Regurgitant Area Research Articles

The mid-term outcomes of minimally invasive plasty for severe tricuspid regurgitation after cardiac surgery

Objectives: To evaluate the efficacy of minimally invasive surgery in patients with late severe tricuspid regurgitation after cardiac surgery, and to evaluate the role of leaflets augmentation technique in tricuspid valvuloplasty. Methods: From January 2015 to June 2019, 85 patients undergoing tricuspid valve repair procedure with minimally invasive approach at Department of Cardiovascular Surgery, Guangdong provincial People's Hospital were enrolled. There were 22 males and 63 females, aging of (53.6±12.4) years (range: 15 to 75 years). The interval between the prior and current operations was (16.0±7.3) years (range: 0.2 to 35.0 years). The diameter of right atrium and right ventricle was (77.3±17.2) mm and (61.0±8.4) mm, respectively. Tricuspid regurgitation was severe or extremely severe, the tricuspid regurgitation area was (19.0±10.3) cm(2). All patients underwent minimally invasive tricuspid valvuloplasty or tricuspid valve replacement on beating-heart with totally endoscopic technique and port-access approach through right chest wall. The operations included tricuspid valve replacement and tricuspid valvuloplasty, the technique of tricuspid valvuloplasty including leaflets augmentation with patch, ring implantation, chordae tendineaes reconstruction, release of papillary muscle, edge to edge method, etc. Postoperative hospitalization days, the time of ICU stay, blood transfusion rate, ventilator time and the results of echocardiography were recorded. Follow-up was completed regularly by WeChat, telephone and outpatient visit. Results: Sixty-five patients underwent tricuspid valve repair, and 20 patients underwent tricuspid valve replacement because of prosthetic failure and plasty failure. Five patients died during hospitalization, with mortality rate 5.9%. One patient was transferred to local hospital for anti-infection treatment, the other 79 patients were discharged from hospital in well condition and followed-up. The postoperative hospitalization time was 7.0 (5.5) days (M(Q(R))) days, the mean ventilator time was 18.0 (16.2) hours, and the mean ICU stay time was 68.0 (75.5) hours. There were 35 patients without blood conduction transfusion, the transfusion rate was only 58.9% (50/85). Four cases of severe, 9 cases of moderate and 67 cases of mild to zero tricuspid regurgitation were examined before being discharged, with tricuspid regurgitation area of (2.8±3.5) cm(2) (range: 0 to 19.1 cm(2)). The follow-up time was 1 to 38 months. Two patients died during follow-up, one patient died from infective endocarditis and mitral perivalvular leakage, the other one died of intractable right heart failure. One patient was implanted with permanent pacemaker due to Ⅲ atrioventricular block. Valvular re-replacement was performed in 2 patients who were re-admitted for the artificial valve infection and mechanical valve obstruction. No re-operation of tricuspid valve. Conclusions: Totally endoscopic minimally invasive technique provided satisfactory surgical outcomes for critically sick patients with severe tricuspid regurgitation following cardiac surgery. The application of leaflets augmentation technique achieved ideal repair effect for previously unrepairable lesions.

Ventricular vortex loss analysis due to various tricuspid valve repair techniques: an ex vivo study.

The deteriorating nature of severe functional tricuspid regurgitation (FTR) has led to the heightened interest in this pathology. However, therapies are heterogeneous and an ideal technique is uncertain. The hemodynamic impact on the cardiac chamber following therapeutic repairs has not been well studied, while its analysis could be used to predict the treatment success. In this study, the hemodynamics of the right ventricle (RV) after 1) clover edge-to-edge tricuspid repair, and 2) double orifice tricuspid repair was evaluated in three right heart models using an ex vivo pulsatile platform emulating severe FTR with the aid of stereoscopic particle image velocimetry. Although all repairs substantially reduced tricuspid regurgitant area, they resulted in a more than 50% reduction in diastolic tricuspid valve (TV) opening area. Splitting the TV orifice into multiple smaller orifices by both repairs eliminated the ring-shaped vortical structure inside the RV observed in FTR cases. Postrepair RV domain was mostly occupied with irregular vortical features and isolated vortex residuals. Moreover, vortical features varied among repair samples, indicating enhanced sensitivity of RV flow to postrepair TV morphology. Compared with clover repair, double orifice subjected the RV to enhanced swirling motions and exposed more regions to vortical motions, potentially indicating better rinsing and lower risk of mural thrombus formation. Double orifice repair increased the levels of RV mean kinetic energy and viscous energy loss than those observed in clover repair, although the impact of these on the cardiac efficiency remains unclear. These preliminary insights could be used to improve future treatment design and planning.NEW & NOTEWORTHY While clover and double orifice tricuspid repairs markedly improved leaflet coaptation, they substantially reduced diastolic tricuspid opening area. Postrepair right ventricle (RV) exhibited specific hemodynamic traits, including the loss of ring-shaped vortical structure and the enhanced sensitivity of RV flow to postrepair tricuspid valve morphology. Compared with clover technique, double orifice repair led to higher swirling motions in the RV domain, which could indicate lower risk of mural thrombus formation.

