Successful Mitral Valve Replacement Research Articles

Post-Pericardiotomy Syndrome Following Mitral Valve Replacement Surgery in a Patient with Rheumatic Fever: A Case Report

Background: Post-cardiac injury syndrome (PCIS) is an inflammatory condition triggered by immune responses following cardiac injury. PCIS encompasses post-myocardial pericarditis, post-pericardiotomy syndrome (PPS), and post-traumatic pericarditis, whether iatrogenic or not. In this case report, we describe a patient who developed PPS after undergoing mitral valve replacement surgery. Case presentation: A young African woman with mitral stenosis caused by rheumatic fever underwent successful mitral valve replacement surgery. Approximately one month later, she developed post-pericardiotomy syndrome, which was subsequently diagnosed and treated. The patient initially presented to the hospital with exertional dyspnoea, and echocardiography revealed severe mitral stenosis, leading to the scheduling of surgery. While awaiting the procedure, she developed atrial fibrillation (AF) and congestive heart failure. In 2022, she underwent mitral valve replacement surgery and was discharged one week later after experiencing a smooth recovery. Two weeks after discharge, she visited the emergency department due to shortness of breath, but no concerning signs were found upon examination. She was prescribed diuretics and discharged. One week later, she was admitted to the hospital again due to chest pain, dyspnoea, and an elevated C-reactive protein (CRP) level of 123. Echocardiography and chest computed tomography (CT) scans were normal. She was treated with antibiotics under suspicion of pneumonia and subsequently discharged. Ten days later, she returned to the emergency department with high fever, chest pain, and dyspnea, and her CRP level had risen to 240. Echocardiography revealed no signs of endocarditis or pericardial effusion. Considering the patient's surgical history and frequent hospitalizations for similar symptoms, PPS was suspected. The patient was administered a first-line treatment of colchicine 0.5mg once a day. As a result, CRP levels decreased, fever and chest pain resolved, and she was discharged in a stable condition. A month later she was re-admitted to the hospital due to PPS relapse, Colchicine dose was elevated to 1mg a day and was discharged in good condition. Colchicine was planned to be continued for six months. Conclusion: PPS is a common complication following open-heart surgery, characterized by a generally mild course but with the potential for severe complications. Treatment typically involves anti-inflammatory agents, aspirin, and colchicine. The recurrence rate is approximately 10-15%. Early diagnosis and treatment of PPS can minimize frequent hospitalizations and reduce the need for extensive testing

Silent Acute Myocardial Infarction and Anterolateral Papillary Muscle Rupture: A Rare Complication in Elderly Patients

Mitral regurgitation (MR) following acute myocardial infarction (AMI) is a common occurrence, often resolving without significant complications. However, severe MR leading potentially to acute heart failure or cardiogenic shock is rare. It can result from papillary muscle rupture (PMR) which is an extremely uncommon and life-threatening mechanical complication of AMI. We present a case of a 77-year-old male with a late-presenting high-risk acute coronary syndrome (ACS) complicated by acute MR due to anterolateral PMR. The patient exhibited atypical symptoms, including dyspnea and cough, and was diagnosed with a STEMI equivalent. Echocardiography revealed severe MR secondary to papillary muscle rupture. The patient underwent successful coronary artery bypass graft (CABG) and mitral valve replacement surgery. We discuss the risk factors, management and complications of papillary muscle rupture, emphasizing the importance of early recognition and intervention. This case underscores the potential for atypical ACS presentations in the elderly and highlights the significance of specific ECG patterns, such as ST segment elevation in leads aVR and/or V1. Despite advancements in therapy, the mortality associated with papillary muscle rupture remains high, underscoring the critical need for preventive measures and heightened clinical awareness

Unveiling the mystery: Infective endocarditis as an etiological cause of recurrent intracranial hemorrhage

Intracerebral hemorrhage (ICH) in the context of infective endocarditis (IE) is an uncommon and complex phenomenon involving diverse underlying mechanisms. We present a compelling case of a 48-year-old patient with recurrent ICH, ultimately leading to the diagnosis of IE with vegetation on the anterior leaflet of the mitral valve. The patient underwent a successful mitral valve replacement followed by a gradual improvement in neurological symptoms. This case report delves into the intricate diagnostic journey, highlighting the significance of suspecting IE in patients presenting with ICH. A multidisciplinary and comprehensive management approach played a pivotal role in achieving positive outcomes.

