDCT and echocardiography in the preoperative evaluation of fungal endocarditis.

Abstract 2066: Does Mitral Regurgitation Regress After Aortic Valve Replacement For Aortic Stenosis ? A Prospective Multicenter Study

Background: Mitral regurgitation (MR) is common in patients undergoing aortic valve replacement (AVR) for aortic stenosis (AS). Whether its severity may decrease after AVR remains controversial. Previous studies were mainly retrospective and the degree of MR was assessed at best semi-quantitatively. This study sought to prospectively and quantitatively assess how AVR may affect MR severity. Methods: Patients with AS scheduled for isolated AVR and presenting holosystolic MR which was not considered for replacement or repair were included. Previous mitral valve surgery; severe aortic regurgitation and poor acoustic windows were excluded. Thirty-five patients (mean age 77±7 years) were studied before (median 1, range 1– 41 days) and after AVR (median 7, range 4 –19 days). All patients underwent a comprehensive echocardiographic examination; MR was assessed by Doppler echocardiography using color flow mapping of the regurgitant jet and the PISA method. No patient had prolapsed or flail mitral leaflet as mechanism of MR. Results: Preoperative maximal and mean transaortic pressure gradients and aortic valve area were 74±26 mmHg, 44±16 mmHg, and 0.57±0.18 cm 2 , respectively. Left ventricular (LV) ejection fraction increased from 49±16 % to 55±15 % after AVR (p&lt;0.001). LV end-diastolic volume decreased from 91±32 ml to 77±30 ml (p&lt;0.001).The ratio of MR jet to left atrial area decreased from 30±16% to 20±14% (p&lt;0.001). MR effective regurgitant orifice (ERO) and regurgitant volume decreased from 10±5 mm 2 to 8±6 mm 2 (p=0.015) and from 19±10 ml to 11±9 ml (p&lt;0.0001). The decrease in ERO and in regurgitant volume was similar in patients with preserved or depressed LV ejection fraction (≤45 %) (2±3 vs 3±6 mm 2 and 7±9 vs 8±7 ml; p=NS, respectively). Conclusions: AVR is associated with an early postoperative reduction of the quantified degree of MR. This mainly results from a decrease in regurgitant volume and only modestly from a reduction in ERO, emphasizing the contributing role of the decrease in driving pressure accross the mitral regurgitant orifice.

Surgical repair of left ventricle to coronary sinus fistula complicating mitral valve replacement

We report the case of a 55-year-old female patient who underwent reoperation because of left ventricular to coronary sinus fistula following previous mitral valve replacement. The fistula was closed surgically with a patch of heterologous bovine pericardium. The postoperative course was uneventful and the patient is recovering well 12 months after the operation.

59 Potential Utility of Brain Natriuretic Peptide in the Evaluation of the Dyspneic Child with Congenital Heart Disease.

BACKGROUND: The use of brain natriuretic peptide (BNP) in the evaluation of the dyspneic pediatric patient is increasingly supported for infants and newborns with congenital heart disease. However, there is scant evidence demonstrating the utility of BNP assay in the evaluation of the dyspneic child or adolescent with congenital heart disease.OBJECTIVE: To report the utility of BNP analysis in differentiating heart failure from other causes of dyspnea in the child with congenital heart disease as well as providing insight into the effectiveness of heart failure therapy.DESIGN/METHODS: Case reportRESULTS: A 13 year old male with Down Syndrome and previous AV canal repair and mitral valve replacement with porcine xenograft in 1998 was admitted to our center for evaluation of increasing fatigue, dyspnea, and orthopnea. These symptoms gradually developed over the past 7 weeks and were associated with a 4 kg weight gain over the past month. The patient had also had a previous episode of viral myocarditis and had undergone treatment with enalapril, spironolactone, and digoxin for several months in 2004, but was currently only on iron, digoxin, and warfarin.Upon admission the patient was shown to have marked dyspnea, hypoxemia requiring 5 liters per minute oxygen by nasal canula, some trace anterior tibial edema, and prominent JVD. Echocardiogram showed increased left atrial pressures and mitral valve stenosis. BNP was drawn at admission and was found to be 5486.91 pg/ml. He was given 40mg furosemide in addition to his home medications and was started on a low-sodium diet. During the night of hospital day 1 the patient's dyspnea improved and his oxygen requirement resolved. On hostpital day 2 the patient was started on enalapril 2.5mg daily and spironolactone 12.5mg daily, and digoxin was increased to 0.125mg twice daily. By hospital day 5 the patient's BNP had decreased to 4007.77 pg/ml, his appetite was back to baseline, and he was ambulating and sleeping flat without difficulty. The patient was transferred to another facility for replacement of his deteriorating mitral valve.CONCLUSIONS: BNP shows promise in differentiating heart failure from non-cardiac causes of dyspnea in the child with congenital heart disease and prior surgical intervention. Additionally, BNP level decrease correlated with clinical improvement in our patient. This may prove insightful in assessing the efficacy of heart failure therapy in this specialized population.First Author is a House Officer

