Valve Repair Research Articles

Presentation and outcomes of women and men undergoing surgery for degenerative mitral regurgitation.

Degenerative mitral regurgitation is associated with heart failure, arrhythmia and mortality. The impact of sex on timing of surgical referral and outcomes has not been reported comprehensively. We examined preoperative status and surgical outcomes of male versus female degenerative mitral valve regurgitation patients undergoing surgery. We reviewed our institutional database for all patients undergoing surgery for degenerative mitral regurgitation between 2013 and 2021. Preoperative clinical and echocardiographic variables, surgical characteristics and outcomes were compared, and left atrial strain in available images. Of 963 patients, 314 (32.6%) were female. Women were older (67 vs 64 years, P = 0.031) and more often had bileaflet prolapse (19.4% vs 13.8%, P = 0.028), mitral annular calcification (12.1% vs 5.4%, P < 0.001) and tricuspid regurgitation (TR; 31.8% vs 22.5%, P = 0.001). Indexed left ventricular end-diastolic and end-systolic diameters were higher in women, with 29.4 vs 26.7 mm/m2 (P < 0.001) and 18.2 vs 17 mm/m2 (P < 0.001), respectively, and left atrial conduit strain lower (17.6% vs, 21.2%, P = 0.001). Predicted risk of mortality was 0.73% vs 0.54% in men (P = 0.023). Women required mechanical circulatory support more frequently (1.3% vs 0%, P = 0.011), had longer intensive care unit stay (29 vs 26 h, P < 0.001), mechanical ventilation (5.4 vs 5 h, P = 0.036), and overall hospitalization (7 vs 6 days, P < 0.001). There was no difference in long-term reoperation-free survival (P = 0.35). Women undergoing mitral valve repair are older and show indicators of more advanced disease with long-standing left ventricular impairment. Guidelines may need to be adjusted and address this disparity, to improve postoperative recovery times and outcomes.

Surgery for the right vertical infra-axillary thoracotomy in treatment of outlet ventricular septal defect in children

BackgroundOutlet ventricular septal defect is often associated with aortic valve regurgitation. Early intervention in these subjects is essential to avoid complications of irreversible aortic valve regurgitation after surgery. ObjectiveThis study aims to evaluate the safety and feasibility of right vertical infra-axillary thoracotomy for the treatment of outlet ventricular septal defect in pediatric patients. MethodsThis report includes data from 39 pediatric patients who underwent right vertical infra-axillary thoracotomy from January 2020 to April 2023. The ventricular septal defect was approached via the pulmonary artery and closed using autologous or bovine pericardium. Intraoperative management of associated lesions included tricuspid valve repair, widening of the right ventricular outflow tract with excision of jet lesions, and ligation of the ductus arteriosus. ResultsThe average weight of the pediatric patients was 8.4 ± 6 kg, with the average age at intervention being 17.1 months. Approximately 50 % of the patients exhibited signs of heart failure preoperatively, and in 38.5 % of cases, the defect was located beneath the two great arteries. The mean durations for extracorporeal circulation and cardioplegia were 113.5 ± 22 min and 70.3 ± 17 min, respectively. There were no postoperative deaths, and no patient required conversion to an alternative surgical approach. The average duration of mechanical ventilation was 17.6 ± 20.7 h, and the postoperative hospital stay averaged 6.8 ± 2.2 days. Follow-up was conducted in all patients, with an average duration of 17.4 months. There was one case of mild residual shunt, one case requiring re-intervention for aortic valve regurgitation, and one case of elevated shoulder blade due to damage to the long thoracic nerve. No instances of mammary asymmetry were observed. ConclusionRight vertical infra-axillary thoracotomy is a safe and feasible alternative for the treatment of outlet ventricular septal defect in children. Further studies across multiple centers are recommended to assess the efficacy of this approach.

Mitral valve repair in ventricular functional mitral regurgitation: a simplified technique of papillary muscles relocation.

