Surgical Mitral Valve Replacement Research Articles

Transseptal transcatheter mitral valve implantation versus redo surgical mitral valve replacement for degenerated mitral bioprostheses

Abstract Background The growing use of surgical bioprostheses raises concerns about a future reoperation for bioprosthesis degeneration. There are few data on outcome after transcatheter mitral valve-in-valve implantation (TMVI) compared with redo surgical mitral valve replacement (SMVR). Purpose To compare the feasibility, safety and outcomes of TMVI versus SMVR for degenerated mitral bioprosthesis in high-risk patients. Methods In our institution, 52 patients underwent TMVI by transseptal approach and 33 SMVR for degenerated mitral bioprosthesis. The composite endpoint of event-free survival included cardiovascular mortality, stroke, major bleeding, hospitalization for heart failure or mitral valve reintervention. Results Mean age and EuroSCORE II were higher in TMVI group vs. SMVR group (age 63±21 years vs. 51±15 years, p=0.002; EuroSCORE II 12.5±12.2% vs. 6.2±3.3%, p=0.001) (Table). In-hospital mortality was 3.8% after TMVI vs. 3.0% after SMVR (p=1.0). Median follow-up was 2.2 years. At 5 years, survival was 69.7±9.4% after TMVI vs. 86.6±7.6% after SMVR (p=0.10) and event-free survival was lower after TMVI (40.1±9.9% vs 78.7±8.8% respectively, p=0.003) (Figure). In multivariate analysis, older age (p=0.02), neurologic history (p=0.05) and non-elective procedure (p<0.0001) were associated with lower event-free survival, while TMVI vs. SMVR was no longer significant (p=0.17). At last follow-up, 84% patients from TMVI group and 78% from SMVR group were NYHA I-II class. Mean mitral valve gradient and pulmonary artery systolic pressure were respectively 6.8±2.5 mmHg and 45±14 mmHg in TMVI group, and 4.8±2.0 mmHg and 37±11 mmHg in SMVR group. Conclusion TMVI is an alternative to SMVR in high-risk patients with degenerated mitral bioprosthesis. Comparison of mid-term results of the two techniques must take into account the differences in patient characteristics. Event-free survival Funding Acknowledgement Type of funding source: None

Symptoms and natural history in patients with isolated severe calcific mitral stenosis

Abstract Background Prevalence of calcific mitral stenosis (MS) increases with age. Mitral valve interventions for calcific MS are often delayed until symptoms are severely limiting because the natural history of calcific MS and its relation to cardiac symptoms or comorbidities have not been well assessed. Objectives We assessed the prevalence of symptoms, comorbidities and determinants of all-cause mortality in patients with severe calcific MS. Methods We retrospectively investigated adults with echocardiographic isolated severe MS, defined as mitral valve area (MVA by the continuity equation) ≤1.5 cm2, from July 2003 to December 2017. Among them, calcific MS was identified as obstruction of left ventricular inflow due to degenerative calcification of the mitral annulus using echocardiography and, whenever available, operative findings including histopathological examination. Inactivity was defined as requirement for assistance with activities of daily living. Follow up was obtained by review of medical records. Results Of 491 patients with isolated severe MS, calcific MS was present in 200 (41%; age 78±11 years, 18% men, 32% with atrial fibrillation). Charlson Comorbidity Index (CCI) was 5.1±1.7 and 14 (7%) were inactive. MVA and transmitral gradient (TMG) were 1.26±0.19 cm2 and 8.1±3.8 mmHg, respectively. Symptoms were present at baseline in 120 (60%) including dyspnea in 97, chest discomfort in 12, syncope in 3, lower extremity edema in 3, thrombosis in 3 and fatigue in 2. Of them, mitral valve interventions including surgical or transcatheter mitral valve replacement and mitral valve bypass were performed in 27 (23%): within 1 year after index TTE in 23 (19%) and at 2, 4, 5 and 6 years in 1 each. Of 80 patients without symptoms at index TTE, 20 (25%) developed symptoms at mean 2.9±3.2 years and interventions were performed in 5 (6%). Of 168 who did not receive interventions, 60 (36%) did not develop symptoms during follow up, 58 (35%) were considered to have moderate MS, 46 (27%) were not offered surgery because of high risk due to advanced age, multiple comorbidities or heavy calcification, and 2 (1%) declined interventions. During follow-up of 2.8±3.0 years, Kaplan-Meier survival at 1 and 3 years without intervention were 72% and 52%, respectively (Fig. A). Inactivity, CCI >5, left ventricular ejection fraction (LVEF) <50%, TMG ≥8 mmHg (the mean TMG) and right ventricular systolic pressure (RVSP) ≥50 mmHg were independently associated with mortality (Fig. B). Symptoms were associated with referral for interventions (OR 3.43, 95% CI 1.22–9.65; p=0.019), but not with mortality. Conclusion Patients with isolated severe calcific MS had a high burden of comorbidities and had high mortality without intervention. Symptoms were common (60%), but were not associated with mortality. TMG ≥8 mmHg, RVSP ≥50 mmHg, LVEF<50%, CCI >5 and inactivity were independently associated with mortality. Funding Acknowledgement Type of funding source: None

