Moderate-severe Regurgitation Research Articles

Predictors of functional mitral regurgitation improvement in patients with left bundle branch block treated with left bundle branch area pacing.

Functional mitral regurgitation (FMR) and its severity are associated with adverse outcomes in heart failure patients. This study aims to analyze the predictors of FMR improvement after successful left bundle branch area pacing (LBBAP) in patients with LVEF<50% and complete left bundle branch block (CLBBB). Consecutive patients with LVEF<50% and CLBBB who underwent successful LBBAP from July 2018 to July 2023 were retrospectively identified. Significant MR was defined as regurgitation of moderate severity or greater. Patients with significant FMR were included in the analysis. FMR improvement (FMRI) was defined as a reduction of at least one grade in regurgitation severity compared to baseline at 3 months or longer follow-up. Among the 81 identified patients, 42 patients with significant FMR preoperatively were included. After LBBAP, QRS duration significantly shortened from 170.6±18.8ms to 114.5±20.2ms (p<.001). Significant FMR improves in approximately 76.2%, and the patients were divided into an FMRI group (n=32) and a non-FMRI group (n=10). Univariate analysis showed that absence of persistent atrial fibrillation, typical CLBBB, and left atrium diameter at baseline were associated with improvement of FMR after LBBAP. Of these variables, only absence of persistent atrial fibrillation remains an independent predictor in the multivariate model (OR 12.436, p=.009). LBBAP is able to improve FMR in heart failure patients who had CLBBB with LVEF<50%. Meanwhile, the absence of persistent atrial fibrillation is an independent predictor of FMR improvement.

892 ELECTRICAL STORM IN ISCHAEMIC HEART DISEASE: A CASE OF LEFT STELLATE GANGLION BLOCK AS BRIDGE TO URGENT PCI RESCUE

Abstract A 73 year-old man was admitted for syncope and sustained ventricular arrhythmia complicated by cardiogenic shock treated with electrical cardioversion and restoration of sinus rhythm. Former smoker, he suffered by arterial hypertension, hypercholesterolemia and known heart failure with reduced ejection fraction. In the 1995 the patient underwent aortic valve replacement surgery with a mechanical prosthetic valve. The patient underwent coronary angiography that showed multivessel coronary artery disease with functional occlusion of posterior interventricular artery (rehabilitated by hetero-coronary circles) and critical stenosis of the middle left anterior descending artery. In this angiographic framework, the indication was collegial revaluation considering other patient's comorbidities (chronic renal dysfunction, mitral moderate-severe regurgitation). The patient underwent ICD implantation for secondary prevention. Despite maximal medical therapy, the patient experienced new episodes of sustained VT complicated by hemodynamic instability. Hypokalemia, hypomagnesemia and hyperthyroidism were excluded as triggering factors for arrhythmias on laboratory investigations. In the following days due to persistent and symptomatic arrhythmias, configuring electrical storm, we decided to proceed with anatomical stellate ganglion block, guarantying a free interval from ventricular arrhythmia about six hours. The anesthetic has been injected at the C6 or C7 vertebral level with the Chassignac's tubercle, the cricoid cartilage, and the carotid artery serving as the anatomic landmarks to the procedure. An aspiration test must be done to avoid the suction of blood or cerebrospinal fluid, then a local anesthetic is injected, and the diffusion of the injectate is seen in real-time. Local anesthetic (lidocaine mixed with bupivacaine) is injected until the fluid spread along the paravertebral fascia to the stellate ganglion. The period free from VA allowed us to transfer the patient in another center in order to receive myocardial revascularization supported by ECMO. Left ganglion stellate block has a central role in the treatment of the refractory ventricular arrhythmias and may offer effective arrhythmia control giving time to rescue and/or other bridge therapy. In our case, it had a key role to perform an inter-hospital transfer and subsequent “rescue PCI therapy”. Thanks to Stellate ganglion block, the sinus rhythm was retained immediately, there were no ventricular tachycardia episodes for at least six hours allowing to perform myocardial revascularization supported by ECMO. No further ventricular arrhythmias occurred after revascularization, corroborating the ischemic trigger of electrical storm.