Mitral valve repair techniques in ventricular functional mitral regurgitation are controversial due to ongoing debates about long-term repair durability in the setting of left ventricular remodelling. To address the limitations of conventional annuloplasty, subannular techniques, such as papillary muscle relocation, have been developed. However, the limited reproducibility of these techniques has hindered their widespread adoption. In this context, we introduce a simplified and reproducible method for papillary muscle relocation. This method utilizes transoesophageal echocardiographic guidance and premeasured polytetrafluoroethylene loops to streamline the procedure.

The value of percutaneous transcatheter mitral valve regurgitation repair in the combination treatment of chronic heart failure patients: Results from a 6-month observational prospective study

Rationale: Surgical interventions have been recognized as the main method to repair of valvular disorders. Percutaneous transcatheter intervention with a clipping system is being actively introduced into the treatment of chronic heart failure (CHF) patients and mitral valve insufficiency (MVI) for correction of mitral regurgitation (MR), along with drug therapy. Aim: To establish the effect of the mitral valve leaflet clipping in the combination treatment of CHF patients on the clinical course of heart failure and the remodeling process. Methods: This single center prospective comparative study included 80 patients with CHF NYHA class II–IV and secondary MR grade 3–4. The patients were on optimal medical treatment (OMT) for CHF for at least 3 months before inclusion into the study. The main group included 55 patients who underwent transcatheter mitral valve repair with the use of MitraClip system, and the control group consisted of 25 patients in whom the surgery for MR was waived for various reasons (refusal of the surgery by the patient, some valve characteristics), and only OMT for CHF was used. At baseline, main clinical and demographic characteristics of the patients in the both groups were comparable. The duration of the follow-up was 6 months. Echocardiography (echoCG), a 6-minute walk test, and measurements of the brain natriuretic propeptide level were performed in all patients at baseline and at 6 months of the follow-up. Results: At 6 months, there was a significant reduction in CHF NYHA class and an increase in the 6-minute walk test distance and a decrease in diuretic requirements (converted to furosemide, from 58.4 ± 17.2 to 38.1 ± 20.7 mg daily, р = 0.02) in the group with the MitraClip implant, but not in the control group. In the OMT only group, there were no changes over 6 months in the diuretic requirements (48.1 ± 6.68 and 43.8 ± 27.15 mg daily, respectively, р = 0.8). The number of hospital readmissions due to CHF decompensation was 7 (12.7%) in the implanted MitraClip group and 4 (16%) in the OMT group (р = 0.69). EchoCG performed at 6 months after the surgical intervention identified no cases of MR grade 2. In the MitraClip implant group, there was a decrease in the size and volumes of the left atrium (р = 0.02 and р = 0.05, respectively), left ventricle (for end-diastolic diameter p = 0.002, end-diastolic volume p = 0.03), mean pulmonary artery pressure (p = 0.03), as well as an increase in cardiac output (р = 0.04). In the patients receiving OMT only, there were no significant changes in EchoCG parameters over time. Conclusion: Our study has shown benefits of the implantation of the mitral valve leaflet clipping system, compared to OMT only, in CHF. The clipping procedure promotes a significant improvement in clinical course of CHF, reverse myocardial remodeling, and reduction in diuretic requirements.

Clinical implications of different methods to assess left atrial remodeling: A comparative study between echocardiography and cardiac magnetic resonance imaging for left atrial volume index quantification

