Mitral Valve Replacement Surgery Research Articles

CHRONIC INFECTION AND SEVERE MITRAL REGURGITATION: A TRICKY CASE REPORT

Abstract Background Techniques of mitral valve repair has improved in the last decades. Percutaneous approach is now a reliable and safe therapy in those patients with high surgical risk. Of note, the presence of implanted prothesis may increase the risk of endocarditis, especially in those patients experiencing recurrent infection. Case Summary We describe a case of a 75–year–old with medical history of chronic lymphedema. It was characterized by periodical episode (yearly) of cellulitis, with a rapid onset of fever (38.5–39° C), lasting for a few days after paracetamol therapy. Patients had severe mitral valve regurgitation due to prolapse of the posterior leaflet (P2). In December 2022, he had percutaneous edge–to–edge mitral valve. Three months later the patient was admitted to the emergency department of our hospital due to fever without any specific symptoms. The patient was well compensated, normal blood pressure, heart rate and oxygen saturation. He had emocolture which revealed the presence of Staphilococcus lugdunensis. Transesophageal echocardiogram confirmed the presence endocarditis, showing a huge (10x12 mm) vegetation at the level of mitral device (Fig 1 and 2). Patients was then referred to cardiac surgery for urgent mitral valve replacement with mitral bioprothesis (Fig 3). He was treated with ev antibiotic for six weeks after cardiac surgery. Additionally, chronic treatment with amoxicillin 500 mg/day was also prescribed at discharge. After six months follow–up, patients had no signs of endocarditis. Conclusion The management and treatment of chronic infection is of paramount importance to reduce the risk of prothesis infection procedure in patients needing a prothesis implantation. The last European Society of Cardiology guidelines on endocarditis do not provide any recommendation regarding a long–term treatment of patients with high risk of infection (i.e. due to chronic infection) and with an implanted cardiac device/prothesis. We believe this represents an important unmeet need.

So sánh chất lượng cuộc sống của người bệnh sau phẫu thuật tim ít xâm lấn có nội soi hỗ trợ và phẫu thuật mở thay van hai lá cơ học tại Trung tâm Tim mạch Bệnh viện E

Objective: Evaluate the quality of life of patients after minimally invasive open heart surgery with endoscopically assisted mitral valve replacement at Hospital E Heart Center and compare the quality of life of patients after surgery Minimally invasive open heart with endoscopic assisted mitral valve replacement and patients after mitral valve replacement surgery using open surgery. Research subjects and methods: Cross-sectional descriptive study on 54 cases after minimally invasive open heart surgery with endoscopic assisted mitral valve replacement at E Hospital Heart Center from January 1, 2022 to March 30 June 2023, using the SF-36 questionnaire. Results: Average scores of 4 areas of physical health including functional activities, functional limitations, pain perception and general health of the group of patients after minimally invasive surgery assisted by endoscopy and The group of patients with open surgery were: 81,03 and 74 respectively; 79,5 and 72,5; 93,97 and 76,16; 62,31 and 56,67. The average scores of 4 mental health domains including sense of vitality, social activities, psychological limits and general spirit are: 78,46 and 74 respectively; 75 and 67,92; 81,41 and 73,89; 85,9 and 79,17. Conclusion: The quality of life scores of patients after minimally invasive open heart surgery with endoscopically assisted mitral valve replacement in all areas are at good and good levels, higher than the group of patients undergoing replacement surgery. mitral valve by open surgery. Therefore, minimally invasive open heart surgery with endoscopically assisted mitral valve replacement is an indication for clear improvement in patients after surgery.

Effect of prophylactic single dose parenteral amiodarone in mitral valve replacement surgery

Effect of prophylactic single dose parenteral amiodarone in mitral valve replacement surgery

Comparing long-term outcomes of septal myectomy and mitral valve replacement in hypertrophic cardiomyopathy patients: A retrospective cohort study in Iran.