Surgical rheumatic mitral valve repair compared with percutaneous balloon mitral valvuloplasty in mitral stenosis in current era: a propensity score matching study.

BackgroundMany comparative studies of percutaneous balloon mitral valvuloplasty (PBMV) and surgical mitral commissurotomy (SMC) in rheumatic mitral stenosis (MS) were done in the last few decades. With the development of valve repair techniques, various surgical rheumatic valve repair techniques have been applied in clinic, but there is a lack of comparison with PBMV. Our study was designed to compare the perioperative and mid-term outcomes of PBMV and mitral valve repair with “four-step” procedure in the treatment of rheumatic MS.MethodsPatients with MS were treated with PBMV or rheumatic mitral valve repair (rMVP) at Beijing Anzhen Hospital between January 1, 2013 and September 30, 2018 were selected. By using propensity score matching (PSM) method, we compared the changes in post-operation clinical outcomes between the two matched groups. Kaplan-Meier analyses was used for survival analysis and drawing the curve, and log-rank test were used to compare intergroup differences.ResultsA total of 252 cases were enrolled after selection, 74 cases in PBMV and 178 cases in rMVP. Seventy-four pairs were matched successfully after PSM. There were 53 females in PBMV and 54 in rMVP. The mean age of two groups was 46.95±12.50 and 47.55±11.91 years respectively. There was no significantly differences in mitral valve orifice area (MVOA) (1.05±0.32 vs. 0.97±0.24 cm2, P=0.12) and left ventricular ejection fraction (EF) (62.36%±5.17% vs. 62.52%±4.94%, P=0.76) between two groups preoperatively. Baseline characteristics were basically balanced after PSM. In each group, there was one case transferred to surgical mitral valve replacement due to the failure of valvuloplasty before discharge. All patients survived the interventions and no severe complications were found. MVOA were significantly increased in rMVP compared with PBMV postoperatively, as well as grading of MS and tricuspid regurgitation (TR) were significantly improved in rMVP. Three cases in PBMV were lost during the follow-up. Mitral replacement was performed in 11 patients and one of them died in PBMV, while none of patients underwent re-intervention in rMVP, but one patient died of pneumonia.ConclusionsFor selected patients with rheumatic MS in China, our study shows that there are comparable clinical outcomes in terms of operative, mid-term mortality and complications between PBMV and surgical rMVP with “four-step” procedure. Surgical rMVP shows more advantageous in the correction of valve stenosis and the management of concomitant tricuspid valve lesions and atrial fibrillation (AF).

Outcomes of surgical mitral valve replacement: A benchmark to assess transcatheter technologies.

