A study of Clinical Profile and in Hospital Outcomes of patients undergoing Percutaneous Transvenous Mitral Commissurotomy at a Tertiary Care Center of Nepal

Introduction

Rheumatic heart disease (RHD), is a common cause of mitral stenosis (MS) in developing nations. As per current recommendation, Percutaneous Transvenous Mitral Commissurotomy (PTMC) is advised as a Class IA (I-Class Of Recommendation, COR; A-Level Of Evidence, LOE) indication in patients with symptomatic severe mitral stenosis. We aim to examine the clinical profile and in-hospital results of PTMC for mitral stenosis.

Methods

A cross-sectional retrospective study was conducted at Manmohan Cardiothoracic Vascular and Transplant Center from April 2020 to May 2022. A structured questionnaire was used to collect the data and ethical approval for conducting the study was taken from the Institutional Review Committee (IRC) of Institute of Medicine (IOM). The data was collected in Microsoft Excel (Ver. 2013). For statistical analysis, SPSS 21 (IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp.) Association was measured using a parametric and non-parametric test (depending upon the distribution of data) and p value < 0.05 was considered significant.

Results

A total of 104 patients who met the inclusion criteria underwent PTMC during the study period. The mean age group of the patient was 41.7 ± 12.5 years, of which 23 (22.1%) were males and 81 (78.9%) were females. Mean mitral valve area prior to PTMC was 0.98 ± 0.19 mm2 that increased to 1.69 ± 0.19 mm2 after the procedure and it was statistically significant (p=<0.001). The post PTMC MVA varied with PTMC Wilkin's score with less than or equal to 8 having favorable outcomes.

Conclusion

Successful PTMC is highly influenced by the patients' increasing age, valve morphology (calcification, thickness, mobility), Left atrial dimensions, Pre PTMC mitral valve area, Degree of Baseline mitral regurgitation. Post procedure development of MR is usually well tolerated but rarely be severe enough requiring surgical valve replacement.

Results of mitral valve reconstruction using substitute extracellular matrix

Background

During the ongoing search for an ideal patch material for reconstructive heart surgery, several versions of extracellular matrix (ECM) have been used. However, long-term performance in different cardiac positions is unknown.

Methods

We performed a retrospective review of outcomes after mitral valve surgery using ECM in 29 patients from 2011 to 2014. Clinical and echocardiographic follow-up was reviewed (mean time, 6.3 ± 2.8 years).

Results

ECM was used to reconstruct the posterior mitral annulus in 69% and to repair the mitral leaflet in 65% of the patients. The most prevalent etiology was dystrophic calcification of the annulus (80%) versus endocarditis for leaflet repair (60%). Fifty-five percent of the patients who required annular reconstruction received a mitral valve replacement (MVR). There were 2 perioperative deaths (7%). Long-term data were analyzed according to surgical technique; namely, isolated leaflet repair compared with annular reconstruction with or without MVR. There were 3 late deaths (1 per group). Overall survival was 83% at 7 years. Ninety percent of cases with mitral valve repair with or without annular reconstruction were free from more than mild mitral regurgitation, compared with 45% in the MVR and annular reconstruction group. The mechanism of failure was patch degeneration creating a severe paravalvular leak due to prosthesis dehiscence.

Conclusions

ECM used to repair the mitral valve leaflets with or without annular reconstruction offers acceptable results. However, caution should be taken with the use of ECM adjacent to prosthetic valve material because of a high rate of failure associated with patch degeneration.

Heart surgery by the locals in resource-limited settings: The experience from Ethiopia

BACKGROUND

In developing countries, despite its demand is high, heart surgery is not always accessible to the neediest patients. We aimed to describe the early outcomes of heart surgeries that were performed by a local cardiac surgical team in Addis Ababa, Ethiopia.

METHODS

Data were collected through chart abstraction of patients who underwent heart surgery from the period of June 2017 to July 2021 by the same local cardiac surgical team at 3 centers in Addis Ababa, Ethiopia. Data were analyzed using the Statistical Package for the Social Sciences for Windows version 20.0.