Hypertrophic cardiomyopathy (HCM) affects millions of individuals worldwide. In severe cases, it can cause life-threatening conditions such as left ventricular outflow tract (LVOT) obstruction, mitral regurgitation (MR), and sudden cardiac death, making surgical treatment necessary. This study aimed to report the long-term outcomes of HCM patients undergoing septal myectomy or mitral valve replacement (MVR) and compare the results between different types of surgeries. This was a retrospective cohort study on HCM patients who underwent surgical treatment in an Iranian referral center between 2005 and 2021. Patients were divided into three groups according to the type of surgery received: septal myectomy, MVR, or a combination of both surgeries. Patient characteristics, surgical and echocardiographic features, and in-hospital and long-term outcomes were reported and compared between the three groups. A total of 102 patients with an average age of 53.3 ± 16.9 were included. Twenty-six patients had septal myectomy, 23 had MVR, and 53 had combined septal myectomy and MVR surgery. All surgeries were associated with a significant reduction in interventricular septum thickness and LVOT gradients. After a median of 6.8-year follow-up time, patients with an isolated septal myectomy had significantly lower mortality and major adverse cardiac and cerebrovascular events rates than the other groups. Isolated septal myectomy showed better long-term survival rates and can correct HCM-related MR, while MVR should be preserved only for intrinsic valve defects. More extensive studies are needed to confirm these findings and achieve a comprehensive guideline on surgical treatment of HCM.

Persistence of SARS-CoV-2 colonization and high expression of inflammatory factors in cardiac tissue 6 months after COVID-19 recovery: a prospective cohort study.

The presence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in myocardial autopsy tissues has been observed in certain individuals with coronavirus disease 2019 (COVID-19). However, the duration of cardiac involvement remains uncertain among recovered COVID-19 patients. Our study aims to evaluate the long-term persistence of SARS-CoV-2 within cardiac tissue. We prospectively and consecutively evaluated the patients undergoing mitral valve replacement (MVR) and left atrial (LA) volume reduction surgery from May 25 to June 10, 2023 at our center, who had been approximately 6 months of recovery after Omicron wave. Patients tested positive for SARS-CoV-2 upon admission were excluded. The surgical LA tissue was collected in RNA preservation solution and stored at -80 ℃ immediately. Then SARS-CoV-2, interleukin-6 (IL-6) and interleukin-1β (IL-1β) RNA expression in LA tissues were assessed through thrice-repeated reverse transcription-quantitative polymerase chain reaction (RT-qPCR) analyses. Categorical variables were assessed using the Chi-square or Fisher's exact tests, and continuous variables was analyzed using the Mann-Whitney U test. Nine of 41 patients were enrolled, all of whom tested negative for SARS-CoV-2 upon admission (two antigen and PCR tests). In four of nine patients, SARS-CoV-2 RNA was detected in their LA tissue, indicating viral colonization. Among the four positive cases, the IL-6 and IL-1β relative expression levels in the LA tissue of one patient were increased approximately 55- and 110-fold, respectively, compared to those of SARS-CoV-2 (-) patients. Increased expression of IL-6 and IL-1β were observed in the myocardium of this patient. Another patient demonstrated a remarkable 7-fold increase in both IL-6 and IL-1β expression, surpassing that of SARS-CoV-2 (-) patients. Additionally, no other cardiac inflammation-related diseases or conditions were presented in these two patients. The IL-6 and IL-1β expression levels of the remaining two patients were not significantly different from those of SARS-CoV-2 (-) patients. The relative expression levels of IL-6 and IL-1β in cardiac tissues of all SARS-CoV-2 (-) patients were relatively low. Interestingly, despite abnormally elevated levels of IL-6 and IL-1β within their cardiac tissue, two patients did not show a significant increase in serum IL-6 and IL-1β levels when compared to other patients. Our research suggests that certain COVID-19-recovered patients have persistent colonization of SARS-CoV-2 in their cardiac tissue, accompanied by a local increase in inflammatory factors.

Impact of Tricuspid Repair on Surgical Death in Patients Undergoing Mitral Valve Surgery Due to Rheumatic Disease