Clinical trials are underway to evaluate the safety and efficacy of transcatheter mitral valve replacement in intermediate and high surgical risk patients. We analyzed outcomes of surgical mitral valve replacement in a regional consortium to provide benchmark data for emerging alternative therapies. All patients undergoing mitral replacement with a Society of Thoracic Surgeons predicted risk of mortality (STS PROM) in a regional consortium from 2001 to 2017 were analyzed. Patients with endocarditis were excluded. Patients were stratified by STS PROM into low (<4%), moderate (4%-8%), and high risk (>8%) cohorts. Mortality, postoperative complications, and resource utilization were evaluated for each group. A total of 1611 patients were analyzed including 927 (58%) low, 370 (23%) moderate, and 314 (20%) high-risk patients. The mean STS PROM was 2%, 5.6%, and 15.4% for each group. Mortality was adequately predicted for all groups while the most common complications included prolonged ventilation, reoperation, and renal failure. Higher risk patients had longer intensive care unitand hospital lengths of stay (2 vs. 3 vs. 5 days, p < .0001 and 7 vs. 8 vs. 10 days, p < .0001) and higher total hospital costs ($38,029 vs. $45,075 vs. $59,171 p < .0001). Mitral valve replacement is associated with acceptable morbidity and mortality, particularly for low and intermediate-risk patients. These outcomes also serve as a benchmark with which to compare forthcoming results of transcatheter mitral valve replacement trials.

Surgical redo versus transseptal or transapical transcatheter mitral valve-in-valve implantation for failed mitral valve bioprosthesis.

Redo surgical mitral valve replacement (SMVR) is the current standard of care for patients with failed bioprosthetic mitral valve (MV). Transcatheter mitral valve-in-valve replacement (TMViV) is arising as an alternative to SMVR in high risk patients. We sought to evaluate procedural safety, early and mid-term outcomes of patients who underwent transseptal TMViV (TS-TMViV), transapical TMViV (TA-TMViV), or redo-SMVR. We identified patients with failed bioprosthetic MV who underwent TS-TMViV, TA-TMViV, or SMVR at four Italian Centers. Clinical and echocardiographic data were codified according to Mitral Valve Academic Research Consortium definition (MVARC), except for significant valve stenosis. Between December 2012 and September 27, 2019 patients underwent TS-TMViV, 22 TA-TMViV, and 29 redo-SMVR. TS-TMViV and TA-TMViV patients presented higher mean age and surgical risk scores compared with SMVR group (77.8 ± 12 years, 77.3 ± 7.3 years, 67.8 ± 9.4 years, p < .001; STS PROM 8.5 ± 7.2; 8.9 ± 4.7; 3.6 ± 2.6, p < .001). TS-TMViV procedure was associated with shorter intensive care unit time and total length of stay (LOS) compared with TA-TMViV and SMVR group. There were no differences in MVARC procedural success at 30-days (74.1, 72.7, and 51.7%, p = .15) and one-year all-cause mortality between groups (14.8, 18.2, and 17.2%, p = 1.0). MV mean gradient was similar between TS-TMViV, TA-TMViV, and SMVR groups at 30 days and 12 months. For the selected patients, TS-TMViV and TA-TMViV are to be considered a valid alternative to redo-SMVR with comparable 1-year survival. TS-TMViV is the less invasive strategy and has the advantage of shortening the LOS compared with TA-TMViV.

PSU2 Clinical Outcomes and Economics Associated with Surgical Mitral Valve Replacement in Taiwan

PSU2 Clinical Outcomes and Economics Associated with Surgical Mitral Valve Replacement in Taiwan

Percutaneous Interventions for Secondary Mitral Regurgitation

Mitral regurgitation is frequently associated with ventricular dysfunction and carries a high mortality. Guideline-directed medical therapy, surgical mitral valve repair or replacement, and, in the setting of advanced heart failure, heart transplant and left ventricular assist devices have been the mainstay of treatment. However, rapid advancement in the field has resulted in approval of edge-to-edge mitral valve repair with the MitraClip, and there are several novel catheter-based percutaneous options in clinical trials. Percutaneous options, while promising, must be deployed in patients who are most likely to benefit, and thus, understanding the pathophysiology of specific subgroups of patients with functional mitral regurgitation (eg, disproportionate versus proportionate mitral regurgitation) is key to the success of new devices. We review the pathophysiology, percutaneous therapeutic treatment options, and ongoing clinical trials for functional mitral regurgitation.