467 Update on supra-annular sizing of transcatheter aortic valve prostheses in raphe-type bicuspid aortic valve disease according to the LIRA method

Abstract Aims Transcatheter Aortic Valve Replacement (TAVR) in patients with bicuspid aortic valve (BAV) still represents a challenge due to the peculiar anatomy and the lack of consensus for the optimal CT scan sizing method for prosthesis selection. Recent evidences have shown that transcatheter heart valve (THV) anchoring in BAV patients might occur at the raphe-level, known as the LIRA (Level of Implantation at the RAphe) plane. Furthermore, a novel supra-annular sizing method based on the measurement of the perimeter at the raphe-level (LIRA-method) was shown to be safe and effective in 20 consecutive BAV patients with severe aortic stenosis. The purpose of this study was to confirm the safety and the efficacy of the LIRA method in a larger study population. Methods and results the LIRA plane method was applied to all consecutive patients with raphe-type BAV disease between November 2018 to September 2021 in our centre. We prospectively sized TAVI prosthesis according to the manufacture recommendations on the basis of baseline CT scan perimeters at the LIRA plane. Post-procedural device success, defined according to Valve Academic Research Consortium-2 (VARC-2) criteria, was evaluated in the overall cohort. Forty-four patients were identified as having a raphe-type BAV disease at pre-TAVI CT scans. Mean patient age was 80 ± 6.2 years and 74% were males; median Society of Thoracic Surgeons (STS) predicted risk of mortality score was 4.3 (3.0–6.5). Three different BAV anatomies (36 patients with BAV type 1 with calcific raphe, 5 patients with BAV type 1 with fibrotic raphe, and 3 patients with BAV type 2) were implanted with different types of TAVI prostheses (6 Acurate Neo 2,16 Acurate Neo, 21 Core Valve Evolut R/Pro , 1 Lotus) sized prospectively according to the LIRA plane method. In all patients, there was a significant discrepancy between LIRA and virtual basal ring (VBR) measurements with LIRA plane perimeter smaller than VBR perimeter (mean perimeter LIRA 73.1 ± 8.3 mm vs. mean perimeter VBR 81.5 ± 6.6 mm; P &amp;lt; 0.001). The prostheses were sized according to the manufacture recommendations on the basis of the LIRA plane perimeter (diameter prosthesis implanted/diameter prosthesis according to LIRA plane = 1) (DPI/DP LIRA = 1) and significantly downsized according to the VBR perimeter (DPI/DP VBR 0.89; P &amp;lt; 0.001). The median prosthesis size was 25 mm (23–27). Pre-dilatation was frequently performed (86%) with a median balloon size of 20 mm (18–22), whereas post-dilatation was applied in 27% of the cases with a median balloon size of 23 mm (20–26). The LIRA plane method appeared to be highly successful (100% VARC-2 device success) with no procedural mortality, no valve migration, residual trivial/mild paravalvular leak with no cases of moderate-severe regurgitation and low transprosthetic gradient (residual mean gradient of 8.3 ± 3.5 mmHg) with no cases of mean gradient &amp;gt;20 mmHg pre-discharge. The rate of new pacemaker implantation was 9%. Conclusions Supra-annular sizing according to the LIRA plane method confirmed to be safe with a high device success in a larger study population. The application of the LIRA plane method might optimize TAVI prosthesis sizing in patients with raphe-type BAV disease.

Case report: Buddy wire technique to facilitate atrial septal crossing during transcatheter transseptal mitral valve implantation.

BackgroundTranscatheter mitral valve-in-valve implantation (MVIV) has emerged as a viable treatment option in patients at high risk for surgery. Occasionally, despite appropriate puncture location and adequate dilation, difficulty is encountered in advancing the transcatheter heart valve across interatrial septum.Case summaryWe describe a case of a 79-year-old woman with severe chronic obstructive pulmonary disease (COPD), prior surgical bioprosthetic aortic and mitral valve replacement implanted in 2007, atrial fibrillation, and Group II pulmonary hypertension who presented with progressively worsening heart failure symptoms secondary to severe bioprosthetic mitral valve stenosis and moderate-severe mitral regurgitation. Her symptoms had worsened over several months, with multiple admissions at other institutions with treatment for both COPD exacerbation and heart failure. Transoesophageal echocardiogram demonstrated preserved ejection fraction, normal functioning aortic valve, and dysfunctional mitral prosthesis with severe stenosis (mean gradient 13 mmHg) and moderate-severe regurgitation. After a multi-disciplinary heart team discussion, the patient underwent a transcatheter MVIV implantation. During the case, inability in advancing the transcatheter heart valve (THV) across interatrial septum despite adequate septal balloon pre-dilation was successfully managed with the support of a stiff ‘buddy wire’ anchored in the left upper pulmonary vein using the same septal puncture. The patient tolerated the procedure well and was discharged home.DiscussionOperators should be aware of potential strategies to advance the THV when difficulty is encountered in crossing the atrial septum despite adequate septal preparation. One such strategy is the use of stiff ‘buddy wire’ for support which avoids the need for more aggressive septal dilatation.