BackgroundTricuspid valve repair during mitral valve replacement surgery remains a controversial topic. The risk-benefit ratio in some populations remains uncertain, especially in rheumatic heart disease patients. Therefore, we aimed to evaluate the impact of concomitant tricuspid repair on surgical mortality in patients undergoing cardiac surgery due to rheumatic mitral valve disease who have moderate to severe functional tricuspid regurgitation. MethodsThis is a prospective cohort study from January 1, 2017, to December 30, 2022. All patients over 18 years of age who underwent cardiac surgery to correct rheumatic mitral valve disease with concomitant moderate to severe tricuspid regurgitation were included. The primary outcome was a surgical death. In an exploratory analysis, clinical and echocardiographic data were obtained 2 years after the procedure. ResultsOf the 144 patients included, 83 (57.6%) underwent tricuspid valve repair. The mean age was 46.2 (±12.3) years with 107 (74.3%) female individuals, the median left ventricular ejection fraction was 61.0% (55-67), and systolic pulmonary artery pressure (sPAP) was 55.0 mmHg (46-74), with 45 (31.3%) individuals with right ventricular dysfunction. The total in-hospital mortality was 15 (10.4%) individuals, and there was no difference between the groups submitted or not to tricuspid repair: 10 (12.0%) vs. 5 (7.5%); p = 0.46, respectively. There was an association with one variable independently: the sPAP value, relative risk 1.04 (1.01-1.07), p = 0.01. The estimated cut-off value of sPAP that indicates higher early mortality through the receiver operating characteristic curve (area 0.70, p = 0.012) was 73.5 mmHg. ConclusionsPerforming tricuspid repair in individuals who were undergoing cardiac surgery to correct rheumatic mitral valve disease was not associated with increased surgical mortality. Our results suggest the safety of tricuspid repair even in this high-risk population, reinforcing the recommendations in current guidelines.

Calcium polystyrene sulfonate-induced rectal ulcer causing E. coli native-valve infective endocarditis.

Escherichia coli-associated native-valve infective endocarditis is a rare disease that affects elderly patients with underlying risk factors such as diabetes mellitus, malignancy, and renal failure. Long-term use of calcium polystyrene sulfonate is a potential risk factor for gastrointestinal mucosal damage or even colorectal ulcers. Herein, we describe a fatal case of a 66-year-old Japanese man with diabetes mellitus and renal failure who was prescribed calcium polystyrene sulfonate (CPS) for 11years and developed a CPS-induced rectal ulcer, leading to E. coli native-valve infective endocarditis. The patient was admitted to our hospital due to acute-onset impaired consciousness. As a result of the systemic investigation, he was diagnosed with E. coli bacteremia accompanied by multiple cerebral infarctions and an acute hemorrhagic rectal ulcer. Transesophageal echocardiography revealed a 20-mm vegetative structure on the mitral valve, resulting in a final diagnosis of E. coli-associated infective endocarditis. After rectal resection, mitral valve replacement surgery was performed; however, the patient died shortly after surgery. Pathological findings of the resected rectum showed deposition of a basophilic crystalline material suggesting the presence of CPS. Our case highlights the potential risk of colorectal ulcers in a long-term CPS user, which can trigger bacterial translocation and endocarditis as fatal complications.

Comparative study of total thoracoscopic mitral valve surgery and traditional open mitral valve surgery :propensity score matching study

