Pathophysiology and management of multivalvular disease

Recovery of left ventricular function after surgery for aortic and mitral regurgitation with heart failure

Background

Severe aortic regurgitation (AR) and mitral regurgitation (MR) can lead to left ventricular (LV) systolic dysfunction; however, there are limited data about recovery of LV after surgery for AR or MR. Little is known to guide the management of combined AR and MR (mixed valvular heart disease [VHD]). This study is sought to investigate the predictors of postoperative LV function recovery in left-sided regurgitant VHD with reduced left ventricular ejection fraction (LVEF), especially for mixed VHD.

Methods

From 2010 to 2020, 2053 adult patients underwent aortic or mitral valve surgery at our center. The patients with valvular stenosis, infective endocarditis, concomitant revascularization, and preoperative LVEF ≥40 % were excluded. A total of 127 patients were included in this study: 22 patients with predominant AR (AR group), 64 with predominant MR (MR group), and 41 with combined AR and MR (AMR group).

Results

The mean preoperative LVEF was 32.4 %, 30.7 %, and 30.2 % (p = 0.44) in the AR, MR, and AMR groups, respectively. The AR group was more likely to have postoperative LVEF recovery. The cut-point of left ventricular end-systolic diameter (LVESD) for better recovery was 49 mm for the MR group and 58 mm for the AMR group.

Conclusion

LV dysfunction due to combined AR and MR has similar remodeling reserve as AR, and better recoverability than MR. Thus, double-valve surgery is recommended before the LVESD is > 58 mm.

The Molecular Mechanisms Underlying the Systemic Effects Mediated by Parathormone in the Context of Chronic Kidney Disease

Chronic kidney disease (CKD) stands as a prominent non-communicable ailment, significantly impacting life expectancy. Physiopathology stands mainly upon the triangle represented by parathormone-Vitamin D-Fibroblast Growth Factor-23. Parathormone (PTH), the key hormone in mineral homeostasis, is one of the less easily modifiable parameters in CKD; however, it stands as a significant marker for assessing the risk of complications. The updated "trade-off hypothesis" reveals that levels of PTH spike out of the normal range as early as stage G2 CKD, advancing it as a possible determinant of systemic damage. The present review aims to review the effects exhibited by PTH on several organs while linking the molecular mechanisms to the observed actions in the context of CKD. From a diagnostic perspective, PTH is the most reliable and accessible biochemical marker in CKD, but its trend bears a higher significance on a patient's prognosis rather than the absolute value. Classically, PTH acts in a dichotomous manner on bone tissue, maintaining a balance between formation and resorption. Under the uremic conditions of advanced CKD, the altered intestinal microbiota majorly tips the balance towards bone lysis. Probiotic treatment has proven reliable in animal models, but in humans, data are limited. Regarding bone status, persistently high levels of PTH determine a reduction in mineral density and a concurrent increase in fracture risk. Pharmacological manipulation of serum PTH requires appropriate patient selection and monitoring since dangerously low levels of PTH may completely inhibit bone turnover. Moreover, the altered mineral balance extends to the cardiovascular system, promoting vascular calcifications. Lastly, the involvement of PTH in the Renin-Angiotensin-Aldosterone axis highlights the importance of opting for the appropriate pharmacological agent should hypertension develop.

Expert proposal to analyze the combination of aortic and mitral regurgitation in multiple valvular heart disease by comprehensive echocardiography

The assessment of valvular pathologies in multiple valvular heart disease by echocardiography remains challenging. Data on echocardiographic assessment-especially in patients with combined aortic and mitral regurgitation-are rare in the literature. The proposed integrative approach using semi-quantitative parameters to grade the severity of regurgitation often yields inconsistent findings and results in misinterpretation. Therefore, this proposal aims to focus on a practical systematic echocardiographic analysis to understand the pathophysiology and hemodynamics in patients with combined aortic and mitral regurgitation. The quantitative approach of grading the regurgitant severity of each compound might be helpful in elucidating the scenario in combined aortic and mitral regurgitation. To this end, both the individual regurgitant fraction of each valve and the total regurgitant fraction of both valves must be determined. This work also outlines the methodological issues and limitations of the quantitative approach by echocardiography. Finally, we present a proposal that enables verifiable assessment of regurgitant fractions. The overall interpretation of echocardiographic results includes the symptomatology of patients with combined aortic and mitral regurgitation and the individual treatment options with respect to their individual risk. In summary, a reproducible, verifiable, and transparent in-depth echocardiographic investigation might ensure consistent hemodynamic plausibility of the quantitative results in patients with combined aortic and mitral regurgitation.