P5569Effective regurgitant oriffice area vs vena contracta method as predictors of outcomes in severe tricuspid regurgitation

Abstract Background There is no gold standard echocardiographic method to evaluate tricuspid regurgitation (TR) severity. ESC guidelines recommend using a combination of several methods. The purpose of this study was to compare the prognostic value of the two most commonly used methods for the evaluation of the TR: Effective regurgitant orifice area (EROA) method and biplane vena contracta (VC) method. Methods Consecutive asymptomatic patients with significant TR (moderate to severe or severe by echocardiography) evaluated in the Heart Valve Clinic between 2015–2018 were included. TR severity was evaluated by a combination of several methods, including EROA method and biplane VC method, using EPIQ system. End-point included cardiovascular mortality, tricuspid valve surgery or heart failure. Results A total of 70 patients were included (mean age was 74±8 years, 71% females). According to aetiology, 94% were functional TR (60% due to left valve disease, 27% due to tricuspid annulus dilatation, 13% others). During a median follow up of 18 months [IQR: 4–28], 35% of the patients reached the combined end-point (n=16 developed right heart failure, n=17 underwent tricuspid valve surgery, and n=3 died). Patients with events showed a larger EROA (0.55 vs 0.40 p: 0.036) but no significance different was found in VC (8.03 vs 7.80 p: 0.27). Among both parameters, the tricuspid EROA was the only prognostic factor of the combined endpoint (EROA, HR 24.22 [1.54–380.86], p=0.023; VC, HR 1.022 [0.882–1.183]. A value of EROA of 0.42 reached the best accuracy to predicted poor outcomes (p<0.01). Conclusion Among the two most commonly used methods for the evaluation of the TR, EROA was the only method that obtained prognostic value during follow-up.

Patient-Specific Computer Simulation of Transcatheter Aortic Valve Replacement in Bicuspid Aortic Valve Morphology.

A patient-specific computer simulation of transcatheter aortic valve replacement (TAVR) in tricuspid aortic valve has been developed, which can predict paravalvular regurgitation and conduction disturbance. We wished to validate a patient-specific computer simulation of TAVR in bicuspid aortic valve and to determine whether patient-specific transcatheter heart valve (THV) sizing and positioning might improve clinical outcomes. A retrospective study was performed on TAVR in bicuspid aortic valve patients that had both pre- and postprocedural computed tomography imaging. Preprocedural computed tomography imaging was used to create finite element models of the aortic root. Finite element analysis and computational fluid dynamics was performed. The simulation output was compared with postprocedural computed tomography imaging, cineangiography, echocardiography, and electrocardiograms. For each patient, multiple simulations were performed, to identify an optimal THV size and position for the patient's specific anatomic characteristics. A total of 37 patients were included in the study. The simulations accurately predicted the THV frame deformation (minimum-diameter intraclass correlation coefficient, 0.84; maximum-diameter intraclass correlation coefficient, 0.88; perimeter intraclass correlation coefficient, 0.91; area intraclass correlation coefficient, 0.91), more than mild paravalvular regurgitation (area under the receiver operating characteristic curve, 0.86) and major conduction abnormalities (new left bundle branch block or high-degree atrioventricular block; area under the receiver operating characteristic curve, 0.88). When compared with the implanted THV size and implant depth, optimal patient-specific THV sizing and positioning reduced simulation-predicted paravalvular regurgitation and markers of conduction disturbance. Patient-specific computer simulation of TAVR in bicuspid aortic valve may predict the development of important clinical outcomes, such as paravalvular regurgitation and conduction abnormalities. Patient-specific THV sizing and positioning may improve clinical outcomes of TAVR in bicuspid aortic valve.