BackgroundLeft atrial volume index (LAVI) serves as a crucial marker for assessing left atrial (LA) remodeling, particularly in patients with mitral valve regurgitation (MR). Recent guidelines recommend a LAVI exceeding 60 mL/m2 as Class IIa recommendation for mitral valve repair surgery in asymptomatic MR patients with preserved left ventricular function. Traditionally, echocardiography is the standard for assessing LAVI in MR patients. However, cardiac magnetic resonance imaging (CMR) is increasingly recognized for its more precise measurements of cardiac dimensions and volumes. But still, literature remains scarce on comparing the efficacy of both modalities in assessing LAVI measurements. MethodsThis retrospective study included 168 MR patients undergoing both echocardiography and CMR assessments within a six-month period. LAVI measurements were compared using Pearson correlation and Bland-Altman plots. Patients were stratified based on MR grades, and clinical implications were assessed. ResultsMean LAVI differed significantly between echocardiography and CMR (47.1 ± 20.8 mL/m2 versus 70 ± 20.3 mL/m2, p < 0.001, respectively). CMR consistently yielded higher LAVI measurements compared to echocardiography, with a mean difference of approximately 20 mL/m2. CMR measurements resulted in an increased incidence of patients meeting the class IIa LAVI criterion (LAVI >60 mL/m2) by 37%. Variations in LAVI did not differ across MR grades. ConclusionEchocardiography systematically underestimates LAVI compared to CMR in MR patients. While current guidelines rely on echocardiography, CMR's precision suggests the need for CMR-specific LAVI cutoff values to guide clinical management effectively. Establishing such values could refine patient stratification and timing of surgery, potentially improving clinical outcomes for MR patients.

Application of machine learning to predict in-hospital mortality after transcatheter mitral valve repair

IntroductionTranscatheter mitral valve repair offers a minimally invasive treatment option for patients at high risk for traditional open repair. We sought to develop dynamic machine-learning risk prediction models for in-hospital mortality after transcatheter mitral valve repair using a national cohort. MethodsAll adult hospitalization records involving transcatheter mitral valve repair were identified in the 2016–2020 Nationwide Readmissions Database. As a result of initial class imbalance, undersampling of the majority class and subsequent oversampling of the minority class using Synthetic Minority Oversampling TEchnique were employed in each cross-validation training fold. Machine-learning models were trained to predict patient mortality after transcatheter mitral valve repair and compared with traditional logistic regression. Shapley additive explanations plots were also developed to understand the relative impact of each feature used for training. ResultsAmong 2,450 patients included for analysis, the in-hospital mortality rate was 1.8%. Naïve Bayes and random forest models were the best at predicting transcatheter mitral valve repair postoperative mortality, with an area under the receiver operating characteristic curve of 0.83 ± 0.05 and 0.82 ± 0.04, respectively. Both models demonstrated superior ability to predict mortality relative to logistic regression (P < .001 for both). Medicare insurance coverage, comorbid liver disease, congestive heart failure, renal failure, and previous coronary artery bypass grafting were associated with greater predicted likelihood of in-hospital mortality, whereas elective surgery and private insurance coverage were linked with lower odds of mortality. ConclusionMachine-learning models significantly outperformed traditional regression methods in predicting in-hospital mortality after transcatheter mitral valve repair. Furthermore, we identified key patient factors and comorbidities linked with greater postoperative mortality. Future work and clinical validation are warranted to continue improving risk assessment in transcatheter mitral valve repair .

Impact of transcatheter edge-to-edge valve repair on hemostasis in patients with severe mitral regurgitation: key findings from the Mitral Fibrin Study.

Impact of transcatheter edge-to-edge valve repair on hemostasis in patients with severe mitral regurgitation: key findings from the Mitral Fibrin Study.

Commentator Discussion: Mitral valve repair with leaflet resection versus preservation for degenerative posterior leaflet prolapse

Commentator Discussion: Mitral valve repair with leaflet resection versus preservation for degenerative posterior leaflet prolapse

Anesthesia management for percutaneous mitral valve repair in a patient with mitochondrial cardiomyopathy and low cardiac function: a case report