Clinical Outcomes after Multivalve Surgery in Octogenarians: Evaluating the Need for a Paradigm Shift

(1) Background: this study addresses the lack of comprehensive research on outcomes in octogenarians undergoing cardiac surgery for multivalvular disease, emphasizing the need for a critical examination of the intervention's overall worth in this aging population. (2) Methods: By analyzing short-term and mid-term data from 101 consecutive octogenarian patients undergoing multivalve surgery, the study identifies predictors for in-hospital and one-year mortality. (3) Results: In-hospital mortality increased fourfold with the occurrence of at least one postoperative complication. Octogenarians undergoing multivalve surgery experienced an in-hospital mortality rate of 13.9% and an overall one-year mortality rate of 43.8%. Postoperative delirium was identified as an independent risk factor, contributing to elevated risks of both in-hospital and one-year mortality. Prolonged surgical procedure time emerged as an independent risk factor associated with increased in-hospital mortality. Continuous veno-venous hemodialysis showed an independent impact on in-hospital mortality. Both re-intubation and the transfusion of packed red blood cells were identified as independent risk factors for one-year mortality. (4) Conclusions: This study urges a critical examination of the justification for multivalve surgeries in high-risk elderly patients, emphasizing a paradigm shift. It advocates for interdisciplinary collaboration and innovative strategies, such as staged hybrid procedures, to improve therapeutic approaches for this challenging patient group to achieve a better therapeutic outcome for these patients.

Prognostic Impact of Residual Moderate Mitral Regurgitation Following Valve-in-Valve Transcatheter Aortic Valve Implantation

INTRODUCTION

The impact of mitral regurgitation (MR) on valve-in-valve transcatheter aortic valve implantation (VIV-TAVI) in patients with failed bioprostheses remains unclear. The purpose of this study was to assess the prognostic impact of residual moderate MR following VIV-TAVI.

METHODS

We retrospectively analyzed 127 patients who underwent VIV-TAVI between March 2010 and November 2021. At least moderate MR was observed in 51.2% of patients before the procedure, and MR improved in 42.1% of all patients. Patients with postoperative severe MR, previous mitral valve intervention, and patients who died before postoperative echocardiography were excluded from further analyses. The remaining 114 subjects were divided into two groups according to the degree of postprocedural MR: none-mild MR (73.7%) or moderate MR (26.3%). Propensity score matching yielded 23 pairs for final comparison.

RESULTS

No significant differences were found between groups before and after matching in early results. In the matched cohort, survival probabilities at one, three, and five years were 95.7% vs. 87.0%, 85.0% vs. 64.5%, and 85.0% vs. 29.0% in the none-mild MR group vs. moderate MR-group, respectively (log-rank P=0.035). Among survivors, patients with moderate MR had worse functional status according to New York Heart Association (NYHA) class at follow-up (P=0.006).

CONCLUSION

MR is common in patients with failed aortic bioprostheses, and improvement in MR-status was observed in over 40% of patients following VIV-TAVI. Residual moderate MR after VIV-TAVI is not associated with worse early outcomes, however, it was associated with increased mortality at five years of follow-up and worse NYHA class among survivors.

Beyond Aortic Stenosis: Addressing the Challenges of Multivalvular Disease Assessment

Aortic stenosis (AS) can often coexist with other valvular diseases or be combined with aortic regurgitation (AR), leading to unique pathophysiological conditions. The combination of affected valves can vary widely, resulting in a lack of standardized diagnostic or therapeutic approaches. Echocardiography is crucial in assessing patients with valvular heart disease (VHD), but careful consideration of the hemodynamic interactions between combined valvular defects is necessary. This is important as it may affect the reliability of commonly used echocardiographic parameters, making the diagnosis challenging. Therefore, a multimodality imaging approach, including computed tomography or cardiac magnetic resonance, is often not just beneficial but crucial. It represents the future of diagnostics in this intricate field due to its unprecedented capacity to quantify and comprehend valvular pathology. The absence of definitive data and guidelines for the therapeutic management of AS in the context of multiple valve lesions makes this condition particularly challenging. As a result, an individualized, case-by-case approach is necessary, guided primarily by the recommendations for the predominant valve lesion. This review aims to summarize the pathophysiology of AS in the context of multiple and mixed valve disease, with a focus on the hemodynamic implications, diagnostic challenges, and therapeutic options.

Clinical Equivalence of Trubond® and Ethibond® Braided Polyester Sutures for Valvular Prosthesis Fixation During Aortic or Mitral Valve Replacement: A Single-Blind Randomized Controlled Trial