Clinical role of transthoracic and transesophageal echocardiography in transapical mitral valve repair

Objective To evaluate the role of transthoracic echocardiography(TTE) and transesophageal echocardiography(TEE) in the process of transapical mitral valve repair using a novel edge-to-edge device(ValveClamp) and this device′s efficacy and safety in a preliminary clinical trial. Methods Six patients with moderate to severe or severe degenerative mitral regurgitation (DMR) confirmed by TTE and TEE were enrolled. TTE was performed pre and post procedure as well as 30 days post procedures.Related cardiac structure and hemodynamic parameters, including mitral regurgitation area(MRA-max), vena contracta width(VCW), mitral valve effective orifice area(MVEOA), left ventricular end diastolic diameter(LVEDD), left ventricular end systolic diameter(LVESD), left ventricular ejection fraction(LVEF), max and mean mitral valve pressure gradient(MVPG-max and MVPG-mean) were recorded and evaluated in a central core laboratory. Results All the procedures were successfully performed.MRA-max, VCW and MVEOA decreased significantly post procedures (all P 0.05). Meanwhile, MVPG-max and MVPG-mean slightly increased (all P 0.05). Conclusions Transapical mitral valve repair using ValveClamp can be performed safely and a significant reduction in mitral regurgitation can be achieved in patients with DMR. TEE and TTE facilitate the patient selection for ValveClamp procedures as well as perioperative navigation and assessment. Key words: Echocardiography, transthoracic; Echocardiography, transesophageal; Transcatheter mitral valve repair; Mitral regurgitation

Why Did COAPT Win While MITRA-FR Failed? Defining the Appropriate Patient Population for MitraClip.

In 2018, the world of functional mitral regurgitation changed with the presentation of two trials — Multicentre Study of Percutaneous Mitral Valve Repair MitraClip Device in Patients With Severe Secondary Mitral Regurgitation (MITRA-FR) and Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation (COAPT). The trials, which seemed to point in two different directions, raised significant questions for the field. This article looks at the differences in effective regurgitant area, guideline-directed medical therapy, patient selection, technical clues and other reasons why the trials had similar aims but very different findings.

MULTISPIRAL COMPUTER TOMOGRAPHY IN DIAGNOSTICS OF PATIENTS WITH THE PATHOLOGY OF ASCENDING DEPARTMENT OF THE AORTA IN BEFORE AND POSTOPERATIVE PERIOD

This review presents current information on the diagnosis of patients with pathology of the ascending aorta in the pre and postoperative period using multispiral computed tomography. The authors paid attention to the importance of valuation of the valvular apparatus elements, the geometry of the root of the aorta (effective coaptation height, Henle triangles, aortic regurgitation area, etc.), the features of which are necessary for the surgeon to solve technical issues of the forthcoming operation. A comparison of the diagnostic value of multispiral computed tomography and transthoracic echocardiography with respect to the visualization of valvular structures is shown. The role of multispiral computed tomography in the planning of transcatheter aortic valve replacement and the determination of results after intervention is described. With the help of multispiral computed tomography, assessing the state of the ascending aorta, the aortic root and aortic valve elements, the surgeon has an opportunity to choose the optimal variant of the valve-preserving operation and to evaluate postoperative results in the preoperative period.

Surgical Treatment for Hypertrophic Obstructive Cardiomyopathy with Concomitant Mitral Valve Abnormalities: A Cohort of 26 Cases.

