Rheumatic Mitral Disease Research Articles

Robotic Mitral Valve Replacement for Severe Rheumatic Mitral Disease; Perioperative Technique, Outcomes and Early Results

OP-069 We report a case series of robotic mitral valve replacement in patients with severe rheumatic mitral disease. From March 2010 to May 2013, a total of 61 patients underwent robotic cardiac procedures. Robotic procedures were performed using the da Vinci Si surgical systems (Intuitive

Extreme Right and Left Atrial Enlargement in a Patient With Rheumatic Valvular Disease and Mitral Mechanical Prosthesis

A 75-year-old woman was admitted to the emergency room because of increasing edema. She had previously been diagnosed with rheumatic mitral disease, which required surgery with implantation of a mechanical prosthesis in 2001. At that time, pulmonary hypertension was present, and during the follow-up, she developed severe tricuspid regurgitation. A single-chamber …

Comparison between Circulating Endothelial Cells and Platelet Microparticles Levels in Egyptians Rheumatic Mitral Diseases with and without Atrial Fibrillation

Comparison between Circulating Endothelial Cells and Platelet Microparticles Levels in Egyptians Rheumatic Mitral Diseases with and without Atrial Fibrillation

The expression and molecular mechanism of M1 macrophages in rheumatic valvular disease

To investigate whether valvular expression of macrophage and its subsets and correlative cytokines of mitral valve are altered in patients with rheumatic valvular disease. The mitral valvular leaflets of 15 rheumatic valvular disease patients were included as the test group, and 7 patients of terminal stage cardiomyopathy as the control. The immunostain of CD68, inducible nitric oxide synthase (iNOS) and CD163 were applied to mark the total macrophages, M1 and M2, respectively. The expression of endothelial nitric oxide synthase (eNOS), IL-10, Arg-1, macrophage-colony stimulating factor (M-CSF) were compared respectively in two groups. The angiogenesis was enormous in the test, whereas the cell proliferation was scanty. Compared with the control, CD68 positive macrophages were markly expressed in the test (4.2 ± 2.0 vs. 3.2 ± 2.3; Z = -3.981, P = 0.000), also the iNOS positive M1 subsets (3.4 ± 1.7 vs. 1.2 ± 1.0; Z = -4.015, P = 0.000). The expression level of CD163 positive macrophages was lower in the test (1.2 ± 1.0 vs. 2.3 ± 1.8; Z = -8.602, P = 0.000). The expression of eNOS was higher in the rheumatic valve disease (4.9 ± 1.1 vs. 1.8 ± 1.1), but the expression levels of Arg-1 (1.0 ± 1.0 vs. 3.3 ± 1.3) and IL-10 (2.1 ± 1.2 vs. 4.9 ± 1.4) were lower (Z = -8.867 to -5.344, P = 0.000). The expression of M-CSF was lower in test (2.0 ± 1.4 vs. 4.3 ± 0.9; Z = -2.741, P = 0.006). The infiltration of M1 macrophages plays an important role in the progression of rheumatic mitral valve disease. It fulfills the pro-inflammation by up-regulating the expression of eNOS. Inversely, it suppresses the expression of IL-10, Arg-1 to relieve the inflammatory action. In according with the down-regulated level of M-CSF, the polarization from M1 macrophages into M2 is depressed, and the inflammation induced by M1 is sustained.

The Global Challenge of Pulmonary Vascular Diseases and its Forgotten Impact in the Developing World

The Global Challenge of Pulmonary Vascular Diseases and its Forgotten Impact in the Developing World

Papillary muscle stump mimicking a left ventricular mass after mitral valve replacement with partial chordal preservation