A pseudoaneurysm of the left atrium as a rare source of coronary artery embolization.

A 67years old woman with history of surgical Mitral valve replacement underwent transoesophageal echocardiography for evaluation of mild dyspnoea. It revealed a large narrow-necked outpouching from medial portion of the inferior wall of the left atrium (LA) that was extended to the interatrial septum. A diagnosis of the LA pseudoaneurysm was made. It contained a fresh clot. Five days later, the patient presented with an acute inferior ST-elevation myocardial infarction. Coronary angiography revealed an occluded right coronary artery at its distal part by a large thrombus. Thromboaspiration was done and resulted in restoration of a Thrombolysis in Myocardial Infarction Score (TIMI) flow 3 without underlying stenosis.

Outcome of Patients Having Transcatheter Mitral Valve Implantation for the Treatment of Degenerated Mitral Bioprostheses

Transcatheter mitral valve implantation (TMVI) is at various levels of preclinical investigation and has proven to be more challenging than transcatheter aortic valve implantation due to more complex anatomy. The purpose of this study is to evaluate the short-term and long-term outcomes of high-risk patients who underwent TMVI for degenerated mitral bioprostheses. In this retrospective, observational study, we reviewed data on the first 26 patients with previous surgical mitral valve replacement or repair with annular ring that underwent TMVI using the balloon-expandable heart-valve system at our institution from 2014 to 2019. We reviewed pre/postprocedure echocardiographic data, in-hospital, 30-day data and 1-year outcomes. The indication for TMVI was mitral regurgitation (MR) in 9 patients, mitral stenosis in 9 patients and mixed mitral disease in 8 patients. There was a 100% device implantation success rate and a 96% in-hospital survival rate. Survival was 96% at 30 days and 85% at 1 year. Mean mitral gradient (MMG) improved postprocedure (13.3 mm Hg to 6.8 mm Hg, p <0.0001) and was sustained at 1 year (13.3 mm Hg to 7.2 mm Hg, p <0.0001). MR grade improved postprocedure (3+ to 1+, p <0.0001) and was sustained at 1 year (3+ to 0, p <0.0001). Additionally there was significant 30-day and 1-year improvements in patients' Kansas City Cardiomyopathy Questionnaire score after TMVI (47.8 to 75.7 to 84.0, p = <0.0001). In conclusion, our early experience with treatment of degenerated mitral bioprostheses using TMVI in high-risk patients resulted in significant short-term and sustained long-term improvements in mean mitral gradient, MR and heart failure symptoms.

Outcome comparison of mitral valve surgery and MitraClip therapy in patients with severely reduced left ventricular dysfunction.

AimsThe aim of this study was to compare the outcomes of surgical mitral valve repair or replacement (sMVR) and percutaneous edge‐to‐edge repair using MitraClip (pMVR) in patients with severe left ventricular dysfunction affected by functional mitral regurgitation (FMR).Methods and resultsWe retrospectively identified 132 patients with left ventricular ejection fraction (LVEF) ≦ 30% submitted to sMVR (n = 47) or pMVR (n = 85) for FMR at our centre from January 2013 to December 2017. To adjust for baseline imbalances, we used a propensity score matching by age, logistic EuroSCORE, and left ventricular end‐systolic volume. After being matched, MitraClip therapy showed lower perioperative mortality and rate of complications yet increased residual mitral regurgitation (MR) grade than did surgery (0.2 ± 0.50 in sMVR vs. 1.3 ± 0.88 in pMVR, P < 0.0001). According to stratified multivariate Cox model analysis, residual MR severity was an independent risk factor for cardiac death [hazard ratio (HR), 2.81; 95% confidence interval [CI], 1.44–5.48, P = 0.0025] and re‐hospitalization for heart failure (HR, 3.07; 95% CI, 1.50–6.29, P = 0.0022) at 1 year follow‐up. Stratified multivariable Cox regression analysis at 3 years identified pMVR as risk factor for cardiac death (HR, 0.19; 95% CI, 0.040–0.86, P = 0.031) and re‐hospitalization for heart failure (HR, 0.28; 95% CI, 0.077–0.99, P = 0.048).ConclusionsIn patients with FMR and LVEF ≤ 30%, MitraClip therapy resulted in lower perioperative complications and mortality than sMVR. However, surgically treated patients who survived the perioperative stage had less residual MR and experienced lower rates of re‐hospitalization for heart failure at 1 year and lower cardiac mortality at 1 and 3 years of follow‐up than did patients undergoing pMVR.