Atrial arrhythmias after cardiac surgery in patients with diabetes mellitus

Postoperative atrial fibrillation (AF) is a common complication of cardiac surgery and has been associated with increased incidence of other complications and increased hospital length of stay (LOS). Prevention of AF is a reasonable clinical goal, and, consequently, many randomized trials have evaluated the effectiveness of pharmacological and non-pharmacological interventions for prevention of AF. To better understand the role of various prophylactic therapies against postoperative AF, a systematic review of evidence from randomized trials was performed. MEDLINE search of English-language reports published between 1966 and July 2005 and a search of references of relevant papers were conducted. Clinical studies on AF after cardiac surgery were selected for this analysis. Relevant clinical information was extracted from selected articles. Postoperative AF is associated with increased morbidity and mortality and longer, more expensive hospital stays. Prophylactic use of beta-adrenergic blockers reduces the incidence of postoperative AF and should be administered before and after cardiac surgery to all patients without contraindication. Prophylactic amiodarone and atrial overdrive pacing should be considered in patients at high risk for postoperative AF (for example, patients with previous AF or mitral valve surgery). For patients who develop AF after cardiac surgery, a strategy of rhythm management or rate management should be selected. For patients who are hemodynamically unstable or highly symptomatic or who have a contraindication to anticoagulation, rhythm management with electrical cardioversion, amiodarone, or both is preferred. Treatment of the remaining patients should focus on rate control because most will spontaneously revert to sinus rhythm within 6 weeks after discharge. All patients with AF persisting for more than 24 to 48 hours and without contraindication should receive anticoagulation. AF frequently complicates cardiac surgery. Many cases can be prevented with appropriate prophylactic therapy. A strategy of rhythm management for symptomatic patients and rate management for all other patients usually results in reversion to sinus rhythm within 6 weeks of discharge.

Oral anticoagulant therapy, endocapsular hematoma, and neodymium:YAG capsulotomy

We present a case of endocapsular hematoma, a rare form of intraocular hemorrhage that developed in a patient with pseudophakia receiving oral anticoagulants for previous mitral valve replacement and cerebrovascular disease.

Cardiac complications after hepatic resection.

During a period of 94 months between 1985 and 1993, 474 hepatic resections were performed in 451 patients, of whom 23 (5 per cent) had cardiac problems: ischaemic heart disease in 16 (previous myocardial infarction in five and angina pectoris in 11), arrhythmic disorders in three, valvular disease in three (previous mitral valve replacement in two) and hypertrophic cardiomyopathy in one. The cardiac patients had a higher incidence of cardiac complications (24 versus 0 per cent, P < 0.0001) including two myocardial infarctions, and of non-cardiac complications consisting of postoperative liver failure (16 versus 4 per cent, P < 0.01) and bile leak (16 versus 5 per cent, P = 0.02), as well as hospital death (16 versus 3 per cent, P < 0.001). However, long-term survival was similar in the two groups. Patients with preoperative cardiac conditions appear to be at increased risk for early postoperative morbidity and mortality after hepatic resection.