Background: Maintaining continuity between the mitral valve and the subvalvular apparatus during mitral valve replacement (MVR) maximizes the left ventricular (LV) function and increases the survival rate. However, MVR potentially cause rupture of the papillary muscles, systemic embolization, or dehiscence of the mitral annulus from the transposed position. Objective: We presented a case with severe rheumatic mitral valve disease treated with MVR and partial preservation of the posterior and anterior chordae tendineae. Methods: Retrospectively review of medical records. Results: Transthoracic echocardiography performed two weeks after surgery revealed a floating mass in the posterior inferior aspect of the left atrium and a lobulated mass joining the tip of the posterior papillary muscle in the left ventricle. Perioperative examination confirmed a large thrombus in the left atrium and the stump of the preserved posterior papillary muscle of the mitral valve. Conclusion: Thus, the papillary muscle could present itself as an abnormal mass on echocardiography, resulting in misdiagnosing. Keywords: Intracardiac mass, mitral valve replacement, papillary muscle

Tricuspid leaflet augmentation with an autologous pericardial patch for recurrent severe tricuspid regurgitation that occurred after suture annuloplasty

We, herein, report the use of tricuspid leaflet augmentation with an autologous pericardial patch to treat a patient with severe tricuspid regurgitation (TR) that occurred after suture annuloplasty. The patient underwent mitral valve replacement for rheumatic mitral disease and tricuspid suture annuloplasty for moderate TR 23years ago. She developed right-sided heart failure associated with severe TR. Leaflet augmentation with an autologous pericardial patch and ring annuloplasty were applied at redo surgery. Postoperative echocardiography showed trivial TR with significant improvement of the patient's symptoms. We have now performed this technique on three cases of severe recurrent TR that occurred after suture annuloplasty, and excellent early results were obtained in each case.

Antithrombotic and Thrombolytic Therapy for Valvular Disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines

Antithrombotic therapy in valvular disease is important to mitigate thromboembolism, but the hemorrhagic risk imposed must be considered. The methods of this guideline follow those described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement. In rheumatic mitral disease, we recommend vitamin K antagonist (VKA) therapy when the left atrial diameter is > 55 mm (Grade 2C) or when complicated by left atrial thrombus (Grade 1A). In candidates for percutaneous mitral valvotomy with left atrial thrombus, we recommend VKA therapy until thrombus resolution, and we recommend abandoning valvotomy if the thrombus fails to resolve (Grade 1A). In patients with patent foramen ovale (PFO) and stroke or transient ischemic attack, we recommend initial aspirin therapy (Grade 1B) and suggest substitution of VKA if recurrence (Grade 2C). In patients with cryptogenic stroke and DVT and a PFO, we recommend VKA therapy for 3 months (Grade 1B) and consideration of PFO closure (Grade 2C). We recommend against the use of anticoagulant (Grade 1C) and antiplatelet therapy (Grade 1B) for native valve endocarditis. We suggest holding VKA therapy until the patient is stabilized without neurologic complications for infective endocarditis of a prosthetic valve (Grade 2C). In the first 3 months after bioprosthetic valve implantation, we recommend aspirin for aortic valves (Grade 2C), the addition of clopidogrel to aspirin if the aortic valve is transcatheter (Grade 2C), and VKA therapy with a target international normalized ratio (INR) of 2.5 for mitral valves (Grade 2C). After 3 months, we suggest aspirin therapy (Grade 2C). We recommend early bridging of mechanical valve patients to VKA therapy with unfractionated heparin (DVT dosing) or low-molecular-weight heparin (Grade 2C). We recommend long-term VKA therapy for all mechanical valves (Grade 1B): target INR 2.5 for aortic (Grade 1B) and 3.0 for mitral or double valve (Grade 2C). In patients with mechanical valves at low bleeding risk, we suggest the addition of low-dose aspirin (50-100 mg/d) (Grade 1B). In valve repair patients, we suggest aspirin therapy (Grade 2C). In patients with thrombosed prosthetic valve, we recommend fibrinolysis for right-sided valves and left-sided valves with thrombus area < 0.8 cm(2) (Grade 2C). For patients with left-sided prosthetic valve thrombosis and thrombus area ≥ 0.8 cm(2), we recommend early surgery (Grade 2C). These antithrombotic guidelines provide recommendations based on the optimal balance of thrombotic and hemorrhagic risk.