One-year outcome with a bovine pericardial valve.

ObjectivesTo evaluate the safety and effectiveness of a novel surgical bovine pericardial valve for aortic and mitral valve replacements.MethodsBetween March 2016 and October 2017, 197 patients (mean age, 66.9 ± 4.9 years; 40.6% were women) underwent aortic valve replacement and mitral valve replacement and were implanted with the Cingular bovine pericardial valve (Shanghai Cingular Biotech Corporation, Shanghai, China) in a prospective, multicenter, single-arm trial in China. A total of 161 aortic and 49 mitral prostheses were implanted. Patients were followed up to 1 year. The primary end point was the 1-year overall rate of valve-related complications, including thromboembolic event, valve thrombosis, major hemorrhage event, major perivalvular leak, and prosthetic valve endocarditis.ResultsThe 1-year overall rate of valve-related complications was 0.5% (95% confidence interval, 0.1%-3.7%). The 1-year survival was 96.4%. The mean gradient and effective orifice area for aortic prostheses at 1 year postoperatively were 12.8 ± 4.4 mm Hg and 1.9 ± 0.3 cm2, respectively. Particularly, the mean gradients and effective orifice area for 19 mm and 21 mm sizes of aortic prostheses at 1 year were 17.0 ± 3.8 mm Hg and 1.6 ± 0.2 cm2, 13.1 ± 4.0 mm Hg and 1.8 ± 0.1 cm2, respectively. Patient–prosthesis mismatch occurred in only 1.3% patients for aortic valve implantation at 1 month. No structural valve deterioration and no endocarditis occurred.ConclusionsThe Cingular bovine pericardial valve was safe and effective for surgical aortic and mitral valve replacement. The 1-year rate of valve-related complications was very low. Early hemodynamic performance was excellent even for the small aortic root.

Effects of Frailty on Outcomes and 30-day Readmissions After Surgical Mitral Valve Replacement

Frailty is increasingly recognized as an important prognostic marker in surgical populations. The effects of frailty on outcomes after mitral valve replacement (MVR) is less clear given the inherent complexity of this patient population. We evaluated the influences of frailty on outcomes and readmission rates after MVR. Adult patients undergoing isolated MVR were queried from the National Readmissions Database from 2010 to 2014. Frailty was defined using the Johns Hopkins Adjusted Clinical Groups frailty-defining diagnoses indicator, a validated instrument developed for use in health administrative data. Multivariable logistic regression was used to determine hospital- and patient-level risk factors for readmission, postoperative complications, and death. Among 50,410 patients who underwent MVR, 7.9% met frailty criteria. Frail patients were more likely to be older, have nonprivate insurance, an index admission from the emergency department, and teaching hospital care (all P < .001). Frail patients had significantly more postoperative complications (77% vs 47%, P < .001), more discharges to a facility (50% vs 21%, P < .001), and higher in-hospital mortality (12% vs 4%, P < .001). Index hospitalization costs were almost doubled in frail patients, and of those who survived to discharge, 30-day readmissions were more frequent (28% vs 20%, P < .001). Frailty independently increased the risk of index hospitalization composite complications (adjusted odds ratio [AOR], 3.28; 95% confidence interval [CI], 2.61-4.12), in-hospital mortality (AOR, 2.35; 95% CI, 1.90-2.92), and 30-day readmission (AOR, 1.47; 95% CI, 1.20-1.78). Frailty is an independent predictor of morbidity, death, and increased costs after MVR. Frailty metrics should be increasingly understood among patients requiring mitral valve intervention as percutaneous approaches for intervention become increasingly used.