Background Paravalvular leak (PVL) following valve replacement is a serious cardiovascular complication that increases morbidity and mortality. Valve replacement with the interrupted suture technique using polyester suture provides adequate tensile strength and reduces the probability of tissue reaction. This study compared the clinical equivalence of Trubond®(Healthium) and Ethibond® (Ethicon, Johnson & Johnson) braided polyester sutures for valvular prosthesis fixation using interrupted suturing, with respect to the proportion of subjects having PVL after aortic valve (AV) or mitral valve (MV) replacement. Methodology Patients undergoing AV/MV replacement were enrolled and randomized in this study. The primary endpoint of this prospective, multicentric, two-arm, randomized (1:1), parallel-group, single-blind study (December 2020-October 2022) was the presence of PVL in Trubond® (n = 40) and Ethibond® (n = 42) groups within 26 weeks of surgery. The secondary endpoints included event rate of all-cause mortality, cardiac death, stroke, myocardial infarction, re-hospitalization, re-intervention, wound infection, operative time, intraoperative suture parameters, postoperative hospital stay, time to resume normal activities and work, quality of life, patient satisfaction, and adverse events in both groups. Results Patients who underwent AV/MV replacement and were followed up until 26 weeks had no incidence of PVL or other postoperative complications. No requirement for readmission or re-intervention was noted in both groups. Intraoperative suture handling characteristics, operative time, and hospital stay were also comparable between the groups. With each follow-up, subjects in both groups exhibited improved postoperative functional abilities, quality of life, and health status. Conclusions Trubond® braided polyester suture is clinically equivalent to Ethibond® braided polyester suture. Trubond® suture is safe and effective for valvular prosthesis fixation in patients undergoing AV or MV replacement.

Treatment of Moderate Functional Mitral Regurgitation during Aortic Valve Replacement: A Cohort Study

Background

Treatment of moderate functional mitral regurgitation (FMR) during aortic valve replacement (AVR) is controversial. This study aimed to evaluate the effect of different surgical strategies in patients with moderate FMR undergoing AVR.

Methods

A total of 468 patients with moderate FMR undergoing AVR from January 2010 to December 2019 were retrospectively studied comparing 3 different surgical strategies, namely isolated AVR, AVR + mitral valve repair (MVr) and AVR + mitral valve replacement (MVR). Survival was estimated using the Kaplan-Meier method and compared with the log-rank test, followed by inverse probability treatment weighting (IPTW) analysis to adjust the between-group imbalances. The primary outcome was overall mortality.

Results

Patients underwent isolated AVR (35.3%), AVR + MVr (30.3%), or AVR + MVR (34.4%). The median follow-up was 27.1 months. AVR + MVR was associated with better improvement of FMR during the early and follow-up period compared to isolated AVR and AVR + MVr (p < 0.001). Compared to isolated AVR, AVR + MVR increased the risk of mid-term mortality (hazard ratio [HR]: 2.13, 95% confidence interval [CI]: 1.01-4.48, p = 0.046), which was sustained in the IPTW analysis (HR: 4.15, 95% CI: 1.69-10.15, p = 0.002). In contrast, AVR + MVr showed only a tendency to increase the risk of follow-up mortality (HR: 1.63, 95% CI: 0.72-3.67, p = 0.239), which was more apparent in the IPTW analysis (HR: 2.54, 95% CI: 0.98-6.56, p = 0.054).

Conclusions

In patients with severe aortic valve disease and moderate FMR, isolated AVR might be more reasonable than AVR + MVr or AVR + MVR.

Characteristics of patients with rheumatic heart disease in a national referral hospital in Indonesia

BACKGROUND Rheumatic heart disease (RHD) is one of the most common cardiovascular problems in Indonesia. Comprehensive data regarding patient characteristics are critical in planning optimal treatment strategies to relieve the burden of RHD. This study aimed to describe the clinical and echocardiographic characteristics of patients across several types of valvular lesions in RHD in the Indonesian population. METHODS This retrospective study was performed between January 2016 and June 2019 at the National Cardiovascular Center Harapan Kita, Jakarta, Indonesia. The study population comprised all patients with significant valve disease aged ≥18 years. Patient characteristics and echocardiographic parameters were collected retrospectively from medical records and hospital information systems. Patients were classified into several groups based on etiologies of valve disease. RESULTS Of 5,482 patients with significant valve lesions, 2,333 (42.6%) were RHD patients. They were predominantly female (64.1%) and younger (mean [standard deviation] age 42.61 [12.01] years). Atrial fibrillation (AF) was the most frequent rhythm disorder observed in RHD (65.4%). Isolated mitral stenosis was the most common valve lesion in RHD patients (46.5%). Most patients with RHD had preserved left ventricular (LV) ejection fraction. Half of the patients with mitral stenosis had reduced right ventricular (RV) contractility (tricuspid annular plane systolic excursion <17 mm). CONCLUSIONS Isolated mitral stenosis was the most observed condition of valve lesions in RHD. Characteristics of RHD patients in this study were predominantly female, younger age, had preserved LV function, reduced RV function, and high prevalence of AF.

Concomitant mitral regurgitation in patients with low-gradient aortic stenosis: an analysis from the German Aortic Valve Registry

BACKGROUND

Patients with severe aortic stenosis (AS) frequently presented mitral regurgitation (MR), which may interfere with the standard echocardiographic measurements of mean pressure gradient (MPG), flow velocity, and aortic valve area (AVA).

AIMS

Herein we investigated the prevalence and severity of MR in patients with severe AS and its role on the accuracy of the standard echocardiographic parameters of AS quantification.