Mild-to-moderate functional tricuspid regurgitation in patients undergoing valve replacement for rheumatic mitral disease: the influence of tricuspid valve repair on clinical and echocardiographic outcomes

BackgroundThe decision to repair mild-to-moderate functional tricuspid regurgitation (TR) during left-side heart surgery remains controversial.ObjectivesTo avoid heterogeneity in patient population, patients with TR undergoing isolated mechanical mitral valve (MV) replacement...

RESPIRATORY FUNCTION IN PATIENTS WITH RHEUMATIC HEART DISEASE COMPLICATED WITH PULMONARY HYPERTENSION

Aim. To evaluate the changes of respiratory function in patients with rheumatic heart disease (RHD) complicated with pulmonary hypertension (PH) by the spirographic investigation. Materials and methods. Patients (n=56; 4 men and 52 women; aged 63,25±7,93) with rheumatic combined mitral and aortic valvular disease were examined. Medical history analysis, physical examination, general clinical investigation including ECG, chest X-ray, 2D-echocardiography and spirography were performed. Results. 36% of the patients had normal pulmonary arterial systolic pressure (PASP) (&lt;30 mm Hg), 48% had PH of degree I and 16% - PH of degree II. Restrictive changes of spirogram were found in 27% of patients: in 30% of patients with PH of degree I, in 44% of patients with PH of degree II and in 5% of patients with no PH. Bronchoobstruction was detected in no one patient. Pulmonary restriction significantly (p&lt;0,05) correlated with PH, but no significant difference was found between groups with PH of I and II degree. No any association between PASP, spirogram changes and type of valvular lesion was revealed. Conclusion. Patients with RHD complicated with PH have pulmonary restrictive changes according to spirographic investigation.

Acute Occlusion of a Bileaflet Mechanical Mitral Valve Prosthesis Resulting from External Cardiac Compression

A 45-year-old woman with a history of rheumatic mitral disease underwent valve replacement. After surgery, the patient became hemodynamically unstable. A transesophageal echocardiogram showed an underfilled left ventricle with a clot impinging on the lateral aspect of the left ventricle and a malfunctioning mitral valve prosthesis. After evacuation of the clot in the operating room, the mitral valve prosthesis began functioning normally. The prosthesis malfunction resulted from external cardiac compression. This dynamic device malfunction was replicated when the surgeon compressed the lateral aspect of the heart. To our knowledge, this dynamic form of leaflet dysfunction from external compression has not been described. This case highlights the importance of closely evaluating prosthetic valve function in the setting of hemodynamic deterioration.

Atrial fibrillation in Africa: clinical characteristics, prognosis, and adherence to guidelines in Cameroon

The purpose of this prospective study was to characterize the clinical profile of patients with atrial fibrillation (AF) in the urban population of a sub-Saharan African country and to assess how successfully current guidelines are applied in that context. This prospective study involved 10 cardiologists in Cameroon. Enrolment started on 1 June 2006 and ended on 30 June 2007. Consecutive patients were included if they were >18 years and AF was documented on an ECG during the index office visit. In this survey, 172 patients were enrolled (75 males and 97 females; mean age 65.8 +/- 13 years). The prevalence of paroxysmal, persistent, and permanent AF was 22.7, 21.5, and 55.8%, respectively. Underlying cardiac disorders, present in 156/172 patients (90.7%), included hypertensive heart disease (47.7%), valvular heart disease (25.6%), dilated cardiomyopathy (15.7%), and coronary artery disease (6%). A rate-control strategy was chosen in 83.7% of patients (144 of 172) and drugs most commonly used were digoxin and amiodarone. The mean CHADS(2) score was 1.9 +/- 1.1 and 158 of 172 patients (91.9%) had a CHADS(2) score > or =1. Among patients with an indication for oral anticoagulation (OAC), only 34.2% (54 of 158) actually received it. During a follow-up of 318 +/- 124 days, 26 of 88 patients died (29.5%), essentially from a cardiovascular cause (15 of 26). Ten patients (16.1%) had a non-lethal embolic stroke and 23 (26.1%) had symptoms of severe congestive heart failure. Clinical presentation of AF in Cameroon is much more severe than in developed countries. A rate-control strategy is predominant in Cameroon and OAC is prescribed in only 34.2% of eligible patients, despite a high CHADS(2) score at inclusion. Death and stroke rate at 1 year are very high in Cameroon possibly because of a lower use of OAC, and a higher prevalence of rheumatic mitral disease and of more severe co-morbidities.