SURGICAL AND TRANSCATHETER MITRAL VALVE REPLACEMENT IN MITRAL ANNULAR CALCIFICATION- A SYSTEMATIC REVIEW

Surgical mitral valve replacement (SMVR) in severe mitral annular calcification (MAC) remains a challenge. Transcatheter mitral valve replacement (TMVR) is an emerging alternative in higher risk patients with appropriate valve anatomy. PubMed, Embase, and Cochrane Register were searched for studies

REVIEW OF RE-OPERATIVE SURGICAL MITRAL VALVE REPLACEMENT VERSUS TRANSCATHETER MITRAL VALVE-IN-VALVE REPLACEMENT

Bioprosthetic mitral structural valve degeneration (SVD) often requires surgical mitral valve replacement (redo-SMVR), which is associated with significant mortality and morbidities. Transcatheter mitral valve-in-valve (MVIV) and valve-in-ring (MVIR) replacement are now feasible but data comparing

Surgical mitral valve replacement using direct implantation of Sapien 3 valve in a patients with severe mitral annular calcification without adjunctive techniques, a case report

BackgroundMitral annular calcification (MAC) occurs represents a challenge to surgeons during mitral valve (MV) surgery with increased perioperative risk.Case presentationWe describe a challenging case of an elderly female patient with multiple comorbidities who presented with symptoms and signs of heart failure with a previous history of mechanical aortic valve replacement 15 years prior to presentation. Echocardiogram showed severe mitral stenosis and regurgitation with severe calcification of the mitral annulus. Given her high-risk profile and unavailability of suitable percutaneous therapeutic options we decided to replace her mitral valve with Sapien 3 valve under direct exposure. The case describes the technical details for the valve implantation and demonstrates the viability of this option in high risk surgical patients without the need for adjunct techniques like predilatation, additional supporting sutures or patches with a review of the literature on open surgical implantation of Sapien 3 valve.ConclusionDirect open surgical implantation of Sapien 3 valve can be implanted safely in patients with severe MAC, without predilatation and without the use of other adjunctive techniques like fixation sutures or patches.

Contemporary Trends and Outcomes of Percutaneous and Surgical Mitral Valve Replacement or Repair in Patients With Cancer

In the era of emerging options for mitral valvular intervention, we sought to characterize the relative utilization, outcomes, and posthospital dispositions of patients referred for transcatheter mitral valve repair (TMVRepair) and surgical mitral valve procedures (SMVP), by cancer-status. Leveraging the National Inpatient Sample, a representative national dataset, ICD-9 codes for all adults >18 years with co-morbid mitral regurgitation, and cancer without metastatic disease admitted from 2003 to 2015 were queried. TMVRepair was performed in 700 hospitalizations from 2012 to 2015, whereas SMVP was utilized during 12,863 hospitalizations from 2003 to 2015. During follow-up, we observed a proportional increase in TMVRepair utilization among cancer patients (vs noncancer), particularly in 2015 (14.2% vs 8.2%, p <0.0001). There was no difference in in-hospital mortality (1.4% vs 1.8%, p = 0.71), ischemic stroke (0.7% vs 0.6%, p = 0.97), major bleeding (8.6% vs 10.9%, p = 0.36), and home discharge (62.1% vs 65.7%, p = 0.45) by cancer-status among patients who underwent TMVRepair; but, cost of care was increased ($52,325 vs $48,832, p <0.0001). Similarly, there was no difference in in-hospital mortality (3.1% vs 3.4%, p = 0.36), ischemic stroke (2.6% vs 3.1%, p = 0.16) as well as the cost-of-care ($58,106 vs $58,844, p = 0.49) among those who underwent SMVP across the same period; but, cancer was associated with increased major bleeding (34.9% vs 30.5%, p <0.0001), and lower likelihood of home discharge (32.8% vs 38.6%, p <0.0001). In conclusion, TMVRepair and SMVP were associated with comparable in-hospital mortality and outcomes in cancer versus noncancer patients. However, cancer patients treated with SMVP experienced more frequent bleeding related complications compared with noncancer patients.