We sought to analyze the pathological characteristics of hypertrophic obstructive cardiomyopathy (HOCM) with concomitant mitral valve abnormalities and to discuss the surgical treatment strategies. The clinical data of 26 HOCM patients treated from January 2014 to March 2016 were retrospectively analyzed. There were 19 males and 7 females with a mean age of 47 ± 16 years (range, 10-70 years). Echocardiography showed HOCM, systolic anterior motion of the mitral apparatus, and concomitant mitral regurgitation. Modified Morrow procedure with expanded resection area was performed in 21 patients. Concomitant mitral valvuloplasty was performed in 4 patients, coronary artery bypass grafting was performed in one patient, and aortic valve replacement was performed in one patient. Echocardiography was performed intraoperatively at postoperative 1 week and at postoperative 1 year to evaluate the left ventricular obstruction and the mitral regurgitation. The left ventricular outflow tract gradient, left ventricular outflow tract velocity, septal thickness, and mitral regurgitation area decreased significantly at postoperative 1 week and 1 year in comparison with the baseline (all P < .001). The postoperative mitral regurgitation and systolic anterior motion of the mitral apparatus were completely abolished or significantly relieved. Only one patient had moderate mitral regurgitation of 7 cm2 after the surgery. At postoperative 1 year, all patients were asymptomatic, and the quality of life was significantly improved. The New York Heart Association (NYHA) class was I-II. Echocardiography showed good anatomy and function of the mitral valve. Concomitant mitral valve abnormality is not uncommon in HOCM. Septal myectomy can adequately expand the left ventricular outflow tract and abolish mitral regurgitation and systolic anterior motion of the mitral apparatus. Concomitant mitral valvuloplasty is indicated for severe congenital abnormalities or secondary lesions of the mitral valve, and the outcomes are satisfactory.

P6054Calcium score of the mitral valve assessed by CT angiography correlates with the severity of mitral regurgitation and mitral valve area in patients with severe aortic stenosis

P6054Calcium score of the mitral valve assessed by CT angiography correlates with the severity of mitral regurgitation and mitral valve area in patients with severe aortic stenosis

Quantitative evaluation of mitral valve structure and function in patients with mitral valvuloplasty by real-time three-dimensional transesophageal echocardiography

Objective To quantitatively evaluate the variation of preoperative and postoperative structure and function of mitral valve after mitral valve annuloplasty(MVP) for mitral valve prolapse by real-time three-dimensional transesophageal echocardiography(RT-3D TEE). Methods Thirty patients with mitral valve prolapse for MVP were studied, the minimum area of the three-dimensional view of the annulus(A3Dmin), three dimensional circumference(C3D), anterolateal-to-posteromedial diameter(DAlPm), anterior-to-posteior diameter(DAP), height (H), the ratio of annulus height to anterolated-to-posteromedial diameter(H/DAlPm), aorto-mitral angle(θ), the ellipticity of the the anterior-to-posterior diameter and anterolateal-to-posteromedial diameter of the annulus(E2D), the three-dimensional exposed area of the leaflet(A3DE), prolapse height(HProl), prolapse volume(VProl), non-planarity angle(θNPA) were evaluated by RT-3D TEE before and after operation. Coaptation area(CoapA), coaptation index(CPI), annulus systolic function index were calculated. Results Compared with the preoperation, A3Dmin, C3D, DAlPm, DAP, H, H/DAlPm, A3DE, HProl, VProl, θNPA of postoperative were reduced, E2D, CoapA, CPI, annulus systolic function index of the postoperation increased, the difference of above parameters were statistically significant (P<0.05). CPI and annulus systolic function index were negatively correlated with the area of valve regurgitation area before and aftere operation (r=-0.79, P<0.01; r=-0.67, P<0.01). Furthermore, CPI was closely correlated with annulus systolic function index (r=0.63, P<0.01). Conclusions After MPV, mitral valve three-dimensional structural parameters are significantly changed, CPI and annulus systolic function are improved. CPI is closely correlated with annulus systolic function, and RT-3D TEE can quantitatively evaluate the structure and function of mitral valve before and after MPV. Key words: Echocardiography, transesophageal, real-time three-dimensional; Mitral valve insufficiency; Mitral valve annuloplasty

Does mitral valve repair matter in infants with ventricular septal defect combined with mitral regurgitation?

