Single Center Prospective Study of Cross-Clamp versus Balloon Occlusion in Robotic Mitral Surgery

BACKGROUND

Both transthoracic aortic cross-clamp and endoaortic balloon occlusion have been shown to have comparable safety profiles for aortic occlusion. Since most surgeons use only one technique, we sought to compare the outcomes when a homogeneous group of surgeons changed their occlusion technique from aortic cross-clamp to balloon occlusion.

METHODS

We changed our technique from aortic cross-clamp to balloon occlusion in November 2022. This allowed us to conduct a prospective treatment comparison study in the same group of surgeons. Propensity score matching (PSM) was used to match cases(balloon occlusion) 1:3 to controls (aortic cross-clamp) based on age, gender, body mass index, concomitant maze, and tricuspid valve repair.

RESULTS

Total of 411 patients underwent robotic mitral surgery from 2020 through 2023. Using PSM, 56 balloon occlusion patients were matched to 168 aortic cross-clamp patients. Median age was 65 years (interquartile range[IQR],55.6-70.0) and the majority were males(n=119,53%). All valves were successfully repaired. Balloon occlusion had a shorter median cardiopulmonary bypass (CPB) time compared to aortic cross-clamp (84.0 vs. 94.5 min,p=0.006). Median cross-clamp time (64.0 vs. 64.0 min,p=0.483) and total surgery time (5.9 vs. 6.1 hours,p=0.495) did not differ between groups. There was no in hospital death. There were five surgeons who performed various combinations of console and bedside roles. CPB, cross-clamp, and surgery durations were not significantly affected by the different surgeon combinations.

CONCLUSIONS

Compared to aortic cross-clamp, balloon occlusion has similar perioperative and early postoperative outcomes. Additionally, it likely introduces a 10-minute reduction in total CPB time.

Successful thrombolysis of early bioprosthetic mitral valve thrombosis following extracorporeal membrane oxygenation: Case report

Introduction: Bioprosthetic mitral valve thrombosis (BPMVT) following post-operative extracorporeal membrane oxygenation (ECMO) is a rare complication with high mortality.Case Report: A 75-year-old man with a flail posterior mitral leaflet underwent a bioprosthetic mitral valve replacement and was subsequently placed on central veno-arterial high flow ECMO following intractable shock after protamine administration. He developed BPMVT over the following 48 hr, which did not resolve with 3 weeks of systemic heparin. He was then treated successfully with 3 days of continuous low dose (1 mg/hr) Tissue Plasminogen Activator (TPA). He suffered no bleeding consequences and had a complete cardiac and end-organ recovery.Discussion: Slow TPA infusion may be an acceptable treatment strategy for alleviating thrombotic burden from a bioprosthetic valve, even in the post-operative setting.

Myocardial Injury After Transcatheter Mitral Valve Replacement Versus Surgical Reoperation

This study aimed to evaluate the incidence and clinical implications of myocardial injury, as determined by cardiac biomarker increase, in patients who underwent mitral bioprosthesis dysfunction treatment with transcatheter mitral valve replacement (TMVR) versus surgical mitral valve replacement reoperation (SMVR-REDO). Between 2014 and 2023, 310 patients with mitral bioprosthesis failure were included (90 and 220 patients for TMVR and SMVR-REDO, respectively). Multivariable analysis and propensity score matching were performed to adjust for the intergroup differences in baseline characteristics. Creatinine kinase-MB (CK-MB) and cardiac troponin I (cTn) were collected at baseline and 6 to 12, 24, 48, and 72 hours after intervention. The cardiac biomarkers values were evaluated in relation to their reference values. The outcomes were determined according to the Mitral Valve Academic Research Consortium criteria. CK-MB and cTn increased above the reference level in almost all patients after SMVR-REDO and TMVR (100% vs 94%, respectively), with the peak occurring within 6 to 12 hours. SMVR-REDO was associated with a two- to threefold higher increase in cardiac biomarkers. After 30 days, the mortality rates were 13.3% in the TMVR and 16.8% in the SMVR-REDO groups. At a median follow-up of 19 months, the mortality rates were 21.1% in the TMVR and 17.7% in the SMVR-REDO groups. Left ventricular ejection fraction, estimated glomerular filtration rate, CK-MB, and cTn were predictors of mortality. In conclusion, some degree of myocardial injury occurred systematically after the treatment of mitral bioprosthetic degeneration, especially after SMVR, and higher CK-MB and cTn levels were associated with increased cumulative late mortality, regardless of the approach.