Coronary artery bypass grafting surgery in left ventricular dysfunction patients complicated with mitral regurgitation

Objective: To evaluate the efficacy of coronary artery bypass grafting (CABG) surgery in left ventricular dysfunction patients complicated with different degrees of ischemic mitral regurgitation (IMR). Methods: The clinical data of 525 patients (428 males and 97 females) undergoing CABG in Fuwai Hospital Chinese Academy of Medical Sciences Shenzhen, and Tianjin Medical University General Hospital between January 2015 and December 2018 were collected. The average age was (61±7) years old. Among them, the patients with moderate to serve IMR and left ventricular ejection fraction(LVEF)≤40% were further selected, and the outcomes of CABG were analyzed. Results: In total, 67 patients (48 males and 19 females) with moderate to severe IMR and LVEF≤40% were enrolled, among which 52 patients had moderate IMR, with a LVEF of 38%(35%, 40%). Transesophageal echocardiography (TEE) of 52 cases displayed no damage of papillary muscles, and ventricular wall motion was improved after CABG. Therefore, no treatment on the mitral valve was performed in this group. Six patients were with moderate-severe mitral insufficiency, with a LVEF of 38%(35%, 39%). After surgery, TEE found that the ventricular wall motion and regurgitation were improved, and the mitral valve structures were well. Thus, mitral valves were not treated in these patients. Nine patients were with severe mitral regurgitation, with a LVEF of 38%(35%, 39%). Two of them received valve repair because the papillary muscle function and the ring were well. Another 7 patients received valve replacements because the valve ring was dilatated and the leaflet was prolapsed. All patients recovered well. The LVEF increased significantly at 6 months after surgery [47%(45%, 48%) vs 38%(35%, 39%), P=0.024], and the left ventricular end diastolic diameter also became smaller [57(56, 59) mm vs 61(59, 64) mm, P=0.002]. Conclusions: For patients suffered from left ventricular dysfunction complicated with IMR, TEE is crucial to evaluate the valve function. To those with moderate-severe regurgitation, if papillary muscle function and the ring were seriously affected by ischemia, the valve replacement could facilitate the improvement of postoperative cardiac function.

Retrospective analysis of tricuspid valve repair using a novel surgical technique: A 7-year single-surgeon experience.

Objectives:Tricuspid annuloplasty is the optimal surgical repair technique for tricuspid regurgitation which improves mortality and morbidity. Ring annuloplasties is the techniques of choice. Here, we evaluate the efficacy and durability of a new method of interrupted pledgeted suture annuloplasty.Methods:Between 2011 and 2018, 39 eligible patients underwent tricuspid valve repair using this novel technique. Indication for repair was a grade of regurgitation at moderate or greater, or an annular diameter >40 mm. Patients were assessed both preoperatively and postoperatively by echocardiogram. Follow-up results were split into the first postoperative echocardiogram and most recent postoperative echocardiogram undertaken.Results:There were two in-hospital mortalities and two patients required permanent pacemaker implantation following surgery. At the time of the first postoperative echocardiogram undertaken (median 3 months postoperatively), freedom from moderate-severe regurgitation was 92.3%. At the time of the most recent postoperative echocardiogram undertaken (median 11 months postoperatively); none or mild regurgitation was detected in 24 patients (61.5%), mild-moderate in 11 (28.2%) and moderate-severe in 4 (10.3%) patients. Freedom from moderate-severe regurgitation was 89.7%. Postoperative grade of regurgitation was significantly reduced from preoperative grades (p < 0.001).Conclusion:Initial and midterm results of our technique show a good durability of repair. We have demonstrated recurrence rates of regurgitation equal and superior to current forms of suture annuloplasty published in the literature. This novel method of suture annuloplasty can be considered in the surgical repertoire of tricuspid valve repair techniques.