Trends and Outcomes With Transcatheter Versus Surgical Mitral Valve Repair in Patients ≥80 Years of Age

Transcatheter mitral valve repair (TMVR) has shown comparable outcomes to surgical mitral valve replacement or repair (SMVR) in patients who are at a higher risk of surgical complications and therefore are not amenable to surgery. Elderly patients are considered poor surgical candidates due to their advanced age, and presence of comorbidities. A sub-analysis of EVEREST II (Endovascular Valve Edge-to-Edge Repair Study) trial identified patients of >70 years of age appear to have a similar risk-benefit profile for either approach of surgery or transcatheter. This finding does have some caveats considering the trial included surgical cohort with both repair and replacement. Utilizing the National Inpatient Sample, we identified a surgical cohort of ≥80 years of age that underwent mitral valve repair and used propensity matching to compare it with a similar cohort that underwent TMVR. In a well-balanced cohort, TMVR was associated with significantly lower in-patient mortality (0.7% vs 3.1%). TMVR was also associated with significantly decreased in-hospital complications such as acute kidney injury, cardiogenic shock, postoperative hemorrhage, transfusion, permanent pacemaker, and respiratory and vascular complications. Owing to this, the duration of hospital stay is approximately 6 days less with TMVR. Trend analysis has shown a paradigm shift in these elderly patients with 85% of all repairs in 2012 were performed surgically, whereas in 2016 almost 94% of all the repairs being performed via a transcatheter approach. In conclusion, in patients ≥80 years of age, the surgical MVR had 4-fold higher mortality compared to TMVR with higher cardiac, vascular, hemorrhagic and respiratory complications. Despite the limitations of being observational in nature, this data strongly supports the preferential use of the transcatheter approach for mitral valve repair in patients ≥80 years of age.

Transcatheter valve-in-valve or valve-in-ring mitral valve implantation in young women contemplating pregnancy

Transcatheter mitral valve implantation (TMVI) is emerging as an alternative to surgical mitral valve replacement (SMVR) in selected high-risk patients. It may avoid redo-biological SMVR and delay definitive mechanical SMVR in young women wishing for pregnancy and suffering from failure of mitral bioprosthesis or annuloplasty. To evaluate the feasibility, safety and outcomes of TMVI in this specific population. From 2013 to 2018, 12 young women with degenerated mitral bioprostheses ( n = 6) and annuloplasties ( n = 6), pregnant ( n = 1) or wishing for pregnancy ( n = 11), were treated with transseptal valve-in-valve or valve-in-ring TMVI, using the Edwards SAPIEN XT/3 valves, and were prospectively followed at 1 month, 6 months, 1 year and yearly thereafter. Mean age was 29 ± 5 years and EuroSCORE II 3.2 ± 0.8%. The mode of failure was stenosis in 9 cases and regurgitation in 3. Systolic pulmonary artery pressure was 56 ± 26 mmHg. One TMVI was performed in emergency, in the setting of severe bioprosthesis failure complicated by cardiogenic shock and multiorgan failure. One per-procedure prosthesis atrial embolization occurred and required a conversion to standard surgery. One intra-ventricular obstruction was secondarily observed and lead to an elective SMVR. Median follow-up was 36 (4–51) months. At 6 months/1 year, 83% of the patients were in NYHA classes I/II. Mitral regurgitation was ≤ 1+ in all the cases and mean gradient was 8 ± 2 mmHg. Three patients could achieve 4 uneventful pregnancies. At last follow-up, there was no death and 3 patients underwent definitive mechanical SMVR. Valve-in-valve and valve-in-ring TMVIs avoid redo biological SMVR and allow young women carrying through uneventful pregnancies. This strategy delays definitive mechanical SMVR and the drawbacks of anticoagulation and may appear as a promising option in young women contemplating pregnancy.