Primary cardiac rhabdomyosarcoma in a mitral valve involved with rheumatic disease

A 51-year-old female underwent emergency mitral valve replacement for mitral stenosis with an undetermined mass which was attached to the anterior mitral leaflet. Histopathological testing of the excised specimen confirmed the diagnosis of rheumatic mitral disease in combination with a primary rhabdomyosarcoma. Postoperative adjuvant chemotherapy with pazopanib hydrochloride was given. At 10 months of follow-up, repeated computed tomographic screening has not shown any signs of local recurrence or secondary metastases. The potential for the existence of primary rhabdomyosarcomas should be borne in mind when faced with undetermined masses on mitral leaflets, even in the presence of rheumatic disease.

Percutaneous treatment of mechanical mitral valve thrombosis

A 75-year-old female was found to have mechanical mitral valve thrombosis complicated by severe mitral stenosis, pulmonary edema, and right heart failure. She was at prohibitive risk for surgical intervention. She did not tolerate thrombolysis due to bleeding. We performed percutaneous intervention with cerebral protection with subsequent restoration of mechanical mitral valve function, resolution of the mitral valve stenosis, and no neurologic complications.

Transcatheter heart valve interventions for patients with rheumatic heart disease

Rheumatic heart disease [RHD] is the most prevalent cause of valvular heart disease in the world, outstripping degenerative aortic stenosis numbers fourfold. Despite this, global resources are firmly aimed at improving the management of degenerative disease. Reasons remain complex and include lack of resources, expertise, and overall access to valve interventions in developing nations, where RHD is most prevalent. Is it time to consider less invasive alternatives to conventional valve surgery? Several anatomical and pathological differences exist between degenerative and rheumatic valves, including percutaneous valve landing zones. These are poorly documented and may require dedicated solutions when considering percutaneous intervention. Percutaneous balloon mitral valvuloplasty (PBMV) is the treatment of choice for severe mitral stenosis (MS) but is reserved for patients with suitable valve anatomy without significant mitral regurgitation (MR), the commonest lesion in RHD. Valvuloplasty also rarely offers a durable solution for patients with rheumatic aortic stenosis (AS) or aortic regurgitation (AR). MR and AR pose unique challenges to successful transcatheter valve implantation as landing zone calcification, so central in docking transcatheter aortic valves in degenerative AS, is often lacking. Surgery in young RHD patients requires mechanical prostheses for durability but morbidity and mortality from both thrombotic complications and bleeding on Warfarin remains excessively high. Also, redo surgery rates are high for progression of aortic valve disease in patients with prior mitral valve replacement (MVR). Transcatheter treatments may offer a solution to anticoagulation problems and address reoperation in patients with prior MVR or failing ventricles, but would have to be tailored to the rheumatic environment. The high prevalence of MR and AR, lack of calcification and other unique anatomical challenges remain. Improvements in tissue durability, the development of novel synthetic valve leaflet materials, dedicated delivery systems and docking stations or anchoring systems to securely land the transcatheter devices, would all require attention. We review the epidemiology of RHD and discuss anatomical differences between rheumatic valves and other pathologies with a view to transcatheter solutions. The shortcomings of current RHD management, including current transcatheter treatments, will be discussed and finally we look at future developments in the field.

The evolution of technical prerequisites and local boundary conditions for optimization of mitral valve interventions-Emphasis on skills development and institutional risk performance

This viewpoint report describes how the evolution of transcatheter mitral valve intervention (TMVI) is influenced by lessons learned from three evolutionary tracks: (1) the development of treatment from mitral valve surgery (MVS) to transcutaneous procedures; (2) the evolution of biomedical engineering for research and development resulting in predictable and safe clinical use; (3) the adaptation to local conditions, impact of transcatheter aortic valve replacement (TAVR) experience and creation of infrastructure for skills development and risk management. Thanks to developments in computer science and biostatistics, an increasing number of reports regarding clinical safety and effectiveness is generated. A full toolbox of techniques, devices and support technology is now available, especially in surgery. There is no doubt that the injury associated with a minimally invasive access reduces perioperative risks, but it may affect the effectiveness of the treatment due to incomplete correction. Based on literature, solutions and performance standards are formulated with an emphasis in technology and positive outcome. Despite references to Heart Team decision making, boundary conditions such as hospital infrastructure, caseload, skills training and perioperative risk management remain underexposed. The role of Biomedical Engineering is exclusively defined by the Research and Development (R&D) cycle including the impact of human factor engineering (HFE). Feasibility studies generate estimations of strengths and safety limitations. Usability testing reveals user friendliness and safety margins of clinical use. Apart from a certification requirement, this information should have an impact on the definition of necessary skills levels and consequent required training. Physicians Preference Testing (PPT) and use of a biosimulator are recommended. The example of the interaction between two Amsterdam heart centers describes the evolution of a professional ecosystem that can facilitate innovation. Adaptation to local conditions in terms of infrastructure, referrals and reimbursement, appears essential for the evolution of a complete mitral valve disease management program. Efficacy of institutional risk management performance (IRMP) and sufficient team skills should be embedded in an appropriate infrastructure that enables scale and offers complete and safe solutions for mitral valve disease. The longstanding evolution of mitral valve therapies is the result of working devices embedded in an ecosystem focused on developing skills and effective risk management actions.