Case Report: Post-operative mitral valve replacement complicating with a large cardiac mass and role of TEE in decision making

Background Postoperative complications are an integral part of valve surgery. Common complications include hematomas, bleeding, valve dehiscence, paravalvular leak, and acute PV thrombosis. With the available data from published articles, the rate of all valve-related complications is 0.7 to 3.5% per patient annually. [1] The pathology involved is multifactorial, often blood vessel injury leading to bleeding and hematoma. Although postoperative complications are evident, incidental diagnosis of a cardiac mass in an asymptomatic and hemodynamically stable patient postoperatively is crucial, requiring non-invasive imaging for immediate surgical action. Case presentation A woman in her 50s presented with chief complaints of worsening dyspnoea with suddenonset and chest pain. Clinical findings showed apex shifted downward and outward, wide split S2, and a mid systolic murmur radiating to the mid axillary line. Twelve-lead ECG showed LA enlargement, that aligned with X-ray findings. 2D Echocardiography revealed MVP with severe MR and a dilated LV. The patient underwent successful mitral valve replacement as per ACC/AHA class I recommendation. However, postoperative TTE showed a remarkably large mass measuring 5.6 cm*4.6 cm in the RA. Reexploration was performed, followed by mass excision. Plenty of organized clots were seen compressing the RA. TEE showed no evidence of mass. Following stabilization,the patient was discharged considering optimal INR values and prosthetic valve function assessed by echocardiography. The patient’s symptoms improved during the first follow-up. Conclusion Although postoperative cardiac complications are common, appropriate diagnosis with TTE and TEE has benefited surgeons. TEE-guided reexploration aids surgeons in decision-making and strategic approaches. Failure to diagnose such complications in asymptomatic patients can ultimately complicate the procedure. Henceforth, sonographers must be skilled in the detection and identification of unusual complications to guide redo interventions. Such an approach minimizes mortality, redo procedures, and avoids CPB hence reducing long-term prognosis and outcomes with valve replacement.

Abstract 14317: Arterial Thromboembolism in a Patient With Primary Antiphospholipid Antibody Syndrome and a Mitral Valve Mass

Background: Antiphospholipid antibody syndrome (APLAS) is an immune-mediated thrombophilia with multisystem venous and arterial thrombosis. Valvular disease is the most common cardiac presentation of APLAS, usually involving the mitral valve, and rarely affects valve function. Arterial thrombosis leading to myocardial infarction (MI) and left ventricular dysfunction have been described but are rare. We present a challenging case of APLAS with mitral valve involvement complicated by MI and new decompensated heart failure. Case: A 48-year-old male with obesity, hypertension, dyslipidemia, type 2 diabetes mellitus, obstructive sleep apnea, and triple-positive primary antiphospholipid antibody syndrome presented with a 3-day history of angina and dyspnea. He was started on rivaroxaban 9 years prior to presentation for breakthrough venous thrombosis while non-adherent to warfarin. During admission, he was found to have a mitral valve mass complicated by moderate mitral valve regurgitation, decompensated systolic heart failure, ST-segment elevation myocardial infarction, and multifocal strokes. Multimodality imaging (figure 1) in the setting of negative blood cultures suggested a non-infectious mitral valve mass with embolization as the culprit for his presentation. He ultimately underwent successful mechanical mitral valve replacement and bypass grafting with pathology confirming the diagnosis. Discussion: We highlight a case of a non-bacterial thrombotic mitral valve mass leading to moderate valvular regurgitation, acute heart failure, and arterial thromboembolic events in the setting of probable rivaroxaban failure. This case highlights the use of multimodality imaging and a team-based approach to correctly diagnose and treat a high-risk patient with APLAS and surgical valvular disease, as well as the inherent challenges of perioperative thrombotic and hemorrhagic risk assessment and monitoring.