BackgroundMitochondrial cardiomyopathy occurs when impaired mitochondrial energy production leads to myocardial dysfunction. Anesthetic management in such cases is challenging due to risks of circulatory depression associated with anesthesia and mitochondrial dysfunction induced by anesthetics. Although there are reports of anesthetic management for patients with mitochondrial diseases, there are few reports specifically addressing cardiac anesthesia for patients with mitochondrial cardiomyopathy. We present a case where percutaneous mitral valve repair with MitraClip™ was successfully performed under remimazolam anesthesia in a patient with mitochondrial cardiomyopathy who developed functional mitral valve regurgitation due to low cardiac function and cardiomegaly.Case presentationA 57-year-old woman was diagnosed with chronic cardiac failure, with a 10-year history of dilated cardiomyopathy. She was diagnosed with mitochondrial cardiomyopathy 8 years ago. Over the past 2 years, her cardiac failure worsened, and mitral valve regurgitation gradually developed. Surgical intervention was considered but deemed too risky due to her low cardiac function, with an ejection fraction of 26%. Therefore, percutaneous MitraClip™ implantation was selected. After securing radial artery and central venous catheterization under sedation with dexmedetomidine, anesthesia was induced with a low dose of remimazolam 4 mg/kg/h. Anesthesia was maintained with remimazolam 0.35–1.0 mg/kg/h and remifentanil 0.1 μg/kg/min. Noradrenaline and dobutamine were administered intraoperatively, and the procedure was completed successfully without circulatory collapse. The patient recovered smoothly from anesthesia and experienced no complications. She was discharged on the eighth day after surgery.ConclusionAnesthesia management with remimazolam appears to be a safe and effective for MitraClip™ implantation in patients with mitochondrial cardiomyopathy.

Advances in Diagnostic and Interventional Catheterization in Adults with Fontan Circulation.

Over the past five decades, the Fontan procedure has been developed to improve the life expectancy of patients with congenital heart defects characterized by a functionally single ventricle. The Fontan circulation aims at redirecting systemic venous return to the pulmonary circulation in the absence of an impelling subpulmonary ventricle, which makes this physiology quite fragile and leads to several long-term complications. Despite the importance of hemodynamic assessment through cardiac catheterization in the management and follow-up of these patients, a thorough understanding of the ultimate functioning of this type of circulation is lacking, and the interpretation of the hemodynamic data is often complex. In recent years, new tools such as combined catheterization with cardiopulmonary exercise testing have been incorporated to improve the understanding of the hemodynamic profile of these patients. Furthermore, extensive percutaneous treatment options have been developed, addressing issues ranging from obstructive problems in Fontan pathway and acquired shunts through compensatory collaterals to the percutaneous treatment of lymphatic circulation disorders and transcatheter edge-to-edge repair of atrioventricular valves. The aim of this review is to detail the various tools used in cardiac catheterization for patients with Fontan circulation, analyze different percutaneous treatment strategies, and discuss the latest advancements in this field.

Machine Learning and Statistical Shape Modelling Methodologies to Assess Vascular Morphology before and after Aortic Valve Replacement.

Introduction: Statistical shape modelling (SSM) is used to analyse morphology, discover qualitatively and quantitatively unique shape features within a population, and generate mean shapes and shape modes that show morphological variability. Hierarchical agglomerative clustering is a machine learning analysis used to identify subgroups within a given population in relation to shape features. We tested the application of both methods in the clinically relevant scenario of patients undergoing aortic valve repair (AVR). Every year, around 5000 patients undergo surgical AVR in the UK. Aims: Evaluate aortic morphology and identify subgroups amongst patients who had undergone AVR, including Ozaki, Ross, and valve-sparing procedures using SSM and unsupervised hierarchical clustering analysis. This methodological framework can evaluate both pre- and post-surgical variability across subgroups undergoing different surgeries. Methods: Pre- (n = 47) and post- (n = 35) operative three-dimensional (3D) aortic models were reconstructed from computed tomography (CT) and cardiac magnetic resonance (CMR) images. Computational analyses for SSM and hierarchical clustering were run separately for the two subgroups, assessing (a) ascending aorta only and (b) the whole aorta. This allows for exploring possible variations in morphological classification related to the input shape. Results: Most patients in the Ross procedure subgroup exhibited differences in aortic morphology from other subgroups, including an elongated ascending and wide aortic arch pre-operatively, and an elongated ascending aorta with a slightly enlarged sinus post-operatively. In hierarchical clustering, the Ross aortas also appeared to cluster together compared to the other surgical procedures, both pre-operatively and post-operatively. There were significant differences between clusters in terms of clustering distance in the pre-operative analyses (p = 0.003 for ascending aortas, p = 0.016 for whole aortas). There were no significant differences between the clusters in post-operative analyses (p = 0.47 for ascending, p = 0.19 for whole aorta). Conclusions: We demonstrated the feasibility of evaluating aortic morphology before and after different aortic valve surgeries using SSM and hierarchical clustering. This framework could be used to further explore shape features associated with surgical decision-making pre-operatively and, importantly, to identify subgroups whose morphology is associated with poorer clinical outcomes post-operatively. Statistical shape modelling (SSM) and unsupervised hierarchical clustering are two statistical methods that can be used to assess morphology, show morphological variations, with the latter being able to identify subgroups within a population. These methods have been applied to the population of aortic valve replacement (AVR) patients since there are different surgical procedures (traditional AVR, Ozaki, Ross, and valve-sparing). The aim is to evaluate aortic morphology and identify subgroups within this population before and after surgery. Computed tomography and cardiac magnetic resonance images were reconstructed into 3D models of the ascending aorta and whole aorta, which were then input into SSM and hierarchical clustering. The results show that the Ross aortic morphology is quite different from the other aortas. The clustering did not classify the aortas based on the surgical procedures; however, most of the Ross group did cluster together, indicating low variability within this surgical group.