Background: Conventional median open mitral valve replacement surgery usually requires a 20-30cm size incision to ensure adequate visual exposure. So, while we complete the valve replacement, it also brings about a series of problems. The appearance of TV thoracoscope changes the exposure of the surgical field. Because the microscopic field is enlarged, it not only makes the surgical vision clearer, but also greatly shortens the incision, reduces bleeding, and conceals the incision, minimizing the trauma and shortening the postoperative recovery time, which is in line with the concept of modern health. Aim: All technological innovation is controversial in the early stage, and it is such debate that can promote the progress and development of technology.This study was conducted in the context of this debate to summarize the experience of Total thoracoscopic mitral valve surgery in our center.Total thoracoscopic mitral valve replacement surgery and traditional median incision mitral valve replacement surgery were compared by the propensity score matching method.Evaluate its safety and merits. Methods: From January 2018 to December 2020, a total of 139 patients in the thoracoscopic group were eligible in the cardiothoracic surgery department of our hospital, and 1066 cases of traditional median sternotomy mitral valve replacement. After propensity score matching, 125 patients were selected in the thoracoscopic group, among 1066 patients with median incision MVR, 1:1 matched to 125, as the control group in the thoracoscopic group. Results: The results showed that the mean operative time in the thoracoscopic MVR group was significantly longer than that in the control group (185.73 ± 43.04 vs. 164.58 ± 40.28, p=0.0016). Similarly, both the mean CPB time and aortic block time were significantly longer than those in the control group (108.37±30.57min vs. 79.18±17.65min, p <0.0001; 66.59±29.63min vs. 45.09±19.68min, p <0.0001. Moreover, the proportion of patients with CPB greater than 120min and aortic block greater than 90min was significantly higher than the control group (24.1% vs. 3.2%, p <0.0001,14.4% vs. 2.4%, p=0.0237). In addition, there was no significant difference in the mean ICU observation time between the two groups (49.35±34.51h vs. 48.72±25.89h, p=0. 8792). Differently, the mean endotracheal intubation time was significantly lower in the thoracoscopic MVR group compared to the control group (18.52±6.07h vs. 25.45±14.18h, p=0.0032). Similarly, the length of stay in the thoracoscopic group was 9.13 ± 4.58 days, which was significantly lower than 11.12 ± 5.76 days in the control group (p=0.0004). There was no significant difference in the postoperative hemoglobin concentration or platelet count between the two groups of MVR patients. Mean intraoperative bleeding volume in the thoracoscopic MVR group was significantly less than that in the control group (158.37±100.91ml vs.250.74 ± 81.34, P <0.0001). Similarly, the mean postoperative discharge in the thoracoscopic MVR group was significantly than in the control group (428.39±361.38ml vs. 514.07 ± 347.92ml, p=0.0383). For patients with postoperative blood products, there were 37 (29.6%) in the thoracoscopic group and 33 (26.4%) in the control group. There was no significant difference between the two groups. Similarly, there was no significant difference in the mean total hospital costs between the two groups. Conclusion: This study shows that it has feasibility and safety for total thoracoscopic mitral valve replacement for mitral valve lesions, which can reduce the time and stay of the hospital compared with conventional direct surgery, and obtain good minimally invasive and cosmetic effect, and lay a theoretical and clinical foundation for the application of thoracoscopic technology in cardiac surgery, which has important scientific significance.

Implementation of Endoscopic Minimally Invasive Mitral Valve Replacement Surgery With Automated Suturing Technology.

In the evolving landscape of cardiac surgery, this article explores the potential of minimally invasive mitral valve replacement procedures as a viable alternative to conventional surgical techniques. Leveraging advancements in automated suturing devices and video endoscopy, our work aims to demonstrate that minimally invasive approaches can be applied across a broad spectrum of surgical scenarios. Herein we highlight preoperative diagnostics and operative techniques, with a focus on infra-axillary anterolateral minithoracotomy as the access point. Our technique utilizes technology from LSI SOLUTIONS® (Victor, NY, USA), including the RAM® Device for automated suturing, which has an ergonomic design and safety features. The device's capabilities are further enhanced by the SEW-EASY® Device, the RAM® RING, and the COR-KNOT MINI® Device, which streamline suture management and securement. This work outlines how these technological advancements can mitigate concerns about technical complexity and learning curves, thereby encouraging wider adoption of minimally invasive techniques. Clinical benefits may include reduced surgical trauma, quicker recovery, and cost-effectiveness, making it a compelling option in an era of aggressively promoted transcatheter interventions.

Clinical Outcome of Rheumatic Mitral Valve Repair and Replacement Surgery in Indonesia; A Comparison with Non-Rheumatic Aetiology.

Mitral valve repair (MVr) has been shown to achieve better outcomes than mitral valve replacement (MVR) in degenerative aetiology. However, that cannot be applied in rheumatic mitral valve disease. Therefore, this study aims to evaluate early and late clinical outcomes and mid-term survival in RHD compared to the non-RHD group and whether mitral valve repair is a better surgical approach in RHD patients. Patients who underwent mitral valve surgery with or without coronary artery bypass grafting were included in this study. All patients were divided into the RHD and non-RHD group by the type of mitral surgery performed. Early and late outcomes were evaluated, and mid-term cumulative survival was reported. A total of 1382 patients post MV surgeries were included. The 30-day mortality was significantly higher in the RHD group compared to the non-RHD group (8.7% vs. 4.4%, p = 0.003). There was no difference in 30-day mortality between repair and replacement in each respective group. During follow-up (12-54 months), all-cause mortality between RHD and non-RHD groups (16.7% vs. 16.2%) was not different. In the RHD group, the survival of MVr was 85.6% (95% CI 82.0%-88.5%), and MVR was 78.3% (95% CI 75.8%-80.6%), p-value log rank 0.26 However, in the non-RHD group, patients who underwent MVr had better survival than MVR, with cumulative survival of 81.7% (95% CI 72.3%-88.2%) vs. 71.1% (95% CI 56.3%-81.7%) p-value log rank 0.007. Early mortality rate in rheumatic mitral valve surgery was higher than in non-rheumatic valve surgery. Although in rheumatic MV disease MV repair did not show a significant survival advantage over MV replacement, a trend towards more favourable survival in the repair group was observed.