Abstract 15299: Cardiogenic Shock and Flash Pulmonary Edema in an Uncommon Nonischemic Nonmyxomatous Spontaneous Rupture of Anterolateral Mitral Valve Papillary Muscle

Introduction: Mitral valve papillary muscle rupture is a rare condition that presents a cardiac emergency requiring rapid identification and treatment. Here we present a case of flash pulmonary edema and cardiogenic shock from severe mitral regurgitation (MR) secondary to spontaneous rupture of the anterolateral papillary muscle. Case Presentation: A 48-year-old female with hypertension presented to the ED with acute shortness of breath. In the ED, she was tachycardiac, hypertensive, tachypnic and saturating 75% on room air. On physical exam a 3/6 systolic murmur was present at the apex. ECG had no signs of ischemia. TTE showed severe MR with a fail anterior mitral leaflet. The patient was intubated and taken emergently to the cath lab for intra-aortic balloon pump placement, TEE (Figure 1A) and coronary angiogram, which was normal (Figure 1B, 1C). She was taken to the OR for successful mitral valve replacement surgery. Discussion: The rapid clinical decline and emergent management of patients who develop cardiogenic shock with pulmonary edema from acute non-ischemic papillary muscle rupture presents a significant challenge for clinicians. The cause of papillary muscle rupture most often occurs due an ischemic event, but can occur spontaneously as in this case. Rapid identification of the etiology of the clinical symptoms is of upmost importance to increase chances of survival. On review, 11 cases have been published between 2000-2015 discussing nonischemic nonmyxomatous spontaneous papillary muscle rupture of which the majority had a posterior muscle rupture. In our case, the 48-year old patient only had mild chordal calcification and essential hypertension and presented with nonischemic nonmyxomatous rupture of the anterolateral muscle. With prompt identification and urgent multidisciplinary team intervention, the patient was eventually discharged after replacement and is doing well at 6 months follow-up.

A Dual-Pathogen Mitral Valve Endocarditis Caused by Coxiella burnetii and Streptococcus gordonii-Which Came First?

Infective endocarditis (IE) is still a life-threatening disease with high morbidity and mortality. While usually caused by a single bacterium, poly-microbial infective endocarditis (IE) is rare. Here, we report a (blood-culture-negative) dual pathogen mitral valve IE caused by Coxiella burnetii and Streptococcus gordonii: A 53-year-old woman was presented to an internal medicine department with abdominal pain for further evaluation. Within the diagnostic work up, transthoracic echocardiography (TTE) revealed an irregularly shaped echogenic mass (5 × 13 mm) adherent to the edge of the posterior mitral valve leaflet and protruding into the left atrium. As infected endocarditis was suspected, blood cultures were initially obtained, but they remained negative. Chronic Q fever infection was diagnosed using serologic testing. After the occurrence of cerebral thromboembolic events, the patient was admitted for mitral valve surgery. Intraoperatively, a massively destructed mitral valve with adhering vegetations was noted. Examination of the mitral valve by broad-range bacterial polymerase chain reaction (PCR) and amplicon sequencing confirmed Coxiella burnetii infection and yielded Streptococcus gordonii as the second pathogen. Based on the detailed diagnosis, appropriate antibiotic therapy of both pathogens was initiated, and the patient could be discharged uneventfully on the 11th postoperative day after a successful minimal-invasive mitral valve replacement.