METHODS

Of all patients with severe AS undergoing transcatheter or surgical aortic valve replacement enrolled in the German Aortic Registry from 2011 to 2017, 119,641 were included in this study. The population was divided based on the values of left ventricular ejection fraction ([LVEF] > 50%, LVEF 31-50%, and LVEF ≤ 30%] and AVA (0.80 to ≤ 1.00 cm2, 0.60 to < 0.80 cm2, 0.40 to < 0.60 cm2, and 0.20 to < 0.40 cm2).

RESULTS

Overall, 77,890 (65%) patients with mild to-moderate and 4262 (4%) with severe MR were compared with 37,489 (31%) patients without MR. Patients with mild-to-moderate and severe MR presented significantly lower mPG (ΔmPG [95%CI] - 1.694 mmHg [- 2.123 to - 1.265], p < 0.0001 and - 6.954 mmHg [- 7.725 to - 6.183], p < 0.0001, respectively), that increased with LVEF impairment. Conversely, AVA did not differ (severe versus no MR: ΔAVA [95%CI]: - 0.007cm2 [- 0.023 to 0.009], p = 0.973). Increasing MR severity was associated with significant mPG reduction throughout all AVA strata, causing a low-gradient pattern, that manifested since the early stages of severe AS (LVEF > 50%: AVA 0.80 to 1.00 cm2; LVEF 31-50%: AVA 0.60 to 0.80 cm2).

CONCLUSIONS

In patients with severe AS, concomitant MR is common, contributes to the onset of a low-gradient AS pattern, and affects the diagnostic accuracy of flow-dependent AVA measurements. In this setting, a multimodality, AVA-centric approach should be implemented. In patients with severe aortic stenosis, concomitant mitral regurgitation contributes to the onset of a low-gradient pattern, warranting a multimodality, and AVA-centric diagnostic approach.

Role of the mitral valve in left ventricular assist device pathophysiology

Functional mitral regurgitation (MR) in the setting of heart failure results from progressive dilatation of the left ventricle (LV) and mitral annulus. This leads to leaflet tethering with posterior displacement. Contrary to common assumptions, MR often does not resolve with LVAD decompression of the LV alone. The negative impact of significant (moderate-severe) mitral regurgitation in the LVAD setting is becoming better recognized in terms of its harmful effect on right heart function, pulmonary vascular resistance and hospital readmissions. However, controversies remain regarding the threshold for intervention and management. At present, there are no consensus indications for the repair of significant mitral regurgitation at the time of LVAD implantation due to the conflicting data regarding potential adverse effects of MR on clinical outcomes. In this review, we summarize the current understanding of MR pathophysiology in patients supported with LVAD and potential future management strategies.

Managing tricuspid valve pathology in multiple valvular heart disease

Introduction

Multiple valvular heart disease (MVD) is a general term to describe regurgitant and stenotic combination involving the same valve and/or occurring in ≥2 cardiac valves. Limited data and paucity in guidelines render the diagnosis and management. This article aims to provide a state-of-the-art review concerning the diagnosis and management strategies of MVD.

Case presentation

We report a 46-year-old female with worsening dyspnea and fatigue. We perform multiple echocardiography parameters. We diagnose patients with the stenotic mitral valve, stenotic-regurgitant aortic valve, and stenotic-regurgitant tricuspid valve (TV). Double mechanical valve replacement and TV commissurotomy with Kay procedure were done with excellent results.

Clinical discussion

The prevalence of MVD is 15% in those undergoing cardiac surgery; however only 1% of those who underwent triple valve surgery involve TV. The presence of TV lesion may complicate the natural history, clinical presentation, management, and outcomes. Echocardiography with valid method remains an important tool in assessment of patients with MVD. Multidiscipline heart team discussion is essential in determining individual risk, appropriate management methods, and long-term survival.

Conclusion

The expertise of multidisciplinary heart valve team is of utmost importance in determining diagnosis and optimal management strategy.

Degenerative Mitral Stenosis-Diagnostic Challenges and Future Directions

Determining the severity of stenosis in degenerative mitral stenosis (DMS) is fraught with challenges. Neither a high trans-mitral gradient nor a small valve area calculation is sufficiently diagnostic for DMS due to variable left atrial and left ventricular compliance in the setting of diastolic dysfunction, and the variable flow seen in patients with chronic kidney disease (i.e., high flow state) and elderly women (low flow state). Three-dimensional measurement of mitral valve area may be underestimated due to shadowing from basal calcium, and mitral valve annulus (MVA) by continuity equation (CEQ) or dimensionless mitral valve index can be erroneous in the presence of significant regurgitation of left-sided valves. The proposed dimensionless mitral stenosis index (DMSI) can be an easy echocardiographic tool to use in daily practice but needs further validation and is limited in the setting of significant regurgitation of left sided valves. Mean trans-mitral gradients > 8 mmHg and pulmonary artery pressure > 50 mmHg are independent predictors of mortality in those with MVA < 1.5 cm 2 derived by CEQ. In patients who have symptoms that are out of proportion to the degree of stenosis reported, exercise stress testing may help determine the physiologic effects of the stenotic valve. A combination of MVA by CEQ or DMSI and mean transmitral gradient at a given left ventricle stroke volume (flow) should be evaluated in larger studies.