Comparative study of outcomes of different approaches in redo mitral valve surgery

Background Redo mitral valve replacement surgery is a challenging procedure as the access of the mitral valve mandates good exposure yet mitral visualization may not be sufficient as previous cardiac operations may complicate mitral valve exposure, as adhesions and loss of mobility in the surrounding tissues may be present. In such cases, the conventional left atrial incision may not offer satisfactory visualization in the surgical site of the valve. Therefore, several alternative approaches have been proposed, such as superior trans-septal approach, for satisfactory visualization of the mitral valve intra-operatively. Patients and methods Between January 2017 and November 2021, 100 patients were enrolled and with 50 patients randomly assigned in each group. Group one on patients undergoing redo surgery via a superior trans-septal approach and group two undergoing redo surgery via left atrial approach. Results Transeptal approach provides same results like left atrial approach in redo mitral valve surgery. Conclusion We conclude that the transseptal approach when compared to left atrial in redo patients provides comparable results in the intraoperative as well as postoperative outcomes

Acute and Resistant İntraoperative Hypertension during Mitral Valve Replacement: A Case Presentation

Background: Intraoperative hypertension continues to be a significant cause of morbidity and mortality for patients undergoing surgery. In this case presentation, an instance of sudden, unexpected, and resistant hypertension during surgery will be discussed in a patient who underwent mitral valve replacement. Case report: A 75-year-old patient with known coronary artery disease and advanced mitral stenosis underwent mitral valve replacement surgery. During the intraoperative process, after the completion of cannulation procedures and transitioning to partial bypass, a sudden increase in blood pressure was observed in the patient. Blood pressure was only brought under control through the intravenous administration of a triple antihypertensive agent. Upon postoperative evaluation following a smooth completion of the surgery and discharge, findings suggested that the cause of the hypertension in the patient might be renovascular hypertension. Conclusions: Intraoperative hypertension, when unexpected and sudden, can lead to an increase in mortality and morbidity. During the intraoperative process, efforts should be made to identify the underlying causes promptly, and appropriate interventions should be carried out. In the postoperative period, patients should be thoroughly evaluated for underlying reasons.

Kiosk 6R-TB-08 - CMR Assessment of Left Ventricular Outflow Tract Obstruction Post Mitral Valve Replacement Surgery

Kiosk 6R-TB-08 - CMR Assessment of Left Ventricular Outflow Tract Obstruction Post Mitral Valve Replacement Surgery

Trends in Isolated Mitral Valve Repair or Replacement Surgery in Australia: A Statewide Cohort Linkage Study

Global trends in mitral valve surgery (MVSx) suggest increasing repair compared with replacement, especially in the United States and European countries. The relative use, and outcomes of, MV repair and replacement in Australia are unknown. New South Wales residents who underwent isolated MVSx between 2001 and 2017 were identified from the Admitted-Patient-Data-Collection database. Mortality outcomes were tracked to 31 Dec 2018 and adjusted based on age, sex, urgency of operation, and comorbidity status. The study cohort comprised 5,693 patients: 2020 (35%) underwent repair (MVr), 1,656 (29%) underwent mechanical replacement (mech.MVR), and 2017 (35%) underwent bioprosthetic replacement (bio.MVR). Respective median ages [interquartile range] were 67 yo [59-75 yo], 64 yo [55-71 yo], and 75 yo [68-80 yo] (p<0.001 across groups). Between 2001 and 2017, total MVSx increased steadily with population growth. Whereas the relative use of MVr remained static (34% to 38%), that for bio.MVR (22% to 50%) and mech.MVR (45% to 13%) changed significantly. MVr had the best outcome with 1.2% in-hospital, 2.5% 1-year, and 21.6% total cumulative mortality during a median follow-up of 6.5 years. Compared to MVr, the adjusted hazard ratio (aHR) for mech.MVR and bio.MVR for long-term mortality were 1.41 (95% confidence interval [CI]=1.24-1.61) and 1.73 (95% CI=1.53-1.95), respectively. Heart failure and sepsis were the main cardiovascular and noncardiovascular causes of death in all groups. In this statewide Australian cohort examined over 17 years, MVr is potentially underutilised despite having superior outcomes to MVR. Access to quality dataset which provides the indication for MVSx and quantitative clinical factors is critical to further improve MVr coverage and outcome MVSx.