OBJECTIVES: This study aimed to assess mitral valve function after repair of ventricular septal defect (VSD) combined with mitral regurgitation (MR) in the mid-term follow-up period, to evaluate the clinical utility of simultaneous mitral valve repair (MVR).&#x0D; METHODS: From June 2005 to March 2014, 60 patients with VSD and MR underwent surgical treatment. After performing propensity score analysis (1:1) for the entire sample, 46 patients were selected and divided into 2 groups: those with VSD closure and MVR - 23 patients and those with VSD closure without mitral valve intervention - 23 patients. The follow-up period - 32 (28;40) months.&#x0D; RESULTS: There was no postoperative mortality in either group. There was no significant difference in the duration of the postoperative period between groups. Mean cardiopulmonary bypass time and aortic cross-clamping time were significantly longer in the 'VSD + MVR' group (cardiopulmonary bypass, P=0.023; aortic cross-clamp, P&lt; 0.001). There was no significant difference in regurgitation area (P=0.30) and MR grade (P= 0.76) between groups postoperatively. There was no significant difference in freedom from MR ≥ 2+ between groups (log-rank test, P= 0.28). The only significant risk factor for recurrent MR ≥ 2+ during the follow-up period was mild residual MR in the early postoperative period ( P=0.037).&#x0D; CONCLUSIONS: In infants with VSD combined with MR, simultaneous MVR has no benefits simultaneous MVR provided no advantage over that of isolated VSD closure. We found that the presence of mild residual MR in the early postoperative period predisposes the development of MR ≥ 2+ in follow-up period.

Predictors of 1-year mortality after transcatheter aortic valve replacement.

To identify variables predictive of increased mortality within 1 year of transcatheter aortic valve replacement (TAVR). We retrospectively reviewed the records of 723 consecutive patients who received TAVR from November 2008 through April 2016. Patient and procedure-related characteristics were analyzed with logistic regression for an association with death within 1 year of TAVR. Patient mean age was 81 ± 9 years, male sex was present in 428 patients (59%), and STS predicted risk of mortality was 9.2 ± 6.2%. There were 107 deaths (15%) within 1 year of operation. Multivariable analysis identified increased risk of death with severe chronic lung disease (odds ratio [OR] 2.01; 95% confidence interval [CI] 1.23-3.29; P = 0.006), severe tricuspid valve regurgitation (OR 2.35; 95%CI 1.17-4.30; P = 0.017), vascular injury (OR 2.23; 95%CI 1.15-4.30; P = 0.017), and new-onset dialysis (OR 8.49; 95%CI 3.00-24.03; P < 0.001) (Area under the curve 0.687). When stratified by arterial access, there was increased risk of death following severe tricuspid valve regurgitation, vascular injury, or new-onset dialysis for transfemoral access and severe chronic lung disease or new-onset dialysis for alternative access. Patient characteristics and procedure-related complications are both significantly associated with increased risk of death within 1 year of TAVR. Patients with the baseline findings of severe chronic lung disease or severe tricuspid valve regurgitation may not experience mortality benefit from TAVR, and they should be assessed and counselled accordingly. Avoiding procedure-related complications is paramount to a good outcome. The findings have important implications for health care delivery services.

Beneficial effects of adaptive servo-ventilation therapy on readmission and medical costs in patients with chronic heart failure.

Adaptive servo-ventilation (ASV) therapy is a novel modality of noninvasive positive pressure ventilation and is now widely utilized to treat patients with chronic heart failure (CHF). However, there has been no clinical study of the effect of ASV therapy on readmission and cost-effectiveness for the treatment of CHF. The present study was conducted to evaluate the clinical efficacy and cost-effectiveness of home ASV therapy in 45 patients with a history of two or more admissions a year for worsening CHF. Seven patients refused to undergo chronic ASV therapy and three died. Thus, 35 patients were eventually enrolled in the present study. New York Heart Association class (2.8±0.4 versus 2.3±0.5, p<0.001), log plasma B-type natriuretic peptide level (2.53±0.44 versus 2.29±0.40pg/mL, p<0.0001), left atrial dimension (47.5±7.0 versus 44.9±7.6mm, p=0.014), and mitral regurgitation area ratio (20.3±12.1 versus 16.9±8.9%, p=0.007) decreased significantly after 12months of ASV therapy. The frequency of hospitalization after ASV was significantly lower than before ASV (1.0±1.0 versus 2.3±0.5times/year/patient, p<0.0001). ASV also decreased the duration of hospitalization from 64.4±46.5 to 22.8±27.5days/year/patient (p<0.0001). Consequently, the total medical costs were reduced by 37% after ASV (1.95±1.37 versus 3.11±1.75 million yen/patient, p=0.003). ASV therapy reduced readmissions and medical costs in patients with CHF.