P1458 Recurrent endocarditis on mitral valve prosthesis

Abstract Patient Presentation and initial work up A 72 years old man with history of hypertension was admitted to our hospital due to acute pulmonary oedema. He had no fever at that time and he had an history of known mitral valve prolapse but with no reported mitral valve regurgitation (MR). Transthoracic Echocardiogram (TTE) was performed and it showed a severe MR. Transesophageal echocardiogram (TOE) showed prolapse of the posterior leaflet of the mitral valve with suspicion of cordal rupture and the presence of an aneurysm of the anterior mitral valve leaflet with perforation of it (panel A and B). Diagnosis and Management Diagnosis of severe MR as the result of previous endocarditis was made. Blood cultures were negative, as well as there were no signs of active endocarditis. However, since there were heart failure and signs of uncontrolled infection, the patient underwent surgical mitral valve replacement (MVR) with bioprosthesis. Moreover, it was started antibiotic therapy with vancomycin, rifampin and ceftriaxone, which was continued for two weeks and then stopped since the microbiological culture of the valve was negative. Follow-up After two months he was re-admitted to the hospital due to a new onset of breathlessness. TTE showed a dehiscence of the mitral prosthetic valve in the inferolateral zone with rocking movement, subvalvular pseudoaneurysm and moderate paravalvular leak (panel C and D). Blood cultures were positive for Staphylococcus Aureus. Consequently, the patient underwent a new surgical MVR. Furthermore, six weeks of antibiotic therapy were carried out with daptomycin and rifampin. However, after another three months, he was admitted once again to the hospital for heart failure with a new evidence of abruption of the mitral prosthesis, again in the inferolateral region and, this time, with the evidence of a vegetation on the atrial side of the prosthesis (panel E and F). Again, blood cultures were positive for Staphylococcus Aureus, and the patient underwent the third surgical intervention of MVR. Another six weeks of antibiotic therapy with daptomycin and rifampin were performed. The patient was then discharged and he is now strictly followed clinically. Conclusion In conclusion, we reported the case of a recurrent relapse of endocarditis on mitral valve prosthesis due to Staphylococcus Aureus infection. Interestingly, the mitral prosthesis was involved always in the same zone (inferolateral area) with abruption of the prosthesis and significant paravalvular regurgitation. At the second relapse there was also a vegetation on it and both times blood cultures were positive. Moreover, antibiotic therapy was conducted for six weeks both times, but the recurrence of endocarditis showed us that he was a sensitive patient and that in cases of relapses like this it should be performed a more careful clinical follow up, involving frequent laboratory tests and clinical and echocardiographic evaluations. Abstract P1458 Figure.

Congenital Mitral Aortic Intervalvular Fibrosa Aneurysm with Submitral Aneurysm

Congenital aneurysm of the mitral aortic intervalvular fibrosa (MAIVF) is a relatively rare condition. It was initially described in the African population and subsequently reported in other racial groups. Many of the subaortic aneurysms arise from the MAIVF; association with submitral aneurysm (SMA) is even rare. They more commonly occur as a pseudoaneurysm of the MAIVF-P, which is usually due to a complication of endocarditis or aortic valve surgery. Diagnosis is usually with echocardiography, and complete confirmation and anatomical assessment are done by computerised tomography and cardiac magnetic resonance imaging, which are useful for surgical evaluation. Surgery is the only treatment when it is large or symptomatic or has related complications, such as rupture, compression of adjacent structures, embolic events, mitral regurgitation, or heart failure. Here, case is presented of a congenital variety of MAIVF aneurysm with congenital SMA, in a 31-year-old female. She presented with breathlessness. She had mitral regurgitation, and had to undergo surgical repair and mitral valve replacement. This may be the first case reported of a congenital MAIVF aneurysm with a congenital SMA.