Incidence and Predictors of Cerebrovascular Accidents in Patients Who Underwent Transcatheter Mitral Valve Repair With MitraClip

Transcatheter mitral edge-to-edge repair (TEER) with transcatheter devices has become a mainstay in the minimally invasive treatment of patients with severe mitral regurgitation at increased surgical risk. Despite its apparently favorable risk profile, there is uncertainty on the risk and features of cerebrovascular accidents (CVAs) early and long after transcatheter mitral valve repair. We aimed to appraise the incidence and predictors of CVA in patients who underwent TEER. We explicitly queried the data set of an ongoing multicenter prospective observational study dedicated to TEER with MitraClip (Abbott Vascular, Santa Clara, California). The incidence of CVAs after TEER was formally appraised, and we explored potential predictors of such events. Descriptive, bivariate, and diagnostic accuracy analyses were performed. Of 2,238 patients who underwent TEER, CVAs occurred in 33 patients (1.47% [95% confidence interval 1.02% to 2.06%]), including 6 (0.27% [0.10% to 0.58%]) in-hospital strokes and 27 events after discharge (0.99% [0.66% to 1.44%]), over a median follow-up of 14 months. Most CVAs were major ischemic strokes during and after the in-hospital phase. Overall, CVAs were more common in patients with atrial fibrillation (p = 0.018), renal dysfunction (p = 0.032), higher EuroSCORE II (p = 0.033), and, as expected, higher CHA2DS2-VASc score (p = 0.033), despite the limited prognostic accuracy of the score. Notably, the occurrence of CVA did not confer a significantly increased risk of long-term (p = 0.136) or cardiac death (p = 0.397). The incidence of CVA in patients who underwent TEER is low, with most events occurring after discharge and being associated with preexisting risk features. These findings, although reassuring on the safety of TEER, call for proactive antithrombotic therapy whenever CVA risk is increased before and after TEER.

The prognostic value of changes in pulmonary vein flow patterns after surgical repair for primary mitral regurgitation

Background: The pulmonary vein (PV) flow pattern is influenced by the presence of mitral regurgitation (MR). After a successful reduction in MR severity, the pattern is expected to be changed. We aimed to evaluate the prognostic value of a change in the PV flow pattern in patients with primary MR undergoing mitral valve repair (MVR). Methods: The PV flow pattern was assessed with transthoracic echocardiography in 216 patients (age 65 [IQR 56–72] years, 70% male) with primary MR before and after surgical MVR. The population was divided according to a change in the PV flow pattern following MVR into ‘improvers’ and ‘non-improvers’. Results: Non-improvers (15%) had a higher prevalence of paroxysmal AF at baseline (46% vs. 22%, p = 0.004), left ventricular dysfunction (LVEF ≤60%) (39% vs. 21%, p = 0.020), and had lower systolic pulmonary artery pressure (28[IQR 25–38] vs. 35[IQR 26–48] mmHg, p = 0.018) compared to improvers (85%). After a median follow-up of 83[IQR 43–140] months, 26(12%) patients died. Non-improvers had higher mortality rates than improvers (p = 0.009). On multivariable Cox regression analysis, a lack of improvement in the PV flow pattern remained independently associated with all-cause mortality (HR 2.322, 95% CI 1.140 to 4.729, P = 0.020). Conclusion: A lack of improvement in the PV flow pattern is independently associated with worse long-term survival in patients with primary MR undergoing MVR.