Quantitative assessment of mitral apparatus in patients with acute myocardial infarction after percutaneous coronary intervention by real-time three-dimensional transthoracic echocardiography

Objective To assess the changes of structure and function of the moderate mitral valvular regurgitation before and after percutaneous coronary intervention (PCI) by real-time 3-dimensional transthoracic echocardiography(RT 3D-TTE). Methods Thirty-two patients with acute myocardial infarction(AMI) and moderate mitral regurgitation were enrolled in the study, while 30 healthy subjects were selected as the control group. All patients accepted RT 3D-TTE, the imaging was analyzed offline with TomTec 4D MV-Assessment software. The mitral valve structure and function parameters were measured. All AMI patients were performed RT 3D-TTE at 12 hours before PCI, 1 week and 3 months after PCI. According to whether improved at 3 months after PCI, patients with moderate mitral regurgitation were divided into two groups: improvement group and no improvement group. Results ①Compared with the control group, anterior-posterior(AP) diameter, anterolateral-posteromedial(AL-PM) diameter, annular circumference(AC), commissural diameter(CD), three-dimensional annular area(AA3D), tenting volume(TV), tenting height(TH), nonplanarity angle(NPA)of mitral regurgitation group were larger(P<0.05), annular height(AH)and maximum annular displacement(ADMax), and maximum annular displacement velocity(ADVMax) of mitral regurgitation group were smaller(P<0.05). ②At three months after PCI, 20 patients with moderate mitral regurgitation were improved(effective regurgitant orific area<0.2 cm2), twelve patients with moderate mitral regurgitation were not improved. Compared with mitral valve parameters before PCI and at one week after PCI, AP, AL-PM, AC, CD, AA3D, and TV in improvement group were discreased at three months after PCI(P<0.05), AH was increased (P<0.05). Compared with mitral valve parameters before PCI, mitral valve structure and function parameters after PCI were not improved, compared with those in no improvement group, AP, AL-PM, AC, CD, and AA3D in improvement group were smaller(P<0.05). ③By analysis of ROC curves AP, AL-PM, AC, and CD for diagnosing mitral regurgitation had good test effectiveness. Conclusions In patients with acute myocardial infarction and moderate mitral regurgitation, the mitral annular is not only presented as the size enlargement but also the flattening of its geometric shape and the decrease of its dynamic, while structure and function parameters of the mitral valve before PCI can predict improvement of mitral regurgitation and provide a reference for the development of clinical programs. Key words: Echocardiography, real-time three-dimensional; Myocardial infarction; Mitral valve insufficiency

Mitral Regurgitation in Dachshund Dogs without Heart Murmurs.

IntroductionOlder small breed dogs are considered at risk for heart failure secondary to chronic mitral valve disease. However, few data are available on the onset of this disease in such dogs. This study was performed to determine if auscultation alone can be used to eliminate clinically relevant mitral valve regurgitation seen in echocardiography in Dachshund dogs.Material and MethodsClinical and echocardiographic data were obtained from 107 dogs without heart murmurs.ResultsThe study revealed that 63.6% of the dogs had mitral regurgitation. Numbers increased with age and a larger percentage of male Dachshunds were affected than female Dachshunds. Mitral valve prolapse and thickening were mild, and the regurgitant area inextensive in most dogs.ConclusionsThe study shows that mitral valve regurgitation is prevalent (63.6%) in Dachshunds without heart murmurs. Typical lesions often become apparent during echocardiographic examinations in dogs under 5 years of age.

Does mitral valve repair matter in infants with ventricular septal defect combined with mitral regurgitation?