Comparison of Clinical Outcomes between del Nido Cardioplegia and Microplegia among Patients Undergoing Elective Mitral Valve Replacement

Background: Cardioplegia solutions are used to protect the myocardium from ischemic injury caused by cardiopulmonary bypass and various types of cardioplegia solutions have been introduced for cardiac surgery. In this study, we aimed to compare the effects of del Nido cardioplegia and microplegia, which were mostly used in our clinic for intraoperative and postoperative processes among patients who underwent elective mitral valve replacement. As a result, the comparison could be performed in a specific patient group without additional valvular or coronary disease, and cardioplegia distribution could be achieved more efficiently. Methods: Between 2018 and 2023, a total of 120 patients who underwent elective mitral valve replacement via sternotomy with del Nido cardioplegia or microplegia were included in the study. Patients were divided into two groups; group 1 (del Nido, n = 64) and group 2 (microplegia, n = 56). Preoperative characteristics, intraoperative and postoperative early clinical data as primary outcomes, and postoperative mortality rates and intensive care costs as secondary outcomes were compared statistically. Results: There were no statistically significant differences in terms of preoperative characteristics between the two groups. Duration of cross clamp differences between group 1 versus group 2 (45 ± 16 vs. 57 ± 19 min), cardiopulmonary bypass (56 ± 17 vs. 65 ± 21 min), intensive care length of stay (18.04 ± 7.41 vs. 22.37 ± 6.86 h), requirement of intraoperative defibrillation (n = 5 vs. n = 13), and intensive care costs were found to be statistically significantly lower in del Nido group. Conclusion: Either del Nido or microplegia solutions can be used safely in mitral valve replacement operations, however, del Nido cardioplegia has some advantages over intraoperative processes, such as lowering the cross clamp and cardiopulmonary bypass time. Furthermore, patients who received del Nido cardioplegia had shorter intensive care stay and required less intraoperative defibrillation compared with the microplegia group. Therefore, less exposure to anesthesia, the prevention of infection due to shortened operation duration, and greater cost-effectiveness can be achieved by using del Nido cardioplegia instead of microplegia.

Endocarditis caused by Aspergillus fumigatus in a patient 9 months after COVID-19 infection recovery: a case report and review of the literature

BackgroundAspergillus spp. are among the fungal pathogens that can cause life-threatening infections in patients with a history of COVID-19.Case presentationWe present the case of a 58-year-old Iranian woman with post-COVID-19 Aspergillus fumigatus endocarditis complicated by numerous thromboembolisms. She underwent mitral valve replacement surgery and multiple lower extremity embolectomies and was treated with voriconazole, which led to her final recovery.ConclusionsAspergillus endocarditis should be considered in any patient with suspected endocarditis who has a history of COVID-19 infection and does not respond to routine antibiotic and antifungal therapy, as COVID-19 interferes with proper immune function, and lack of underlying cardiac conditions and immunodeficiencies does not preclude the diagnosis. Culture and histopathological evaluation of vegetations and emboli, as well as PCR, can confirm the diagnosis. Early initiation of antifungal therapy and surgical removal of infected valves and emboli can improve prognosis in patients with Aspergillus endocarditis.

Abstract 18142: A Silent Heart Break: An Uncommon Case of Silent Mitral Valve Perforation Secondary to Infective Endocarditis