Flecainide for conversion and maintenance of sinus rhythm after mitral valve replacement in rheumatic atrial fibrillation

BackgroundDespite successful mitral valve replacement (MVR), many patients remain in AF. Flecainide can be useful in these patients but has not been used because of underlying structural heart disease. MethodsWe assessed oral flecainide for conversion and maintenance of SR in 25 patients of chronic rheumatic AF following MVR (age 34.4 yrs, mean AF duration: 3.6 yrs). Non-converters underwent DC cardioversion at 24 h and 4 weeks. Patients received flecainide and bb/diltiazem at discharge. ResultsSingle oral dose of Flecainide achieved SR in 6/25 (24%) while 19/25 achieved SR after DCC; at24 h 21/25 (84%) were in SR. With mean flecainide dose (93.10 ± 9.40 mg), successful maintenance of SR at 6 months was seen in 16/23 (69.5%). No significant changes in PR interval, QRS duration or QTc were noted; flecainide was well tolerated. Patients in SR had significantly better functional status, QOL scores and higher LA strain at 6 months (25.25 vs 17.43%, p < .0001). Baseline LA diameter ≤ 61 mm predicted SR at 6 months (sensitivity/specificity 93.7% and 85.71%) while the values for AF duration ≤ 4 years and LA strain > 21% for predicting SR were 87.5/71.43% and 100/85.71% respectively. ConclusionOral flecainide was safe and effective in post MVR rheumatic AF patients; maintenance of SR was achieved in 76% of initial converters and 64% of overall population, with better LA strain values. More studies are needed to validate these results.

Трансмитральная миоэктомия и протезирование митрального клапана из минидоступа при обструктивной гипертрофической кардиомиопатии

Primary hypertrophic cardiomyopathy is an isolated genetic heart disease characterized by thickening of the myocardium in the absence of an apparent hemodynamic cause. There are two patterns of the obstruction: static, with a muscle band narrowing the outflow tract of the left ventricle, and dynamic, which implies elongation of the anterior mitral valve leaflet. The key to correct treatment of the condition is understanding of the mechanism behind the obstruction. Myectomy is the gold standard of invasive treatment of obstructive hypertrophic cardiomyopathy; it aims to remove the static component of the obstruction. Another common adidition is the mitral valve surgery, aimed at elimination of the obstruction's dynamic component. This article presents a successful mini-invasive transmitral myectomy and mitral valve replacement in a case of obstructive hypertrophic cardiomyopathy with a damaged mitral valve.

A challenging triple valve surgery for long-standing pulmonary hypertension in rheumatic heart disease: a case report

Background Pulmonary hypertension is an increase in the mean pulmonary arterial pressure, greater than 25mmHg at rest, or greater than 30mmHg while exercising. In valvular heart disease its presence indicates a decompensated state of the disease. Surgical interventions are the ultimate treatment for the correction of valvular heart disease. Case Report A 38-year-old female was admitted to the Emergency Department (ER) with complaints of shortness of breath, chest pain, palpitations, and history of fainting. The patient was initially scheduled for aortic and mitral valve replacement and tricuspid valve repair at the end of year 2020. However, due to covid-19 pandemic, the patient was re-scheduled for surgery. On the 15th of June 2022, the patient was admitted to the ER of Zainoel Abidin General Hospital, and was consulted to the CTVS division. On the 17th of June 2022, the patient underwent a successful mitral valve replacement using mechanical St. Jude 29 mm valve, mechanical St. Jude 17 mm for aortic valve position, and tricuspid valve repair commissurotomy and using MC3 Edward ring annuloplasty. The patient was hospitalized for seven days and underwent successful first phase cardiac rehabilitation before discharge. The patient has since made remarkable improvements, establishing better quality of life. Conclusion Reduced pulmonary pressures postoperatively are often modest, and persistent pulmonary hypertension (PH) is known to be common and an indicator of poor prognosis. For patients with long-standing pulmonary hypertension due to rheumatic heart disease, valve replacement surgery effectively reduces pulmonary hypertension caused by damage to the left heart valve.