Clinical presentation and surgical outcomes in patients with Shone's complex: a systematic review.

Shone's complex comprises ofa combination of congenital cardiac anomalies causing obstructions in the left ventricle's inflow and outflow tracts. This systematic review aims to evaluate the clinical features and surgical outcomes of Shone's complex. An electronic literature search of PubMed and Scopus was performed to identify relevant studies related to the presentation, management, and outcomes of Shone's complex. Two reviewers independently performed selection. Data on study characteristics, participant demographics, interventions, outcomes, and follow-up durations were extracted and analyzed. A total of 691 papers were identified, with 18 studies included in the final analysis. The majority of the studies (n = 12) focused on the pediatric age group. The most common clinical presentations were coarctation of the aorta (n = 17) and mitral stenosis (n = 12). Surgical interventions often involved staged approaches, prioritizing outflow before inflow obstructions. Mitral valve repair was preferred over replacement due to better long-term outcomes (n = 8). Biventricular repair was recommended due to improved postoperative outcomes, but often needed reoperations. Reoperations were common, primarily due to recurrent coarctation (n = 10), subaortic stenosis (n = 8), and mitral valve dysfunction (n = 7). Pulmonary hypertension (n = 10) and arrhythmias (n = 11) were significant complications. Most patients were in modified Ross/NYHA functional class 1 on follow-up. Mortality rates ranged from 4 to 28%, with better outcomes associated with early and strategic surgical interventions. Early diagnosis and biventricular repair were associated with better outcomes while transplantation was often an eventuality. Standardized diagnostic criteria, long-term follow-up, and consensus guidelines are needed to improve the management of this congenital heart disease.

Impact of Complex Anatomy and Patient Risk Profile in Minimally Invasive Mitral Valve Surgery

BackgroundWe aimed to assess the impact of complex mitral valve disease and patient risk profile on operative outcomes in the large cohort of the Mini-Mitral International Registry. MethodsPatients were assigned to categories of complex degenerative mitral valve regurgitation (DMR; bileaflet or anterior mitral leaflet prolapse/flail) and simple DMR (posterior mitral leaflet prolapse/flail). Subgroup analyses was performed in low-risk (EuroSCORE II <8%) and high-risk (EuroSCORE II >8%) cohorts. A logistic regression model was applied to investigate the impact of valve anatomy and patient risk factors on valve repair rate and operative risk. ResultsThe study cohort consisted of 4524 patients with DMR (complex DMR, 1296; simple DMR, 3228). Valve repair rate was 87.3% and 91% in complex DMR and simple DMR, respectively. Predictors of valve replacement were anterior leaflet prolapse/flail, bileaflet flail, female sex, age, and reoperation, whereas Barlow disease was protective. Clinical results were comparable between complex DMR and simple DMR. On subgroup analyses, high-risk patients showed less satisfactory outcomes with respect to both the valve repair and operative mortality rates. ConclusionsOur findings suggest that complex DMR can be satisfactorily addressed by minimally invasive techniques. However, whereas complex disease was associated with low operative risk, anterior leaflet lesions and bileaflet flail remain negative predictors of successful valve repair. Conversely, valve repair rate was less satisfactory in high-risk patients, regardless of DMR complexity.

Risk Factors and Outcomes of Acute Kidney Injury After Cardiac Surgery: A Retrospective Observational Single-Center Study.