Comparative outcomes of percutaneous transvenous mitral commissurotomy between low and high Wilkins score

BACKGROUND

Percutaneous transvenous mitral commissurotomy (PTMC) is one of the non-surgical methods for patients with significant mitral stenosis. It is less invasive, less complicating with better outcomes compared to surgery. The Wilkins score ≤8 is used to select patients for PTMC, but the results of several studies suggest that PTMC can also be successful in a higher Wilkins score. The aim of this study is to compare the outcomes of PTMC between two groups.

METHODS

In this retrospective study, patients who underwent PTMC between April 2011 and December 2019 were included. Patients were divided into two groups based on Wilkins score: 196 patients (57.64%) with a Wilkins score ≤8 (group I) and 134 patients (39.4%) with a Wilkins score >8 (group II).

RESULTS

There was no difference in demographic characteristics between two groups except for age (p = 0.04). Pre and post-interventional echocardiographic and catheterization measurements including left atrial pressure, pulmonary artery pressure, mitral valve area, mitral valve mean, and peak gradient were measured, and there was no difference between the two groups (p > 0.05). The most common complication was mitral regurgitation (MR). Serious complications such as stroke and arrhythmias were rare in both groups (<1%). There was no difference between MR, ASD (atrial septal defect) and serious complications between the two groups.

CONCLUSION

This study shows that the Wilkins score with a cutoff value of 8 is not suitable for patient selection and novel criteria including both mitral valve features and other variables affecting the PTMC outcomes is needed.

Transthoracic Aortic Clamp Technique for Port-Only Endoscopic Robotic Mitral Surgery

OBJECTIVE

Many robotic mitral surgeons utilize right thoracotomy with transthoracic clamping of the aorta, while a smaller number employ a port-only endoscopic approach with endoaortic balloon occlusion of the aorta. We present our technique for a port-only endoscopic robotic approach with transthoracic clamping.

METHODS

From July 2019 through December 2022, 133 patients underwent port-only endoscopic robotic mitral surgery with transthoracic clamp aortic occlusion and antegrade cardioplegia. Perfusion was through the femoral artery in 101 patients (76%) and axillary in 32 patients (24%). Clamp technique involved placing the clamp at the mid-ascending aorta, dynamic valve testing to 90 mm aortic root pressure, and closure of the cardioplegia cannula site prior to clamp removal. Indications for clamp utilization over balloon occlusion included both balloon supply issues and aortoiliac anatomy.

RESULTS

Mitral repair was performed in 122 patients (92.7%) and mitral valve replacement in 11 patients (8.3%). Mean aortic occlusion time was 92 ± 21.4 min. Mean time from left atrial closure to clamp removal was 8.7 (7.2 to 12.8) min. There were no injuries to the aorta or surrounding structures, mortality, strokes, or renal failure.

CONCLUSIONS

For robotic teams with endoaortic balloon capability, this technique may be useful in certain patients with aorto-iliac pathology or limited femoral artery access. Alternatively, robotic teams who employ transthoracic aortic clamping through a thoracotomy may find this technique useful to transition to a port-only endoscopic approach.

[Simultaneous surgery for upper gastrointestinal cancer and cardiovascular diseases]

OBJECTIVE

To analyze the immediate and long-term results of simultaneous surgical treatment in patients with upper gastrointestinal cancer and cardiovascular diseases.

MATERIAL AND METHODS

There were 9 patients with upper gastrointestinal cancer and cardiovascular diseases who underwent simultaneous surgical treatment. We assessed safety and efficacy of this approach. Mean age of patients was 65.7±5.7 years. Coronary artery disease was diagnosed in 3 patients, aortic valve disease - 1 patient, abdominal aortic aneurysm - 2; 4 patients suffered from isolated mitral valve disease, stenosis of the left vertebral artery, internal and external carotid arteries and Leriche syndrome.