Evaluating the effect of multivalvular disease on mortality after transcatheter aortic valve replacement for aortic stenosis: a meta-analysis and systematic review

Aims: To determine the prognosis of multivalvular disease in patients undergoing transcatheter aortic valve replacement (TAVR) for severe aortic stenosis. Methods: Patients undergoing TAVR for aortic stenosis with covariate-adjusted risk of mortality associated with concomitant valve disease (mitral regurgitation [MR], mitral stenosis [MS] or tricuspid regurgitation [TR]) were included. Results: Moderate-to-severe MR was associated with increased mortality at 30 days (hazard ratio [HR]: 1.60; 95% CI: 1.11-2.30; p = 0.01) and 1 year (HR: 1.87; 95% CI: 1.22-2.87; p = 0.004). The presence of all-grade MS did not impact 30-day or 1-year mortality (HR, 30 days: 1.60; 95% CI: 0.71-3.63; p = 0.26; and HR, 1 year: 1.90; 95% CI: 0.98-3.69; p = 0.06); however, an increased risk of 1-year mortality (HR: 1.67; 95% CI: 1.03-2.70; p = 0.04) was observed with severe MS compared with no MS. Moderate-to-severe TR had a higher risk of all-cause mortality at 1 year (HR: 1.49; 95% CI: 1.24-1.78; p < 0.001) compared with no or mild TR. Conclusion: Moderate-to-severe MR or TR, and severe MS, significantly increase mid-term mortality after TAVR.

Design Variation, Implantation, and Outcome of Transcatheter Mitral Valve Prosthesis: A Comprehensive Review

The transcatheter mitral valve prosthesis is ideally suited for patients with inoperable mitral etiology. The transcatheter mitral valve implantation (TMVI) procedure has closely followed the evolution of transcatheter aortic procedures. There are considerable design variations amongst the limited TMVI prostheses currently available, and the implantation profiles of the devices are notably different. This comprehensive review will provide an overview of the current clinically tried TMVI devices with a focused outcome analysis. In addition, we have discussed the various design characteristics of TMVI and its associated failure mode, implantation technology, delivery methods, first-in-man trials, and pivotal trial summary for the synthesis of recent evidence.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021255241, identifier: CRD42021255241.

Mixed-Valve Disease: Management of Patients with Aortic Stenosis and Mitral Regurgitation: Thresholds for Surgery Versus Percutaneous Therapies

Significant mitral regurgitation (MR), frequently seen in the presence of severe aortic stenosis (AS), results in an association that negatively affects prognosis and imposes particular challenges for both the assessment of the severity of valvular lesions and decisions regarding treatment allocation. This article reviews the available literature with regards to the assessment of MR and AS in the presence of both; surgical management and results in patients with concomitant AS and MR; the effect of MR on outcomes in patients undergoing transcatheter aortic valve replacement; the effect of transcatheter aortic valve replacement on MR severity; and percutaneous treatment for MR after transcatheter aortic valve implantation. The authors aim to provide assistance in the decision-making process to treat patients with either a higher-risk double-valve procedure or a simpler, but perhaps incomplete, single-valve option.

Clinical impact of mitral regurgitation in aortic valve stenosis: Insight from effective regurgitant orifice area

PURPOSE

Mechanisms leading to heart failure (HF) symptoms in aortic valve stenosis (AS) are contentious. We examined the impact of secondary mitral regurgitation (MR) on the symptomatic status in patients with AS.

METHODS

Outpatients performing echocardiography with any degree of AS, without organic mitral valve disease, mitral valve intervention, or aortic insufficiency were enrolled. MR was quantitatively defined through mitral effective regurgitant orifice area (EROA) using the proximal isovelocity surface area method. Patients were divided into two groups (New York Heart Association [NYHA] class I-II vs. NYHA class III-IV).

RESULTS

Five hundred and eighty-four patients were enrolled (484 NYHA I-II, 100 NYHA III-IV). More symptomatic patients had smaller aortic valve area (AVA), lower left ventricular ejection fraction (LVEF) and stroke volume, higher E/E', and LV global afterload. MR was present in 178 (30%) patients and EROA was <.20 cm² in 158 (89%). NYHA III-IV patients showed higher prevalence of MR (78% vs 21%, P < 0.0001) and larger EROA (.13±.08 cm² vs .09±.07 cm² , P < 0.0001). An association between EROA and symptoms was present in the total cohort and in subgroups with preserved LVEF, AVA ≥ 1 and <1 cm² , EE' 8-14 and ≥14 (P < 0.05 for all). EROA was associated with severe symptoms after adjustment for LVEF, E/E', and AVA in the overall population (OR 1.10 [1.06-1.15]; P < 0.0001) and in the 516 patients with preserved LVEF (OR 1.13 [1.08-1.19]; P < 0.0001).