Acute kidney injury (AKI) following cardiac surgery is a well-described phenomenon, usually associated with hemodynamic changes ultimately leading to ischemic injury to the kidneys. In this study, we assessed the occurrence of AKI in a cohort of patients undergoing elective cardiac surgery at a single center. Patients undergoing elective cardiac surgery (coronary artery bypass grafting (CABG) and/or valve repair) between the years 2016 and 2022 were retrospectively included in the study. During the study, 167 patients underwent CABG, valve replacement, or both procedures. The majority were male (85.0%). Post-operative AKI was observed in 27.5% of patients, with 2.4% requiring continuous renal replacement therapy (CRRT)/dialysis. The majority of AKI cases were staged as Kidney Disease: Improving Global Outcomes (KDIGO) stage 1. Among patients needing CRRT/dialysis, 1.8% recovered renal function within 3 months, with 0.6% experiencing 30-day mortality. In univariate analysis, factors associated with AKI included older age (P = 0.003), severe anemia (P < 0.0001), pre-operative creatinine elevation (P < 0.0001), complex surgeries (P < 0.0001), blood product transfusion (P < 0.0001), longer cross-clamp (XC) and cardiopulmonary bypass (CPB) times (P < 0.0001), and inotropes usage (P < 0.0001). Classical risk factors like diabetes mellitus (DM) and hypertension did not show significant differences. The majority of these factors (severe anemia, age, pre-operative creatinine, post-operative inotrope usage, and cross-clamp times) were consistently significant (P < 0.05) in logistic regression analysis. Post-operative AKI following cardiac surgery is frequent, with significant associations seen especially with pre-operative anemia. Future investigations focusing on the specific causes of anemia linked to AKI development are essential, considering the high prevalence of hemoglobinopathy traits in our population.

Incidence and Risk Factors for Permanent Pacemaker Implantation After Tricuspid Valve Repair

BackgroundAlthough the likelihood of needing a permanent pacemaker (PPM) after tricuspid valve (TV) repair has been thought to be low compared with TV replacement, the incidence and determinants are controversial. This study aimed to evaluate the incidence and risk factors for PPM implantation after TV repair. MethodsA total of 1237 consecutive patients undergoing TV repair from 1997 to 2019 were reviewed using a prospectively maintained database, and 1058 patients were enrolled. ResultsIncidence of PPM implantation was 10.3% (n = 109). Median time to PPM implantation was 7 (range, 6-9) days. Indications for PPM implantation were heart block (n = 62, 56.9%), junctional or sinus bradycardia (n = 21, 19.3%), and ventricular arrhythmia (n = 17, 15.6%). Likelihood of PPM varied with concurrent procedures: left ventricular assist device (3.4%), mitral repair (11.2%), mitral valve replacement (13.7%), aortic and mitral valve replacement (19.2%), and isolated tricuspid repair (6.5%). Older age (odds ratio [OR], 1.020; 95% CI, 1.003-1.036), prior mediastinal radiation (OR, 4.106; 95% CI, 1.598-10.554), and concomitant mitral and aortic valve replacement (OR, 1.963; 95% CI, 1.046-3.683) were risk factors, and concomitant left ventricular assist device implantation (OR, 0.325; 95% CI, 0.139-0.759) was a protective factor for PPM implantation. PPM implantation did not affect the early outcomes, overall survival (P =.287), or cumulative incidence of recurrent moderate or greater tricuspid regurgitation (P =.890) or TV reoperation (P =.602). ConclusionsThe likelihood of PPM implantation after TV repair is relatively high, but PPM implantation does not affect the early and long-term clinical outcomes. Older age, prior mediastinal radiation, and concomitant mitral and aortic valve replacement are risk factors, and concomitant left ventricular assist device implantation is a protective factor for PPM implantation after TV repair.