RESULTS

A total of 290 patients who underwent heart surgery during the specified period were included in the study. Of the total, 192 patients underwent valve surgery (177 were patients with rheumatic valvular disease and 15 were valve surgeries with other causes) with a 30-day mortality rate of 9 (4.7%), 33 patients underwent coronary artery bypass graft with a 30-day mortality rate of 3 (9.1%), 58 patients underwent repair for congenital heart diseases with no 30-day mortality. Specifically, button Bentall was done for 1 patient; maze procedure was done for 2 patients along with mitral valve surgery, and a total of 7 out of 290 (2.4%) underwent redo heart surgery. The overall procedure-related mortality was 4.1%.

CONCLUSIONS

In addition to operating on a large number of cardiac patients, the local cardiac surgical team was able to do complex surgical procedures such as button Bentall, left maze procedure, redo valve surgeries, and coronary artery bypass graft surgery in a resource-limited setup. The overall patient outcome was comparable to reports from other centers.

Early outcomes of transatrial mitral valve replacement in severe mitral annular calcification

Objective

Mitral valve replacement (MVR) in the setting of severe mitral annular calcification is a technically challenging operation with increased morbidity and mortality. Transseptal/apical transcatheter MVR (TMVR) in mitral annular calcification has emerged as an option for these cases, although may not be feasible due to anatomical reasons. Transatrial TMVR is a potential treatment option for this subgroup of patients.

Methods

Patients who underwent transatrial TMVR between June 2018 and November 2020 at a single institution were included. Patients were selected by a structural heart team based on their surgical risk, pattern of mitral annular calcification, risk of valve migration, left ventricular outflow obstruction, and paravalvular leak.

Results

A total of 11 patients underwent transatrial TMVR. Mean patient age was 74.2 years and mean Society of Thoracic Surgeons predicted risk of mortality score was 9.1%. All patients had the presence of both mitral stenosis and regurgitation—dominant etiology—was mitral stenosis in 81.2%, and mitral regurgitation in 18.8%. Among patients, 54.5% had a concomitant cardiac procedure. There was no in-hospital or 30-day mortality. Technical success defined by the Mitral Valve Academic Research Consortium was achieved in 90.9% of patients. Postoperative paravalvular leak was mild or less in all patients.

Conclusions

In this series, transatrial TMVR was shown to be a safe and effective treatment option for patients who are high risk for surgical MVR and should be in surgeons' armamentarium in the treatment of this high-risk patient population. Dissemination of safe technique will be critical in the successful conduct of this surgery.

Repetitive Immune-Mediated Noninfectious Endocarditis Necessitating 5 Mitral Valve Replacements

We present a young patient who had to undergo 5 mitral valve replacements (MVR) because of a repetitive immune-mediated noninfectious endocarditis. The patient was treated with multiple anti-inflammatory drugs and high-dose prednisone. After the fifth MVR, the patient remained in stable condition using Anakinra after 22 months of follow-up. (Level of Difficulty: Advanced.).

Failure of Complete Endothelialization of a Watchman Device 3 Years Post-Implantation

We report an unusual case of incomplete endothelialization of the Watchman device >3 years after its implantation. Animal data suggest that device endothelialization occurs ∼45 days post-implantation; however, data on humans are lacking. Guidelines on anticoagulation are based on expectation from animal studies. (Level of Difficulty: Advanced.)

Severe Intermittent Transvalvular Mitral Valve Regurgitation: Serious Complication of Mitral Valve Replacement With Subvalvular Preservation

Mitral valve replacement with subvalvular preservation is a favorable technique to protect left ventricular function and improve long-term survival. However, complications of the procedure should be considered. We report the case of a patient with a history of prosthetic mitral valve replacement with severe intermittent transvalvular mitral regurgitation and reduced ejection fraction. (Level of Difficulty: Advanced.)

Transcatheter Aortic Valve Replacement for Aortic Stenosis With Prosthetic Mitral Paravalvular Leak and Hemolytic Anemia

This report describes a successful transcatheter aortic valve replacement in an older patient with severe aortic stenosis, mitral paravalvular leak, and associated hemolytic anemia. Transcatheter aortic valve replacement is worth considering as a first-line procedure in this high-risk patient because of its beneficial impact on reducing shear forces at the mitral valve. (Level of Difficulty: Intermediate.).

A 27-Year-Old Woman With Postpartum Papillary Muscle Rupture

Postpartum papillary muscle rupture (PMR) is extremely uncommon and tolerated poorly with limited management options other than emergency surgical intervention. This case demonstrates the challenges of postpartum PMR in a young woman with unrecognized vascular Ehlers-Danlos syndrome and highlights the importance of preconception screening of cardiovascular disease. (Level of Difficulty: Beginner.).