This study aimed to assess mitral valve function after repair of ventricular septal defect (VSD) combined with mitral regurgitation (MR) in the mid-term follow-up period, to evaluate the clinical utility of simultaneous mitral valve repair (MVR). From June 2005 to March 2014, 60 patients with VSD and MR underwent surgical treatment. After performing propensity score analysis (1:1) for the entire sample, 46 patients were selected and divided into 2 groups: those with VSD closure and MVR (VSD + MVR, 23 patients) and those with VSD closure without mitral valve intervention (VSD only, 23 patients). The follow-up period ranged from 12 to 48 months (median 32 months; interquartile range 28-40 months). There was no postoperative mortality in either group. There was no significant difference in the duration of the postoperative period between groups (ventilation time, P = 0.49; inotropic support, P = 0.50). Mean cardiopulmonary bypass time and aortic cross-clamping time were significantly longer in the 'VSD + MVR' group (cardiopulmonary bypass, P = 0.023; aortic cross-clamp, P < 0.001). There was no significant difference in regurgitation area (P = 0.30) and MR grade (P = 0.76) between groups postoperatively. There was no significant difference in freedom from MR ≥ 2+ between groups (log-rank test, P = 0.28). In the 'VSD + MVR' group, 12-, 36- and 42-month freedom from MR ≥ 2+ values were 100%, 59 ± 10.4% [95% confidence interval (CI) 36.1-76.2%] and 44 ± 15% (95% CI 15.8-69.7%), respectively, while in the 'VSD only' group, these values were 100%, 54.5 ± 10.6% (95% CI 32-72.3%) and 54.5 ± 10.6% (95% CI 30-72.3%), respectively. The only significant risk factor for recurrent MR ≥ 2+ during the follow-up period was mild residual MR in the early postoperative period (P = 0.037). In infants with VSD combined with MR, simultaneous MVR has no benefits simultaneous MVR provided no advantage over that of isolated VSD closure. We found that the presence of mild residual MR in the early postoperative period predisposes the development of MR ≥ 2+ in follow-up period.

Strategies for surgical treatment of ischemic mitral incompetence

Treatment of ischemic mitral incompetence (IMI) is an important problem in cardiovascular surgery, and it is arguing to the best strategies for surgical treatment of IMI. IMI can be quantitative assessment precisely by three-dimensional ultrasonic sound. Perioperative transesophageal echocardiography can acquire detailed information about IMI, but it is possible to underestimate the degree of IMI. The effective mitral regurgitation area at resting are the independently prognosis factor in patients with IMI. So it is necessary to sufficiently evaluate the patients before operation in order to predict the operative effect and risk. It is the choice for the best strategies for surgical treatment of IMI regarding to patients symptom, the degree of IMI, cardiac reconstruction. The therapy strategies should be weighed the operative risk and long-term benefit for moderate IMI, so that combining CABG with concomitant mitral surgery or not would be decided. It is arguing to mitral valve replacement or repair for surgical treatment of severe IMI. The surgical methods should be chosen carefully according to left ventricular remodeling and pathological changes of mitral valve. The effect of mitral valve repair is dependent on correctly perform. The suitable repair technique and plasty ring should be selected actively.

Reasearch on correlation between lung ultrasound findings of interstitial lung diseases and cardiac involvement

Objective To assess the relationship between lung ultrasonography and cardiac involvement (pulmonary artery systolic pressure, right ventricular function) in patients with interstitial lung diseases(ILD) by integrative cardiopulmonary ultrasound (also called thoracic ultrasound, TUS). Methods Seventy two patients with clinically diagnosed ILD were investigated at the Department of Respiratory Medicine in our hospital. The tranditional echocardiographic parameter included pulmonary arterial systolic pressure(PASP), tricuspid regurgitation area(ATR), main pulmonary artery diameter(DMPA), left pulmonary artery diameter (DLPA), right pulmonary artery diameter(DRPA), right ventricular outflow tract dimensions at the proximal or subvalvular level(DRVOT1), right ventricular outflow tract dimensions at the distal or pulmonic valve(DRVOT2), right ventricular basal diameter(RVTD), mid-right-ventricular diameter(RVDm), tricuspid annular plane systolic excursion(TAPSE), left ventricular ejection fraction (LVEF) and left ventricular end-diastolic diameter (LVEDd). Tissue Doppler parameters includpeak velocity of tricuspid annulus (S′, e′, a′) and myocardial performance index(MPI); Two-dimensional speckle tracking imaging(2D-STI) parameter was right ventricular global strain(RVGLS). The number of B lines and the performance of pleural line were evaluated by lung ultrasound.Statistical analysis was performed on the above TUS indexes. Results ①With the use of PASP higher than 36mmHg as the criterion for pulmonary hypertension(PH), all patients were divided into group ILDPH and group ILDNPH, comparison of TUS parameters in two groups, several parameters had statistical difference including ATR, RVD, RVDm, RPA, RVGLS, MPI, FAC, the number of B lines and the grade of pleural line. ②According to the degree of pleural involvement, all patients were divided into severe group and mild-moderate group, in the comparison of echocardiographic parameters, only ATR, RPA and RVGLS had statistic difference. ③A positive correlation was found between the number of B lines and PASP(r=0.547), a weak correlation was found between the grade of pleural line and PASP or RVGLS. ④A cut off more than 35 B lines had 95.8% sensitivity, 37.5% specificity in predicting elevated PASP(>36 mmHg), and the area under the ROC curve was 0.707. Conclusions TUS can effectively assess ILDs. With the disease progresess, the structure or function of right ventricular will gradually damaged.Lung ultrasound can not only evaluate the changes of lung in ILD, but also indirectly reflect PASP and the function of right ventricle, and it combined with echocardiography can provide more useful information for clinical diagnosis and management of ILDs. Key words: Integrative cardiopulmonary ultrasound; Interstitial lung diseases; Pulmonary hypertension; Ventricular function, right