The cone repair allows right ventricle rehabilitation with excellent tricuspid valve function following the Starnes procedure

BackgroundWe present a case series of right ventricle (RV) rehabilitation after the Starnes procedure in patients with Ebstein anomaly (EA), applying the Cone repair of the tricuspid valve (TV) to achieve 2-ventricle or 1.5-ventricle physiology. MethodsThis is a retrospective database analysis from 2 institutions in North America. We included all consecutive cases of Cone repair after the Starnes procedure. The data are expressed as median and interquartile range (IQR). ResultsEleven patients underwent RV rehabilitation between 2019 and 2023 after initial Starnes palliation at a median age of 27 months (IQR, 20.5 months). All patients were critically ill before their Starnes procedure, and 4 were on extracorporeal membrane oxygenation. Before the Cone repair, the median preoperative regurgitant velocity at the Starnes patch was 1.65 m/s (IQR, 1.3 m/s). During the Cone procedure, 9 patients required a concomitant pulmonary valve repair, of whom 3 needed a transannular monocusp patch. Four patients were successfully rerouted to a 2-ventricle repair, and 7 patients with a previous Glenn achieved 1.5-ventricle circulation. There were no cases of heart block and no deaths. Seven patients had trivial, 3 patients had mild, and 1 patient had moderate tricuspid regurgitation (TR) at a median follow-up of 11 months (IQR, 21.5 months). There was no significant TV stenosis; all patients had good functional status at the last follow-up despite severe RV dysfunction in 1 patient. ConclusionsAfter the Starnes procedure, the Cone repair allowed RV rehabilitation, resulting in trivial or mild TR at a midterm follow-up. The Starnes procedure is a reproducible technique that no longer commits patients to lifetime single-ventricle physiology.

Antithrombotic therapy for transcatheter structural heart intervention.

Percutaneous transcatheter structural heart interventions have considerably expanded within the last two decades, improving clinical outcomes and quality of life versus guideline-directed medical therapy for patients frequently ineligible for surgical treatment. Transcatheter structural heart interventions comprise valve implantation or repair and also occlusions of the patent foramen ovale, atrial septal defects and left atrial appendage. These procedures expose structural devices to arterial or venous blood flow with various rheological conditions leading to potential thrombotic complications and embolisation. Furthermore, these procedures may concern comorbid patients at high risk of both ischaemic and bleeding complications. This state-of-the-art review provides a description of the device-related thrombotic risk associated with these transcatheter structural heart interventions and of the current evidence-based guidelines regarding antithrombotic treatments. Gaps in evidence for each of the studied transcatheter interventions and the main ongoing trials are also summarised.

Comparison of preoperative aortic valve imaging techniques for patients with aortic insufficiency undergoing aortic valve repair surgery

ObjectiveTo report the accuracy of preoperative 4-dimensinal cardiac computed tomography angiogram (CTA), real-time 3-dimensional transesophageal echocardiography (TEE) and intraoperative techniques in aortic valve (AV) measurement and phenotype determination in patients undergoing surgery for aortic insufficiency and/or root aneurysm. MethodsThis is a prospective, observational study of preoperative AV imaging for AV repair surgery. Twenty-two patients were accrued over 12 months. Preoperative TEE and CTA were obtained and measurements provided by dedicated imaging cardiologists. Intraoperative measurements were obtained from the arrested heart and reported by the surgeon before repair. Intraoperative assessment was considered the gold standard of height measurements, with CTA being the standard assessment for commissural orientation. Correlation coefficients were used to describe agreement of measurements. ResultsBaseline characteristics and assessment of phenotype and measurement of commissural orientation, geometric height and commissural heights are reported. TEE (κ = 0.833; P < .01) and CTA (κ = 0.729; P < .01) both agreed with intraoperative assessment of AV phenotype. TEE appeared more accurate than intraoperative measurement at predicting commissural orientation (rs = 0.79; P < .01 vs rs = 0.58; P = .01). CTA and TEE were unlikely to predict and measured shorter than intraoperative geometric height measurement. Measurements of commissural heights by CTA did not agree with and were shorter than intraoperative measurement. ConclusionsTEE and CTA both appear accurate in predicting the AV phenotype identified intraoperatively. CTA and TEE predicted shorter heights than intraoperative measurement.