RESULTS

Considering immediate and long-term postoperative results, we can emphasize advisability of simultaneous surgeries in appropriate patients.

Robotic Redo Mitral Valve Replacement and Atrioventricular Groove Pseudoaneurysm Repair

We report the use of robot-assisted right thoracotomy in the management of a patient who presented with acute-on-chronic congestive heart failure, associated with a contained atrioventricular dissection and 2 prior mitral valve replacements. Our patient had evidence of a contained rupture, as represented by preoperative cross-sectional imaging. The anatomic sequela from this was a ventricular pseudoaneurysm, which was likely survivable due to adhesions from prior operations buttressing the margins of the defect. Expansion of the pseudoaneurysm likely contributed to the dehiscence of the prosthesis. Our case illustrates an unprecedented resolution of a serious complication, managed effectively and efficiently by a robot-assisted procedure. With a successful outcome of totally endoscopic and robot-assisted repair, we demonstrate the versatility of minimally invasive techniques in addressing complicated anatomy as well as a surgical field scarred by multiple prior surgeries.

Two hundred robotic mitral valve repair procedures for degenerative mitral regurgitation: the Yale experience

Background

Robotic surgery has gained popularity over the past two decades due to the benefits related to smaller surgical incisions, enhanced technical dexterity and better intraoperative visualization. We present the Yale experience of the first two hundred totally endoscopic, robotic-assisted mitral valve repair procedures for the treatment of degenerative mitral regurgitation.

Methods

We performed a retrospective cohort study of patients undergoing totally endoscopic, robotic-assisted isolated or concomitant mitral valve repair for degenerative mitral regurgitation at Yale-New Haven Hospital from October 2018 to April 2022. Mitral valve repair procedures for rheumatic or secondary functional mitral regurgitation and planned robotic-assisted mitral valve replacement cases were excluded.

Results

Two hundred consecutive procedures were performed. The median age was 65 years (interquartile range, 58-73 years). Six patients (3.0%) had a history of mediastinal radiation, four patients (2.0%) had previous cardiac surgery, and one patient (0.5%) had cardiac dextroversion. Median cardiopulmonary bypass and aortic cross-clamp times were 122 and 79 minutes, respectively. Femoral vessel cannulation was performed percutaneously in 57 (28.5%) patients with no major access-site related complication. Aortic cross-clamping was performed with the endoaortic balloon occlusion device in 151 (75.5%) patients. No conversions to sternotomy occurred. Satisfactory repair was achieved in 100% of cases, with 184 (92.0%) and 16 (8.0%) of patients having trace/none or mild residual mitral regurgitation, respectively. Forty-two patients (21.0%) underwent concomitant Cox-maze procedure and 25 patients (12.5%) underwent concomitant tricuspid valve repair. Thirty-day mortality rate was 0.5%, with an observed-to-expected ratio of 0.53. Two patients (1.0%) underwent re-exploration for bleeding, one had early postoperative stroke (0.5%), five developed pneumothorax (2.5%) and two required dialysis for acute renal failure (1.0%). The median length of hospital stay was four days.

Conclusions

Excellent short-term outcomes can be achieved in experienced centers for the treatment of degenerative mitral regurgitation with a totally endoscopic, robotic-assisted approach.

Endoscopic Robotic Mitral Valve Surgery in Patients With Previous Sternotomy Cardiac Surgery

Objective: Mitral surgery is higher risk in patients with a previous median sternotomy. We describe an endoscopic robotic approach in this higher-risk cohort by an experienced robotic team. Methods: From January 2006 through June 2021, 152 consecutive patients with previous sternotomy cardiac surgery underwent mitral surgery using endoscopic robotics. Peripheral perfusion with endoaortic balloon occlusion was used in 148 patients (97.4%) and ventricular fibrillation in 4 patients (2.6%). Results: Mitral repair was performed in 73 patients (48%) including primary repair in 57 patients and re-repair in 16 patients, mitral replacement in 78 patients (51.3%) including primary replacement in 26 patients, conversion of a previous repair to replacement in 28 patients, and re-replacement in 24 patients. A paravalvular leak was primarily repaired in 1 patient (0.7%). Concomitant procedures included tricuspid repair in 28 patients (18.4%) and cryoablation in 8 patients (5.3%). Postoperative echocardiography in the mitral repair patients demonstrated none to mild regurgitation in 72 patients (98.6%). One repair patient (1.4%) had severe regurgitation and required robotic mitral replacement 5 days postoperatively. There were no paravalvular leaks in the mitral replacement patients. Operative mortality occurred in 3 patients (1.97%). Stroke occurred in 1 patient (0.7%), prolonged ventilation in 18 patients (11.8%), renal failure in 2 patients (1.4%), and re-exploration for bleeding in 10 patients (6.6%). Mean length of stay for the entire cohort was 5 ± 5.4 days. Conclusions: Robotic mitral valve surgery can be extended to patients with previous sternotomy with satisfactory efficacy and low operative mortality and morbidity.