Abstract 14138: “RAC”ing up the Coronaries: An Underrecognized Echocardiographic Sign

Background: Both the retro-aortic anomalous coronary (RAC) and bleb signs are underrecognized echocardiographic findings suggestive of an anomalous left circumflex (LCx) coursing posterior to the aortic root. We present a patient in whom these echocardiographic signs were identified and confirmed on additional imaging. Case Presentation: A 77-year-old male presented with heart failure secondary to severe MR. In the apical 4 chamber (A4C) view, tilting anterior demonstrated the RAC sign, a highly echogenic tubular structure in the retro-aortic region above the mitral valve (panel A). In the parasternal long-axis view, the bleb sign, a round structure next to the aorto-mitral curtain, was identified (panel B). The RAC sign was also seen in the short-axis (SAX) as a tunnel-shaped structure behind the aortic root. This structure also represents an orthogonal view of the “bleb sign” (panel C). An anomalous LCx was suspected and was confirmed on both CTA and coronary angiography (panel D). The patient underwent successful mitral valve replacement. Discussion: The most common coronary anomaly is a LCx artery arising from the right sinus of Valsalva. Traditionally, either coronary angiography or CTA, has been required for diagnosis; however, these tests are expensive and invasive. The bleb and RAC signs must be differentiated from other more common echocardiographic findings. In the A4C view, the RAC sign can be mistaken for the coronary sinus, which is typically a more posterior structure, or for calcifications of the aortic valve, which would move with the valve and would not have internal anechoic components. The bleb sign can be differentiated from an abscess of the mitral-aortic fibrosa by identifying the tubular retro-aortic appearance of the structure in the SAX view. Conclusion: The RAC and bleb signs offer a noninvasive means identifying an anomalous LCx; however, they must be differentiated from other cardiac structures which can mimic their appearance.

Chordal Preservation Mitral Valve Replacement for Delayed MitraClip Failure.

Mitral valve replacement may be indicated in delayed MitraClip (Abbott) failure. Although it would be best to preserve the chordal apparatus during surgical mitral valve replacement, this has not been reported for delayed MitraClip failure, probably because there is almost always impressive inflammation around the MitraClip, which has likely precluded previous attempts at chordal preservation. A successful surgical chordal preservation mitral valve replacement in delayed MitraClip failure is reported here.

Anomalous origin of the left coronary artery from the pulmonary artery as a rare cause of mitral valve prolapse: a case report

Background Mitral valve prolapse (MVP) is an etiologically heterogeneous disorder. Early diagnosis and prompt treatment of the underlying disease are of great significance. Herein, we present a rare case of MVP caused by anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA).Case presentationA 22-year-old female presented with a 16-year history of anterior mitral leaflet prolapse. However, she had never experienced any discomfort before. At a routine follow-up, a transthoracic echocardiogram showed anterior mitral leaflet prolapse (A2) with moderate mitral regurgitation, and a retrograde blood flow from an extremely dilated left coronary artery (LCA). Further coronary angiography and coronary computed tomography angiography confirmed the diagnosis of ALCAPA. She subsequently underwent successful LCA reimplantation and concomitant mitral valve replacement. Intraoperatively, her mitral annulus was mildly dilated, anterior mitral valve leaflet appeared markedly thickened with rolled edges, and a chordae tendineae connecting the anterior leaflet (A2) was ruptured and markedly shortened.ConclusionsALCAPA is a rare and potentially life-threatening congenital coronary artery anomaly that may cause mitral valve prolapse. Echocardiogram is an important screening tool for this disorder.

Redo Mitral Valve Replacement Using St. Jude Medical Mechanical Prosthesis via Transseptal Approach in a Patient with Degenerated Mitral Epic Bioprosthesis: A Video Presentation

AbstractA 58-year-old male patient with degenerated St. Jude Epic mitral bioprosthesis underwent successful mitral valve replacement using 29 mm St. Jude Medical mechanical prosthesis. Case history presented here to prevent organ injury via a transeptal approach for a degenerated epic bioprosthesis.