Early evaluation of the aortic root after Nicks' procedure

Objective(s)

To determine the influence of surgical techniques adopted to avoid suture line disruption, periprosthetic leakage, patch dislodgement, pericardial patch aneurysm formation, and the long-term stability of aortic root enlargement (ARE) during aortic valve replacement (AVR).

Methods

One hundred fifteen patients undergoing AVR or combined aortic and mitral valve replacements with Nicks' posterior ARE between 1997 and 2019 underwent long-term echocardiographic and angio-computed tomographic evaluation. Age was 11-72 years (AVR: median, 30; interquartile range, 21-47 years; AVR and mitral valve replacement: median, 27.5; interquartile range, 20-37.5 years). The aortotomy was closed using autologous pericardial patch and Teflon-buttressed sutures.

Results

Hospital mortality was 1.7% (n = 2), with 4 (3.5%) late deaths. At a mean follow-up of 123.11 ± 77.67 months, the survival probability from Kaplan–Meier was 93.25 ± 0.03%. No cases of severe prosthesis–patient mismatch (PPM) were observed, and only 2 patients had moderate PPM. Median aortic root diameters at the level of sinus of Valsalva and sinotubular junction were 32 (29-35) mm and 33 (30-36) mm, respectively, at discharge, and were 33 (30-36) mm, and 33 (31-37) mm, respectively, at latest follow-up, with no cases of late pericardial patch aneurysm.

Conclusions

ARE is a safe adjunct to AVR in patients with a small aortic annulus to prevent PPM. Retention of a pericardial collar and Teflon-buttressed sutures is an expedient, safe, and effective technique in reducing bleeding at the enlarged ventriculo-aortic junction. Autologous pericardial patch aortoplasty is not associated with late aneurysm/pseudoaneurysm formation.

Urgent Open Atrial Transcatheter Mitral Valve Replacement as Bailout for Planned Surgery

Hybrid transcatheter mitral valve replacement (TMVR) has shown great promise for patients with severe mitral annular calcification. However, there have been limited reports of its use as a bailout for planned surgical MVR. Here, we present a bailout TMVR with an excellent patient outcome. (Level of Difficulty: Advanced.)

A Cardio-Obstetric Approach to Management of the Complex Pregnant Cardiac Patient

A 23-year-old female presented at 28.5 weeks gestation with symptomatic heart failure due to severe mitral stenosis and severe pulmonary arterial hypertension. After multidisciplinary planning, she underwent caesarean delivery with mitral valve replacement 48 h postpartum. Cardio-obstetric teams provide expert coordinated care for complex cardiovascular disease in pregnancy. (Level of Difficulty: Beginner.)

Rheumatic Heart Disease Screening Among School Children in Central Nepal

Rheumatic heart disease is the most common heart disease in developing countries. This Global Health Report uses the results of screening 28,050 school children clinically with 2-dimensional echocardiography. A total of 1,739 students had cardiac murmur, with the most dominant lesion being rheumatic mitral regurgitation. This report concluded that the burden of rheumatic heart disease is decreasing, but it is still significant in Nepal. That is why echocardiographic screening is important in early diagnosis and management. (Level of Difficulty: Beginner.)

Apico-Aortic Conduit for severe aortic stenosis: Technique, applications, and systematic review

Patients referred for aortic valve replacement are often elderly and may have increased surgical risk associated with ascending aortic calcification, left ventricular dysfunction, presence of coronary artery disease, previous surgery, and/or presence of several co-morbidities. Some of these patients may not be considered candidates for conventional surgery because of their high risk profile. While transcatheter aortic valve replacement constitutes a widely accepted alternative, some patients may not be eligible for this modality due to anatomic factors. Apico-Aortic Conduit (AAC) insertion (aortic valve bypass surgery) constitutes a possible option in those patients. Apico-Aortic Conduit is not a new technique, as it has been used for decades in both pediatric and adult populations. However, there is a resurging interest in this technique due to the expanding scope of elderly patients being considered for the treatment of aortic stenosis. Herein, we describe our surgical technique and provide a systematic review of recent publications on AAC insertion, reporting that there is continued use and several modifications of this technique, such as performing it through a small thoracotomy without the use of the cardiopulmonary bypass.