328 Early postoperative results of De Vega tricuspid annuloplasty for tricuspid regurgitation in rheumatic Mitral disease

Tricuspid regurgitation (TR) in patients with mitral valve (MV) disease is associated with poor outcome and predicts poor survival, heart failure, and reduced functional capacity. We review our early results in patients who required surgical correction of tricuspid valve disease with concomitant rheumatic disease of the mitral valve operated on between 2005 and 2008. We studied 68 consecutive patients (mean age, 32 years). All patients were investigated perioperatively by Doppler echocardiography. Echocardiographic assessment of tricuspid incompetence was on the basis of gradation of tricuspid regurgitation severity according to color Doppler flow criteria, the flow convergence region proximal to the regurgitant orifice (PISA), the size of the tricuspid annulus, and estimation of the pulmonary artery systolic pressure by continuous Doppler. Median tricuspid insufficiency was 3+. Tricuspid lesions were functional in 59 patients and organic in 9 patients. The cause was rheumatic mitral valve disease in all patients. Any patient has an aortic surgical dlession. All patients underwent De Vega tricuspid annuloplasty at the time of mitral surgery. There was one operative death. Prosthetic mitral replacement was performed in 57 patients (83.82%) and a mitral valve repair in 11 patients (16.17%). There was 1+ or less TR in 59 patients (86.7%), moderate TR 2+ in 7 patients (10.2%) and severe TR 3+ in two patients how had a severe pulmonary hypertension. Aggressive repair of accompanying TR should be undertaken at the time of initial mitral surgery. Tricuspid valve repair, described by De Vega, is a simple, short, and inexpensive procedure with few complications.

ECHOCARDIOGRAPHIC AND LABORATORY MARKERS OF CHRONIC HEART FAILURE: WHETHER IT IS POSSIBLE TO USE THEM IN RHEUMATIC MITRAL DISEASES?

Aim. To find echocardiographic indicators of heart remodelling that improve estimation of heart failure (HF) severity. To evaluate sensitivity of laboratory markers of HF, brain (BNP) and atrial (ANP) natriuretic peptides, in patients with mitral heart diseases of rheumatic aetiology. Material and methods. 100 patients with rheumatic mitral disease and chronic HF (CHF) of I-IV class (NYHA) were examined. Echocardiography was performed in all patients with evaluation of the standard indices to define disease severity. Indices of sphericity, myocardial stress of the left ventricle, etc were also evaluated. BNP and ANB levels were assessed by enzyme immunoassay method. Results. CHF severity had the strongest correlations with atrial sizes, left atrial systolic function and level of pulmonary hypertension. Moderate increase of BNP level in severe CHF (III-IV class) and its rare increase in mild CHF (I-II class) were detected. Significant changes of ANP level were not found. Moderate correlation of BNP level with myocardium mass index, level of pulmonary hypertension and mitral regurgitation was detected. Conclusion. Intensity of heart remodelling in rheumatic mitral diseases is mainly determined by the left atrial area, left atrial systolic function, mitral orifice size, levels of mitral regurgitation and pulmonary hypertension, size and ejection fraction of right ventricle. Normal BNP level does not confirm an absence of CHF or negative prognosis in patients with rheumatic heart disease.