Introduction: Infective Endocarditis (IE) is an endocardial surface infection of the heart which may lead to valve damage and if severe, this may even lead to valve perforation which can cause significant regurgitation and cardiac function compromise. We present an uncommon case of IE complicated by mitral valve perforation. Case presentation: A 46-year old male with AIDS and polysubstance use was brought to the ED from a shelter after exhibiting erratic behavior with confusion. On exam, he was febrile and tachycardic. Lab data pertinent for lacticaemia and leukocytosis. Blood cultures grew Streptococcus Pneumoniae. MRI Brain was unremarkable. Echocardiography was unremarkable. Antibiotic was initiated leading to marked improvement in patient’s mental status. Despite clinical improvement, days into hospital course, a new holosystolic murmur was audible with left axillary radiation necessitating a repeat echocardiogram which revealed moderate-to-severe mitral eccentric jet regurgitation concerning for anterior leaflet perforation. He remained euvolemic without symptoms of heart failure and was subsequently transferred to a tertiary facility where a mitral valve surgery replacement was scheduled. Discussion: Most patients with infective endocarditis have no preceding valvular abnormality. This case is unusual as there was valvular perforation with no evidence of valvular involvement on prior imaging which could possibly be as a result of invasive streptococcus pneumonia IE potentially coexisting with bacterial meningitis which carries a high mortality rate. Invasive streptococcus pneumonia is an unusual cause of IE since wide availability of antibiotics and vaccines. This case reminds us of the need of thorough physical exam and sequential imaging in such immunocompromised patient groups. Conclusions: A high suspicion for mitral valve perforation should be maintained in patients with invasive streptococcus pneumoniae and new cardiac murmur.

Abstract 12522: Non-Ischemic Papillary Muscle Rupture Due to MRSA Myocarditis

Case Presentation: A 46-year-old male with diabetes, ESRD, and recurrent MRSA bacteremia, presented with septic shock and suffered cardiac arrest. Following resuscitation EKG showed inferolateral ischemia. TTE revealed acute mitral valve regurgitation resulting from posteromedial papillary muscle rupture (PMR). An intra-aortic balloon pump was implanted for cardiogenic shock. Coronary angiography revealed right dominant circulation and thrombotic occlusion of a small caliber distal left circumflex artery (LCX). Emergent mitral valve replacement surgery was performed. Pathologic analysis of the excised muscle and leaflet showed marked acute inflammation, bacterial invasion, and myocyte necrosis, confirming non-ischemic rupture due to MRSA myocarditis. Discussion: PMR predominantly occurs after MI, complicating 0.03% of STEMI cases in the reperfusion era. Non-ischemic causes are rare. Coexistence of myocarditis, infective endocarditis (IE), and MI poses a challenge in determining etiology. Establishing causation guides whether to expedite emergent valve surgery or focus on cardiomyocyte salvage by revascularization. The posteromedial papillary muscle is most commonly involved in PMR due to single blood supply from the PDA (most commonly a branch of the RCA, and less commonly the LCX). Coronary angiography, postoperative histopathology, and culture results determined the etiology of PMR was fulminant MRSA bacteremia culminating in myocarditis. Bacterial colonization and resultant inflammation induced physical and mechanical strain leading to complete rupture. The occluded LCX was incidental, and may have been the result of septic embolization, which occurs in up to 65% of left-sided IE. Albeit rare, non-ischemic etiologies must be considered when the anatomic presentation of acute PMR on TTE is incongruent with angiography. Definitive treatment relies on surgical intervention and mechanical circulatory support is often necessary.

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.

Impact of Bariatric Surgery on Mortality of Mitral Valve Surgery: A National Analysis.

Obesity is a common comorbidity of cardiac surgery patients. The goal of this study is to determine if a lower weight achieved through bariatric surgery has any association with mitral valve (MV) replacement or repair surgery mortality. This study used a retrospective analysis of the National Inpatient Sample dataset from 2012 to 2020. Adult patients who underwent MV surgery with normal weight following bariatric surgery (n = 1,125) and patients with obesity (n = 48,555) were compared. The primary outcome was in-hospital mortality. This study included 49,680 patients. The median age was 64 (55 to 71) years, and the majority were female (55%). Bariatric surgery was found to significantly decrease the odds of mortality, even after adjusting for important covariates, indicating a reduction of mortality risk by 54% (adjusted odds ratio = 0.46, p = 0.024). Other significant protective factors include isolated and elective surgery. Significant risk factors were older age, female sex, and diabetes mellitus. Patients who were obese demonstrated longer lengths of stay (LOS), greater transfers to other facilities, and higher hospital costs. In patients receiving MV surgery, bariatric surgery demonstrated significant survival benefits during hospitalization, in addition to reducing LOS and cost. Our data support prior evidence of bariatric surgery improving cardiovascular outcomes. Therefore, bariatric surgery may be a meaningful method of weight loss to improve surgical patient outcomes in patients with obesity. However, longer-term data are needed.