Percutaneous coronary intervention for acute myocardial infarction with mitral regurgitation.

Ischemic mitral regurgitation (IMR) is a common complication of acute myocardial infarction (AMI). Current evidences suggest that revascularization of the culprit vessels with percutaneous coronary artery intervention (PCI) or coronary artery bypass grafting can be beneficial for relieving IMR. A 2.5-year follow-up data of a 61-year-old male patient with ST-segment elevation AMI complicated with IMR showed that mitral regurgitation area increased five days after PCI, and decreased to lower steady level three months after PCI. This finding suggest that three months after PCI might be a suitable time point for evaluating the possibility of IMR recovery and the necessity of surgical intervention of the mitral valve for AMI patient.

Surgery for mitral regurgitation in patients with aortic root aneurysm: Transaortic or transseptal approach?

ObjectiveMitral regurgitation is common in patients with aortic root aneurysm. Mitral valve repair (MVP) or replacement (MVR) can be performed for these patients through either a transverse aortotomy (TA) or transseptal approach (TS). This study sought to compare the early outcomes of mitral valve surgery through the TA and TS approaches and decide which is optimal for this subset of patients. MethodsBetween March 2013 and April 2015, we operated on 99 patients (81 males, 81.8%) with aortic root aneurysm who developed mitral regurgitation. Mean age was 47.8±16.5years. MVR was performed in 66 patients (TAR=27; TSR=39) and MVP in 33 (TAP=8; TSP=25). The baseline and operative outcomes data were compared between patients with MVR and MVP through the TA vs TS approaches. ResultsPreoperatively, the mitral regurgitation area was significantly larger in the MVR than MVP groups (8.9±2.0 vs 7.8±3.8 cm2, p=0.0009), and in the TSP vs TAP groups (8.5±4.1 vs 5.6±1.3cm2, p=0.0049), but no significant difference was found between the TAR and TSR groups (8.7±2.2 vs 9.0±1.8cm2, p=0.4681); the aortic sinus size was significantly larger in the TAR than TSR group (66.7±15.8 vs 52.1±8.8mm, p=0.0061). Subvalvular structure was preserved in 12 MVR patients (18.2%). In MVP patients, Kay annuloplasty was used in 11 (33.3%) and annuloplastic ring in 22 (66.7%). The times of cardiopulmonary bypass (CPB) and cross-clamp in patients with TA approach were significantly shorter compared to those with the TS approach (139±34 vs 176±38min, p=0.0001; 101±26 vs 129±31min, p=0.0002). No cases of mortality, stroke and renal failure occurred in the whole series. The amount of transfusion, lengths of ICU and hospital stay did not differ between patients with MVR and MVP, and between the TA and TS approaches. ConclusionsBoth the TA and TS approaches achieved good early outcomes in MV surgery for patients with root aneurysm. The transverse aortotomy was associated with shorter CPB and cross-clamp times. Surgical approaches should be selected according to the underlying mitral valve etiology and the size of the aortic root.