CONCLUSION

In patients with AS, greater EROA values are associated with HF symptoms, even though MR degree is far from the threshold of MR severity. Therefore, even a mild MR represents a supportive marker of HF symptoms presence.

Long-term fate of moderate aortic regurgitation left untreated at the time of mitral valve surgery

OBJECTIVES

The appropriateness of moderate aortic regurgitation treatment during mitral valve (MV) surgery remains unclear. The goal of this study was to evaluate the immediate and long-term outcomes of patients with moderate aortic regurgitation at the time of MV surgery.

METHODS

We included 183 patients admitted to our institution for elective treatment of MV disease between 2004 and 2018, in whom moderate aortic regurgitation was diagnosed during preoperative evaluation. One hundred and twenty-two patients underwent isolated MV surgery (study group) whereas 61 patients underwent concomitant MV surgery and aortic valve replacement (control group).

RESULTS

One death (0.8%) occurred in the study group, and 3 deaths (4.8%) occurred in the control group (P = 0.52). The rate of the most common postoperative complication was similar between the 2 groups. At 12 years, the cumulative incidence function of cardiac death, with non-cardiac death as a competing risk, was 4.7 ± 2.8% in the study group; no cardiac deaths were observed in the control group (P = 0.078). At 6 and 12 years, in the study group, the cumulative incidence function of aortic valve reintervention, with death as a competing risk, was 2.5 ± 1.85% and 19 ± 7.1%, respectively.

CONCLUSIONS

The appropriate management of moderate aortic regurgitation at the time of MV surgery deserves a careful evaluation by balancing the reintervention rate with the age, the operative risk and the life expectancy of the patient. Our findings suggest that a patient-tailored approach is the key to achieving the best clinical outcome for each individual patient.

Combined transcatheter mitral and tricuspid edge-to-edge repair: expanding the horizons of interventional heart failure

PURPOSE OF REVIEW

The combination of mitral regurgitation and tricuspid regurgitation is common in patients with multiple valvular disease and patient management can be challenging. Surgical combined mitral and tricuspid valve surgery is a treatment option for patients meeting criteria but has demonstrated inconsistent long-term benefits.

RECENT FINDINGS

Transcatheter mitral and tricuspid edge-to-edge repair has demonstrated early promising results in patients with a prohibitive surgical risk, making it an interesting treatment option. The present review will discuss the physiopathology of this complex disease and contemporary data regarding treatment options for the treatment of combined mitral and tricuspid regurgitation.

SUMMARY

Combined transcatheter mitral and tricuspid edge-to-edge repair is a novel treatment option for patients with multiple valvular disease. Further studies are needed to determine optimal patient selection and timing of intervention and demonstrate survival benefit and improvement in clinical outcomes. Advances in technology, with dedicated devices and enhanced imaging techniques may also improve patient outcomes.

Assessment of mitral regurgitation and mitral complex geometry in patients after transcatheter aortic valve implantation

Introduction

Mitral regurgitation (MR) of varying degrees and mechanisms is a common finding in patients with aortic stenosis with different improvement after transcatheter aortic valve implantation (TAVI).

Aim

To evaluate the impact of TAVI on mitral complex geometry and the degree of MR.

Material and methods

A total of 31 patients (29.0% males) with severe aortic stenosis and moderate or severe MR at the baseline who underwent TAVI were included in this study. Clinical and echocardiographic characteristics were determined at baseline and at 6 and 12 months.

Results

After TAVI, decrease of MR vena contracta width (p = 0.00002, p = 0.00004), aorto-mural mitral annulus diameter (p = 0.00008, p = 0.02), increase of mitral annular plane systolic excursion (p = 0.0004, p = 0.0003), left ventricular stroke volume (p = 0.0003, p = 0.0004), ejection fraction (p = 0.0004, p = 0.01) and decrease of major dimension of left ventricle in three chamber view (p = 0.05, p = 0.002) were observed in patients at both time points. Additionally, we observed a decrease of distance between the head of the papillary muscles (p = 0.003) at 6 months and a decrease of left atrium volume index (p = 0.01) and systolic pulmonary artery pressure (p = 0.01) at 12 months.

Conclusions

Patients with moderate or severe MR undergoing TAVI achieved significant improvement of mitral valve complex function resulting in the reduction of MR degree.

Hybrid Double Valve Replacement for Multivalvular Disease With Severe Mitral Annular Calcification

Severe mitral annular calcification poses a significant challenge, particularly in higher risk, frail, elderly patients with multivalvular disease. Both surgical and transcatheter options exist but remain fraught with risks of paravalvular leak, atrioventricular groove disruption, patient prosthesis mismatch, and left ventricular outflow tract obstruction. We present an innovative hybrid surgical approach to manage severe aortic and mitral valve disease in a Jehovah's Witness patient with severe circumferential mitral annular calcification.