An analysis of 24 autopsied cases with supramitral rings

The supramitral ring is a rare congenital malformation formed by presence of a ridge of connective tissue, usually attached at or above the mitral annulus. The incidence and clinical presentation is highly variable due to difficulty in diagnosis. A review of autopsied congenital heart diseases at our institute over a 17-year-period revealed 24 cases of supramitral ring. These were classified with respect to the morphology of the ridge and the presence of associated cardiac lesions. The ring was found in 1.5% of the autopsied specimens of congenitally malformed hearts, and in 37.5% of those with obstructed left-sided inflow tracts. The majority of the specimens came from children (79.2%). A clinical diagnosis had been made in only two. In one-third of the cases, the ring was associated with incomplete Shone's complex. Varied anomalies were seen in others, chiefly ventricular septal defects. An interesting association was the presence of rheumatic mitral valvar disease, found in 3 cases. There was no difference in the completeness or width of the supramitral ridge in the hearts from those with or without Shone's complex. Circumferential rings were fleshy and stenosing, while incomplete rings had variable locations and stenosis. The presence of a supramitral ring may be underestimated due to association with other cardiac anomalies, both congenital and acquired. Since the ridge need not always produce stenosis, the correct designation would be simply a supramitral ring.

Analysis of 92 mitral pulmonary autograft replacement (Ross II) operations

The study objective was to find a mitral valve substitute that does not require lifelong anticoagulation and is not affected by tissue degeneration in the long term. Between July 14, 1997, and August 8, 2004, a total of 92 patients with irreparable mitral valve disease underwent mitral valve replacement with the pulmonary autograft encased within a Dacron tubing for support. In 4 patients, the autograft had to be sacrificed at the initial operation. Of the remaining 88 patients, 62 were female, and the age ranged from 4 to 64 years (mean 39 years). Eighty-six patients had rheumatic mitral disease, and 2 patients had congenital mitral disease. Operative transesophageal echocardiography initially showed adequate valve characteristics (mean valve area 2.8 cm2, mean gradient 3.9 mm Hg, no significant regurgitation) in all 88 patients. Operative mortality was 4.6%, and late mortality definitely related to the operation was 7.9%. Four patients were lost to follow-up; the mean follow-up was 60 months. Progressive regurgitation and stenosis developed in 9 patients over 2 to 5 years, 4 of whom had their grafts explanted. The autograft was explanted in 1 patient because of endocarditis. Mild pulmonic stenosis developed in 3 patients, and critical pulmonic stenosis developed in 1 patient. At 5 years follow-up, freedom from degeneration was 93.4%, freedom from reoperation was 94.2%, and freedom from all death was 86.0%. Although the Ross II operation is difficult and harbors significant risk, it remains an option for patients with irreparable mitral disease who have a long life expectancy and who cannot be placed on lifelong anticoagulation.

Cytoflavin as an Additional Method for Myocardial Salvage During Operations Under Extracorporeal Circulation

The paper presents the results of use of the combined antihypoxant Cytoflavin during operations under extracorporeal circulation. Twenty-nine patients operated on for rheumatic mitral valvular disease were examined. The examinations have shown that the use of Cytoflavin positively affects the restoration of cardiovascular performance and improved tissue oxygen transport in the postperfusion period.

Complete Calcification of a Rheumatic Left Atrium

A 71-year-old man who had had rheumatic fever as a child presented with prosthetic-valve endocarditis. A mitral valvotomy had been performed 37 years before, and 21 years later, his mitral valve was replaced with a Starr–Edwards prosthesis. Lateral chest radiography showed complete calcification of the left atrial wall (Panel A, arrows). A transesophageal echocardiogram showed calcification of the interatrial septum (Panel B, arrow). This rare condition was first described in 1898, in association with chronic rheumatic mitral disease, and is more common in women, most of whom have symptoms for more than 20 years. The condition is assumed to be . . .