Retrograde arterial perfusion and its outcome in robotic mitral-valve surgery

ObjectiveRetrograde arterial perfusion is frequently used in minimally invasive cardiac surgery. However, there are concerns about its safety. MethodsA prospective observational cohort study was conducted in a tertiary university affiliated medical center during 2016–2018. Right side femoral artery and femoral vein are used for bypass route. We set cardiopulmonary bypass flow to 2.5–3.0 L/min/m2, and adjust pump flow rate to achieve adequate cerebral oxygenation. The upper limit of arterial cannula pressure was 250 mmHg. We divided our patients into four groups by average pump flow 2.2 L/min/m2 and average mean arterial pressure 45 mmHg. Compared outcomes included surgical mortality, hospital stay, ventilator use, neurological outcomes, acute kidney injury, distal limb saturations, and post-operative clinical complications. ResultsWe included 117 patients in this study, and all participants had successful mitral valve repair or replacement. Our longest CPB duration was 210 minutes. Surgical mortality was 1.7%. Hemorrhagic stroke rate was 1.7%, and there was no ischemic stroke event. CPB flow did not affect survival rate, hospital stay, intensive care unit stay, or serum lactate in post-operative day 1, but serum creatinine (mg/dL) level increased transiently in patients with low pump flow group(0.9 ± 0.4 vs 1.3 ± 0.7,p < 0.05). Cannulation limb had decreased oxygenation during CPB, but their oxygenation all recovered after surgery. No limb ischemia event happened. ConclusionRetrograde arterial perfusion is a safe method for minimally invasive cardiac surgery less than 3.5 hours under mild hypothermic status.

Giant Left Atrium in Rheumatic Mitral Disease: Beyond a Simple Adaptive Mechanism: A Case Report

Giant left atrium is a condition characterized by an extreme enlargement of the left atrium with a diameter more than 80 mm and it is usually associated with long standing rheumatic mitral valve disease. We present a case of giant left atrium in a 47-year-old female patient who had a history of rheumatic heart disease, severe mitral disease, permanent atrial fibrillation and causing the compression of adjacent intra-thoracic structures. The patient underwent a successful mitral valve replacement with reduction of the enlarged sized left atrium with good outcomes.

“It Will Work”: The Story of Nina Starr Braunwald and the First Successful Mitral Valve Replacement

Cardiothoracic surgery is a clinical and scientific discipline that has evolved enormously over the last decades. Cardiac problems that were historically death sentences can now be addressed with approaches that only continue to improve. In the late 1950s, while cardiothoracic surgery was still a nascent field, Nina Starr Braunwald emerged as a pioneer for this exponential improvement. As the first woman cardiac surgeon in an era in which general surgery and surgical specialties were dominated by men, Dr Braunwald not only made revolutionary contributions to cardiothoracic surgery, but also did so while balancing roles as a dedicated mother and supportive partner.

New stent for transapical mitral valve replacement in acute swine experiment

BackgroundMany patients with mitral regurgitation are denied open-heart surgery due to perceived high risk. Transcatheter mitral valve replacement is a therapeutic alternative for patients at high surgical risk. This study aimed to assess the feasibility of a new self-expanding valved stent for transcatheter mitral valve replacement via apex in an acute animal model.MethodsEight porcine experiments were performed in the acute study. A left thoracotomy was performed, and the new self-expanding transcatheter valved stent was deployed under fluoroscopic guidance in the native mitral annulus via apex. Hemodynamic data were recorded before and after implantation. Mitral annulus diameter and valve area were measured using echocardiography. Transvalvular and left ventricular outflow tract pressure gradients were measured using invasive methods.ResultsSeven animals underwent successful transapical mitral valve replacement; the implantation was unsuccessful in one animal. The mean procedure time, defined from placement to tightening of the purse-string suture, was 17.14 ± 7.86 min. Hemodynamic data before and after transapical mitral valve replacement showed no difference in statistical analysis. The mean diameter of the self-expanding device after implantation was 2.58 ± 1.04 cm; the mean functional area was 2.70 ± 0.26 cm2. Trace-to-mild central and paravalvular leaks were detected in 7 valves. The mean pressure gradient across the self-expanding device was 2.00 ± 0.82 mmHg; the corresponding gradient across the LVOT was 3.28 ± 1.11 mmHg. Postmortem evaluation confirmed precise device positioning in 7 animals with no signs of LVOT obstruction.ConclusionTranscatheter mitral replacement of the new valved stent was confirmed feasible in acute preclinical models. The new stent reveals optimal design parameters.