Case of calcific tricuspid and pulmonary valve stenosis

Isolated right-sided valvular disease is a much less recognised entity when compared with left-sided valvular heart disease. Almost all the cases of combined pulmonary valve with tricuspid valve involvement are a consequence of underlying carcinoid heart disease. Moreover, severe calcification of tricuspid valve is an extremely unusual finding. We report a case of a severe calcific tricuspid valve stenosis along with severe pulmonary valve stenosis where the exact aetiology could not be established. On reviewing the literature, we did not find any reports describing such a morphology.

Comparison of outcomes between minimally invasive and median sternotomy for double and triple valve surgery: A meta-analysis

BACKGROUND

Limited data exists demonstrating the efficacy of minimally invasive surgery (MIS) compared to median sternotomy (MS) for multiple valvular disease (MVD). This systematic review and meta-analysis aims to compare operative and peri-operative outcomes of MIS vs MS in MVD.

METHODS

PubMed, Ovid, and Embase were searched from inception until August 2019 for randomized and observational studies comparing MIS and MS in patients with MVD. Clinical outcomes of intra- and postoperative times, reoperation for bleeding and surgical site infection were evaluated.

RESULTS

Five observational studies comparing 340 MIS vs 414 MS patients were eligible for qualitative and quantitative review. The quality of evidence assessed using the Newcastle-Ottawa scale was good for all included studies. Meta-analysis demonstrated increased cardiopulmonary bypass time for MIS patients (weighted mean difference [WMD], 0.487; 95% confidence interval [CI], 0.365-0.608; P < .0001). Similarly, aortic cross-clamp time was longer in patients undergoing MIS (WMD, 0.632; 95% CI, 0.509-0.755; P < .0001). No differences were found in operative mortality, reoperation for bleeding, surgical site infection, or hospital stay.

CONCLUSIONS

MIS for MVD have similar short-term outcomes compared to MS. This adds value to the use of minimally invasive methods for multivalvular surgery, despite conferring longer operative times. However, the paucity in literature and learning curve associated with MIS warrants further evidence, ideally randomized control trials, to support these findings.

Is There Currently a Place for Combined Mitral and Aortic Transcatheter Interventions?

PURPOSE OF REVIEW

The goal was to evaluate published data on the incidence, diagnosis, and management of symptomatic combined mitral and aortic valvular disease. Furthermore, to identify the role of treatment using contemporary transcatheter techniques.

RECENT FINDINGS

Up to a quarter of symptomatic adult valvular disease is caused by multiple left-sided valvular lesions. The etiologic spectrum of this combined disease has shifted from rheumatic to degenerative. Both presentation and diagnosis of lesions are modified compared with isolated disease. Based upon narrative review, there are only limited observational experiences, insufficient to provide robust guidance. These data, however, indicate the feasibility of interventions such as transcatheter aortic valve replacement and edge-to-edge mitral valve repair to treat such disease and mitigate the risks of open surgery. Combined aortic and mitral valve disease is commonly encountered. There is a role for transcatheter interventions based on limited data; however, more research is needed.

Sudden cardiac death and valvular pathology

Sudden death due to valvular heart disease is reported to range from 1% to 5% in native valves and around 0.2%-0.9%/year in prosthesis. The nature of the diseases is varied, from heritable, congenital to acquired. It may affect both genders in multiple age groups. The authors show and comment examples of the major nosologic aetiologies underlying unexpected exitus letalis of valvular nature.

Pathophysiology and management of combined aortic and mitral regurgitation

The combination of aortic and mitral regurgitation is a typical example of a frequent yet understudied multiple valve disease scenario. The aetiology is often rheumatic or degenerative; less frequently it can be induced by drugs or radiation, or caused by infective endocarditis or congenital valvular lesions. Aortic regurgitation resulting in secondary mitral regurgitation is also not uncommon. There are limited data to guide the management of combined aortic and mitral regurgitation. Left ventricular dysfunction is frequent at initial presentation, and even more so postoperatively, suggesting that surgical management should not be delayed, particularly when symptoms occur or when there is evidence of even subtle left ventricular dysfunction. The decision to operate on one or both valves not only depends on the severity of each lesion, but also on several other factors, including age, co-morbidities and frailty, the increased operative risk of double valve surgery, the increased risk of long-term thrombotic and bleeding complications with multiple mechanical valves, the risk of leaving one valve unoperated and the probability of requiring redo surgery. The role of a multidisciplinary heart valve team is critical in this setting to optimize management and outcomes. The role of transcatheter approaches is currently limited, but technological advances will probably soon change the management paradigm.

Impact of concomitant mitral regurgitation on transvalvular gradient and flow in severe aortic stenosis: a systematic ex vivo analysis of a subentity of low-flow low-gradient aortic stenosis

AIMS

Evaluation of aortic stenosis (AS) is based on echocardiographic measurement of mean pressure gradient (MPG), flow velocity (Vmax) and aortic valve area (AVA). The objective of the present study was to analyse the impact of systemic haemodynamic variables and concomitant mitral regurgitation (MR) on aortic MPG, Vmax and AVA in severe AS.