Fetomaternal outcome in pregnancy with cardiac disease.

To determine fetal and maternal outcomes in women presenting with heart disease during pregnancy and labor. Descriptive study. Department of Gynae/Obstetrics, MCH, Center, Unit II, PIMS, Islamabad, during a period of 2 years from March 2001 to February 2003. Forty-two pregnant women with heart disease delivered at MCH Center, Unit II, during the study period were included. Maternal outcome measures included obstetric and medical complications and maternal mortality while fetal outcome measures were prematurity, intrauterine growth restriction and perinatal mortality, intrauterine death and indicated terminations of pregnancy. The mean age was 27.50 -/+ 5.17 years (standard deviation). Of the 42 women, 33 (78.6%) were booked for antenatal care and 9 (21.4%) were non-booked. Congenital heart disease was present in 7 (16.7%) while 28 (65.3%) had rheumatic heart disease and mitral valve disease was the commonest. Among the remaining 7 women with acquired heart disease, 3 (7.1%) women had ischemic heart diseases (IHD), 1 (2.4%) had primary pulmonary hypertension, 2 (4.8%) patients had peripartum cardiomyopathy and 1 (2.4%) had aortic dissection. Based on New York Heart Association Functional classification (NYHA) 16 (38.1%) patients were asymptomatic (class I) and 3 (7.1%) in class IV. Thirty-two (76.2%) achieved spontaneous vertex delivery (SVD), LSCS was performed in 4 (9.5%) women, 2 (4.8%) women had spontaneous expulsions of dead fetus and 2 (4.8%) had suction and curettage for therapeutic termination of pregnancy on medical grounds. Obstetric complications occurred in 17 (40.4%) women, 5 (11.9%) had medical complications and 3 (7.1%) maternal mortalities occurred. Regarding fetal outcome, 6 (14.3%) infants had intrauterine growth restriction (IUGR), 2 (4.8%) perinatal deaths occurred due to prematurity while there was 1 (2.4%) intrauterine death. Indicated terminations of pregnancy were done for 4 gestations (7.1%). Low birth weight was noted in 12 (28.6%) infants. Heart disease with pregnancy is a very high risk condition and maternal mortality ratio (MMR) was 7142/100,000 births. The management of these cases should be multidisciplinary to optimize care for these patients and large families be strongly discouraged.

The mitral pulmonary autograft: assessment at midterm

BackgroundThere is a dire need, especially in emergent societies, for a mitral substitute that does not require anticoagulation, and is not affected by early degeneration. MethodsBetween 1997 and 2003, 80 patients had successful mitral valve replacement with a pulmonary autograft. Fifty-five patients were female, and the mean age was 39.3 years. Seventy-eight patients had rheumatic mitral disease and 2 congenital. The autograft was placed inside a rigid Dacron tubing for support, and the right ventricular outflow was reconstructed with a xenograft or a homograft. Recently we have used microwave energy to ablate atrial fibrillation when present. ResultsIntraoperative transesophageal echocardiography revealed adequate mitral valve areas (mean area 2.76 cm2) and acceptable mitral gradients (mean 4.3 mm Hg) in all 80 patients. There was no mitral regurgitation or trace amounts in 61 patients, and mild regurgitation in 19. Operative mortality was 5.0%, and late mortality clearly related to the procedure 6.25%. Follow-up was complete except for 2 lost patients, with a mean of 25 months, and echocardiographic findings were generally stable during follow-up. One patient developed uncritical mitral stenosis and another uncritical stenosis and insufficiency during 4 to 5.5 years. Four more patients had progression of mitral regurgitation from “mild” to “moderate” over a period from 8 months to 3 years. Uncritical xenograft pulmonic stenosis developed in 2 patients. Most of the surviving patients (83%) remain in class I status. ConclusionsWe believe the pulmonary autograft is a good mitral substitute at the disposal of cardiac surgeons, especially when patients are young and when life anticoagulation is contraindicated or impractical.