Efficacy and Safety of AlbisD Compared With Omeprazole 20 mg in Patients With Non-erosive Reflux Disease: A Randomized, Open-label, Active-controlled, Pilot Study

Background/AimsProton pump inhibitors (PPIs) are frequently used to treat non-erosive reflux disease (NERD), but their effect is limited. It is not known whether a potential alternative, AlbisD, containing ranitidine hydrochloride, sucralfate hydrate, and tripotassium dicitrato bismuthate, is effective and safe in treating NERD. The aim of the study is to evaluate the efficacy and safety of AlbisD compared with omperazole in patients with NERD.MethodsThis was a multicenter, randomized, open-label, parallel-group, non-inferiority comparative study. A total of 126 patients with NERD were randomly allocated to either AlbisD twice daily or omeprazole 20 mg once daily for 4 weeks from February 2016 to August 2016. The study patients had histories of heartburn or regurgitation of moderate severity (> score 2) and a frequency of at least 2 episodes per week, and had no mucosal breaks of the esophagus on endoscopy. The primary efficacy variable was complete cure of heartburn at week 4. Secondary efficacy variables evaluating symptoms of heartburn and acid reflux as well as safety profiles were compared in the 2 groups at week 2 and 4 after treatment.ResultsA total of 113 patients completed the study (57 and 56 in AlbisD and omeprazole groups, respectively). The proportion of patients with complete cure of heartburn at week 4 was not significantly different between the AlbisD and omeprazole groups (35.1% vs 32.1% respectively, P = 0.740). There were no significant differences between the 2 groups in the any secondary variables including proportions of days without heartburn or acid reflux over 4 weeks (including daytime and nighttime). Adverse events were similarly reported in the 2 groups (7 [12.3%] vs 6 [10.7%]), and there were no serious adverse events.ConclusionsThe efficacy and safety of AlibsD in treating NERD patients are not inferior to those of omeprazole. Therefore, AlbisD can be an alternative to PPIs for NERD.

RF57 OUTCOMES OF DIFFERENT REPAIR TECHNIQUES FOR FUNCTIONAL TRICUSPID VALVE REGURGITATION IN ADULT WITH CONGENITAL HEART DISEASE

Objectives and aim: Functional tricuspid valve (TV) regurgitation frequently affects adult with congenital heart disease (ACHD).The aim of our study was to analyze which surgical repair (suture plasty vs. ring plasty) offers the best post-operative and medium-term TV competence in ACHD. Methods: Retrospective study of ACHD patients that underwent TV repair at our institution (01/2000-12/2016). Patient's chart were reviewed to collect pre, post-operative and follow-up data. We compared efficacy of ring plasty with suture plasty in terms of early and medium-term regurgitation degree. Results: 95 patients had functional TV regurgitation and underwent surgery. Median age was 41.2 years (IQR:29.8-55.6 years). Pre-operative TV regurgitation: mild (n = 6), moderate (n = 42), severe (n = 47). Surgical procedure were suture plasty (n = 53), ring anuloplasty (n = 34) and in 8 it was replaced. Median hospital stay was 12 days (IQR:8-18), 2 hospital deaths (2.1%). At discharge 13.2% of the suture plasty and 11.8% of the ring anuloplasty had moderate TV regurgitation, no one had severe. After a median follow-up of 4.6 years (IQR:1.4-8.9) there were 6 late deaths giving 89% survival (95%CI:79%-94%) at 5-10 years. No tricuspid valve reoperation were performed. On follow-up echocardiographic was available in 69 patients. Suture repair present a significantly higher incidence of moderate-severe regurgitation (Figure 1) compared to the ring anuloplasty (55%vs.27.6%,p = 0.023). Conclusions: Suture plasty and ring anuloplasty have comparable early postoperative results in terms of restoring valve competence. The use of prosthetic rings should be preferred to support the TV because it provides a significantly lower occurrence relevant regurgitation in the medium term.

A Rare Case of Corynebacterium Endocarditis

A 26-year-old gentleman presented with a 1-month history of fevers, malaise and weight loss. He was born in China and had moved to Australia during his childhood. He was appropriately vaccinated. There was no history of recent dental procedures or illicit drug use. On examination, the temperature was 39 °C. Heart rate, blood pressure and oxygen saturations were normal. There was a pan-systolic murmur over the apex. There were small, non-tender, erythematous macules over both palms consistent with Janeway lesions. Neurological examination was unremarkable. Blood tests revealed raised inflammatory markers (C-reactive protein 87 mg/L). Four separate sets of blood cultures at admission isolated Corynebacterium pseudodiphtheriticum, sensitive to penicillin. Urgent transthoracic echocardiography revealed a large vegetation (11 × 9 mm) attached to the anterior mitral leaflet with associated moderate-severe regurgitation. Left ventricular function was preserved. The patient was commenced on empirical therapy for endocarditis, subsequently rationalised to intravenous benzylpenicillin. Embolic workup revealed multiple cerebral lesions suspicious for mycotic aneurysms and a small subacute infarction in the right frontal lobe. He underwent mechanical mitral valve replacement after 2 weeks of intravenous antibiotic therapy. Valve tissue and subsequent blood cultures were negative and the patient was discharged home following a 6-week admission.