METHODS AND RESULTS

A pulsatile circulatory model was designed to study function and interdependence of stenotic aortic (AVA: 1.0 cm², 0.8 cm² and 0.6 cm²) and insufficient mitral prosthetic valves (n=8; effective regurgitant orifice area [EROA] <0.2 cm² vs. >0.4 cm²) using Doppler ultrasound. In the absence of severe MR, a stepwise increase of stroke volume (SV) and a decrease of AVA was associated with a proportional increase of aortic MPG. When MR with EROA <0.2 cm² vs. >0.4 cm² was introduced, forward SV decreased significantly (70.9±1.1 ml vs. 60.8±1.6 ml vs. 47.4±1.1 ml; p=0.02) while MR volume increased proportionally. This was associated with a subsequent reduction of aortic MPG (57.1±9.4 mmHg vs. 48.6±13.8 mmHg vs. 33.64±9.5 mmHg; p=0.035) and Vmax (5.09±0.4 m/s vs. 4.91±0.73 m/s vs. 3.75±0.57 m/s; p=0.007). Calculated AVA remained unchanged (without MR: AVA=0.53±0.04 cm² vs. with MR: AVA=0.52±0.05 cm²; p=ns). In the setting of severe AS without MR, changes of vascular resistance (SVR) and compliance (C) did not impact on aortic MPG (low SVR and C: 66±13.8 mmHg and 61.1±20 mmHg vs. high SVR and C: 60.9±9.2 mmHg and 71.5±13.5 mmHg; p=ns) In concomitant severe MR, aortic MPG and Vmax were not significantly reduced by increased SVR (36.6±2.2 mmHg vs. 34.9±5.6 mmHg, p=0.608; 3.89±0.18 m/s vs. 3.96±0.28 m/s; p=ns).

CONCLUSIONS

Systemic haemodynamic variables and concomitant MR may potentially affect diagnostic accuracy of echocardiographic AS evaluation. As demonstrated in the present study, MPG and Vmax are flow-dependent and significantly reduced by a reduction of forward SV from concomitant severe MR, resulting in another entity of low-flow low-gradient aortic stenosis. In contrast, calculated AVA appears to be a robust parameter of AS evaluation if severe MR is present. Changes of SVR and C did not affect the diagnostic accuracy of AS evaluation.

Mitral Valve Stenosis after Transcatheter Aortic Valve Replacement: Case Report and Review of the Literature

Mitral stenosis is a rare and potentially severe complication of transcatheter aortic valve replacement (TAVR). Given the anatomic coupling and interdependence of the aortic and mitral valves, it comes by itself that procedures (either surgical or percutaneous) involving the aortic valve imply the risk of altering mitral valve function. Indeed, transcatheter aortic prostheses may impair adequate anterior mitral leaflet (AML) opening, especially when implanted in a "low" position, thus resulting in high transvalvular gradients. Hereby, we report the case of a 71-year-old male with symptomatic severe aortic stenosis and a history of previous surgical mitral valve repair who underwent TAVR with a self-expandable prosthesis. Notwithstanding an acceptable angiographic position, the prosthetic frame was shown to interfere with the AML, as evidenced by augmented transmitral gradients; nonetheless, pulmonary artery pressures remained unchanged, and the patient experienced symptomatic improvement. Therefore, a conservative approach was chosen and the patient was discharged home after medical therapy optimization. Moreover, we provide a review of the available literature regarding the incidence, predictors and possible management of this infrequent complication.

In-frame Variants in FLNA Proximal Rod 1 Domain Associate With a Predominant Cardiac Valvular Phenotype

INTRODUCTION AND OBJECTIVES

X-linked cardiac valvular dysplasia is a rare form of male-specific congenital heart defect mainly characterized by myxomatous degeneration of the atrioventricular valves with variable hemodynamic consequences. It is caused by genetic defects in FLNA-encoded filamin A, a widely expressed actin-binding protein that regulates cytoskeleton organization. Filamin A loss of function has also been associated with often concurring neurologic and connective tissue manifestations, with mutations in the first half of the Rod 1 domain apparently expressing the full cardiac phenotype. We contribute to previous genotype-phenotype correlations with a multidisciplinary approach in a newly-described family.

METHODS

Cardiologic, dysmorphologic, and genetic evaluation of available members were complemented with transcriptional and X-chromosome inactivation studies.

RESULTS

A novel FLNA mutation c.1066-3C>G cosegregated with a male-expressed, apparently isolated, cardiac phenotype with no skewed X-inactivation pattern in female carriers. This variant was shown to result in an in-frame deletion of 8 amino acid residues near the N-terminal region of the protein.

CONCLUSIONS

A nonimprinted, partial loss of function of filamin A proximal Rod 1 domain seems to be the pathogenetic mechanism of cardiac valvular dysplasia, with some cases occasionally expressing associated extracardiac manifestations.

[Management of multiple valve disease]

Polyvalvular disease is not a rare condition, the lack of specific data for each situation does not allow perfoming standardized management and guidelines. We want to present by this review available data on the management of polyvalvular disease, taking into account different possible associations between the valve lesions.