The Novel Use of Mechanical Circulatory Support to Demonstrate Pulmonary Hypertension Reversibility in Mitral Stenosis

<h3>Introduction</h3> Pulmonary Hypertension (PHT) presents a significant risk factor for cardiac surgery. Patients with reversible PHT have better surgical outcomes. We present a novel and successful approach to demonstrate PHT reversibility and relieve pulmonary congestion in a patient with severe mitral stenosis using extracorporeal left atrial to femoral artery bypass MCS. <h3>Case Report</h3> A 56-year-old female with a history of rheumatic mitral stenosis presented with severe pulmonary edema. Transthoracic echocardiogram demonstrated severe MS (mean valve area .5 cm2, mean gradient of 20 mmHg) with preserved left ventricular ejection fraction. TEE confirmed no thrombus formation in the left atrium. Right heart catheter exam demonstrated elevated pulmonary artery (PA) pressures of 110/80 mmHg and a wedge pressure of 40 mmHg. PHT reversibility was desired to demonstrate the benefit of surgical intervention. A simulation using pulmonary vasodilator therapy would likely exacerbate her pulmonary venous congestion; an intra-aortic balloon pump or a percutaneous left ventricular assist device would not adequately unload the pulmonary venous pressure. Extracorporeal left atrial to femoral artery bypass MCS was used to unload the left atrium directly. After MCS initiation, PHT reversibility and surgical indication was confirmed with significantly improved pulmonary pressures (Table 1). The volume status and lung congestion were optimized preoperatively. Intraoperatively, the MCS left atrial inflow cannula was pulled back into the right heart and used as a venous cannula for cardiopulmonary bypass. Successful mitral valve replacement was performed. Postoperatively, the mitral valve mean gradient was 3 mmHg. The patient was discharged home on day 15. <h3>Summary</h3> The novel use of extracorporeal MCS with left atrial to femoral arterial bypass provides a novel strategy to simulate PHT reversibility and optimization for MS surgery.

The Optimal Suture Technique for Mitral Valve Replacement in an &amp;lt;i&amp;gt;Ex Vivo&amp;lt;/i&amp;gt; Animal Model

Objective: This study compared and evaluated three suture methods in order to find the method with the best durability for mitral valve replacement. The methods evaluated are horizontal mattress suture with subanular pledgets, horizontal mattress suture with supraanular pledgets and continuous running suture. Methods: Thirty hearts were explanted from newly terminated pigs. The hearts were randomized in the three groups. After an atriotomy, the mitral valve was cut out, and a patch was sutured into its place. An air pump model was connected to a balloon which was placed in the left ventricle through aorta and continuously filled with air to a maximum of 300 mmHg. The peak pressure at rupture was noted. If no rupture occurred before reaching 300 mmHg, the suture was found competent. Results: Two out of ten hearts in the continuous running suture-group had myocardial rupture within a pressure of 300 mmHg. In the remaining eight hearts there were no ruptures within 300 mmHg. In the two groups sutured with horizontal mattress with pledgets placed either subanular or supraanular, no rupture of myocardium occurred. When comparing continuous running suture with the horizontal mattress with subanular pledgets or the horizontal mattress with supraanular pledgets, the 1-sided Fishers’ exact was 0.237. At 5% significance level, there was no difference between the three suture methods. Conclusion: There was no statistically significant difference between the durability of the three suture methods, though rupture was only evident in the continuous running suture line. Since it is the surgeon’s choice to select the optimal suture technique, our study should be a reminder for the surgeon to reflect on the suturing factors that have an influence on successful mitral valve replacement.