Transcatheter aortic valve implantation for mixed versus pure stenotic aortic valve disease.

In addition to patients with pure/predominant aortic stenosis (PAS), real-world transcatheter aortic valve implantation (TAVI) referrals include patients with mixed aortic valve disease (MAVD; severe stenosis+moderate-severe regurgitation). We sought to compare TAVI outcomes in patients with MAVD vs. PAS. Out of 793 consecutive patients undergoing TAVI, 106 (13.4%) had MAVD. Patients with MAVD were younger and had a higher operative risk, a more severe adverse cardiac remodelling, and a worse functional status than patients with PAS. Moderate-severe prosthetic valve regurgitation (PVR) was significantly more frequent in patients with MAVD than in patients with PAS (15.7% vs. 3.6%, p=0.003), even after propensity-score and multivariable adjustments. Moderate-severe PVR was associated with increased one-year mortality in patients with PAS (log-rank p=0.002), but not in patients with MAVD (log-rank p=0.27). Eventually, all-cause and cardiac mortality as well as the functional capacity were similar in the two study groups up to one year. A significant proportion of patients referred for TAVI in a real-world registry has MAVD. Moderate-severe AR at baseline can influence the rate and modify the clinical sequelae of post-TAVI PVR. Eventually, clinical outcomes in patients with MAVD are comparable to those in patients with PAS in the acute and midterm phases, in spite of a baseline higher risk. MAVD should not be considered a contraindication for TAVI.

Issue Highlights

Issue Highlights

A case of biatrial mass mimicking myxoma with rheumatic mitral stenosis with regurgitation of moderate severity

Atrial masses are uncommon and mainly consist of tumours, thrombus and vegetation.1 Cardiac myxoma is the most common type of benign cardiac tumour and accounts for 30–50% of all primary tumours of the heart.2 Most of them occur in the left atrium, but the occurrence of biatrial mass/myxoma or concomitant left atrial mass with rheumatic valvular disease is uncommon. We describe a case of biatrial mass mimicking myxoma with rheumatic mitral stenosis. A 40-year-old woman presented with exertional dyspnoea and palpitation was diagnosed to have biatrial mass with rheumatic mitral stenosis and underwent a successful biatrial mass excision and valve replacement.

Incomplete isolated cleft of the anterior mitral valve: first reported as triangular defect

A 16-year-old girl with a 12 year history of systolic murmur at the apex presented with mitral regurgitation. Two-dimensional echocardiography in the parasternal long-axis view showed the part of the anterior mitral valve (AMV) which near the root was thin without echo drop-out ( Panel A , arrowhead). The parasternal short-axis view showed a cleft on AMV ( Panel B , arrowhead) and moderate-severe regurgitation through the …

Fate of mild aortic valve disease after mitral valve intervention

Objective: This study was performed to assess the long-term outcome of untreated mild aortic valve disease present at the time of initial mitral valve intervention. Methods: A total of 284 patients with rheumatic heart disease aged 7 to 62 years (mean, 23.5 ± 12.2 years) who underwent mitral valve intervention and had mild aortic valve disease initially were followed up for 2 to 18 years (mean, 10.8 ± 3.7 years). At initial intervention, 232 patients had pure mild aortic regurgitation, and 52 patients had mild aortic stenosis with or without aortic regurgitation. Results: Among patients with mild aortic regurgitation initially, 11 (5%) patients progressed to moderate (n = 6) or severe (n = 5) regurgitation over an interval of 9 to 17 years (mean, 12.1 ± 2.8 years), and 1 patient had moderate aortic stenosis and severe aortic regurgitation after 10 years. Freedom from development of moderate-severe aortic valve disease in patients who initially had mild aortic regurgitation was 100%, 97.0% ± 1.7%, and 87.4% ± 4.6% at 5, 10, and 15 years, respectively. Seventeen (35%) patients with initial mild aortic stenosis (with or without regurgitation) had moderate or severe stenosis (with or without moderate-severe regurgitation) after an interval of 4.9 ± 3.8 years. Freedom from development of moderate-severe aortic valve disease in patients who initially had mild aortic stenosis was 75.6% ± 6.2%, 61.5% ± 8.5%, and 46.1% ± 11.2% at 5, 10, and 15 years, respectively. Ten patients required aortic valve replacement for aortic valve dysfunction. Conclusions: Mild aortic regurgitation present at the time of mitral valve intervention progresses very slowly and less frequently requires reintervention. However, mild aortic stenosis diagnosed initially progresses more often and more rapidly and thus needs closer follow-up.