One-shot cardioplegia for minimally invasive mitral valve repair-a comparison of del Nido and Bretschneider Histidine-Tryptophan-Ketoglutarate solutions

BACKGROUND

Minimally invasive procedures are demanding in terms of cardioprotection. In many leading centres Bretschneider HTK solution is used for mitral valve surgery. The study was designed to provide comparison of the del Nido and Bretschneider HTK protocol.

METHODS

Patients who underwent minimally invasive mitral valve repair for primary mitral regurgitation and received single delivery of either del Nido (Group 1) or Bretschneider HTK cardioplegia (Group 2) were matched on basis of age, gender and length of the cross-clamp time. The groups were compared in terms of major adverse cardiac and cerebrovascular events (death, myocardial infarction, stroke), high sensitivity troponin T (hs-TnT) and creatine kinase- MB isoenzyme (CK-MB) release at 12 h and 24 h following the surgery, incidence of low cardiac output syndrome (LCOS), postoperative arrhythmia, transfusions and postoperative renal function.

RESULTS

Case control matching selected 38 pairs of patients. None of patients died, nor suffered from myocardial infarction or stroke. Troponin values did not differ at 12 h (median: 281.0 pg/mL vs 313.0 pg/mL; p = .38) and 24 h (median: 261.0 pg/mL vs 299.0 pg/mL; p = .54), as well as CK-MB at 12 h (median: 25.0 ng/mL vs 29.0 ng/mL; p = .31) and 24 h (median: 11.0 ng/mL versus 9.6 ng/mL; p = .46). Difference in occurrence of LCOS was insignificant (2 vs 7; 5.2% vs 18.4%; p =.15). No difference was shown in incidence of postoperative arrhythmia, transfusions and renal function.

CONCLUSIONS

Del Nido cardioplegia can be used safely as an alternative for Bretschneider HTK for minimally invasive mitral valve surgery.

Transcatheter mitral valve replacement for degenerated mitral bioprostheses: a systematic review

Background

Treatment of degenerated mitral bioprostheses with transcatheter mitral valve-in-valve (MVIV) implantation is increasingly used. The goal of this review was to evaluate the one-year outcomes of this therapy using the most recent evidence.

Methods

A MEDLINE, Cochrane database and SCOPUS search was performed of published observational studies involving patients undergoing transcatheter MVIV for degenerated bioprosthesis to determine procedural success, thirty-day and one-year survival.

Results

A total of 2,684 patients undergoing transcatheter MVIV were identified from five studies with mean age of 73-75 years, 57-63% female and Society for Thoracic Surgery (STS) risk score ranging from 9-13%. Procedural technical success ranged from 94-98%, with 1-3% rates of periprocedural death, 0-2% stroke and 1-5% risk of left ventricular outflow tract (LVOT) obstruction. Thirty-day post-procedure mean mitral prosthetic gradient ranged from 6-7 mmHg and residual mitral regurgitation was mild or less in 96-100% of patients. Thirty-day survival and one-year survival ranged from 93-97% and 83-89% respectively.

Conclusions

Transcatheter MVIV is an effective treatment for structural degeneration of biologic mitral valve replacement with low complication rates and favorable one-year outcomes. Accordingly, MVIV should be considered as a reasonable alternative to re-do surgical mitral valve replacement in high risk patients with comorbidities. Further study of long-term outcomes of this treatment is needed.

Comparison of a new bioprosthetic mitral valve to other commercially available devices under controlled conditions in a porcine model

Background/Aim

To evaluate three mitral bioprostheses (of comparable measured internal diameters) under controlled, stable, hemodynamic and surgical conditions by bench, echocardiographic, computerized tomography and autopsy comparisons pre‐ and postvalve implantation.

Methods

Fifteen similar‐sized Yorkshire pigs underwent preprocedural computerized tomography anatomic screening. Of these, 12 had consistent anatomic features and underwent implantation of a mitral bioprosthesis via thoracotomy on cardiopulmonary bypass (CPB). Four valves from each of three manufacturers were implanted in randomized fashion: 27‐mm Epic, 27‐mm Mosaic, and 25‐mm Mitris bioprostheses. After CPB, epicardial echocardiographic studies were performed to assess hemodynamic function and define any paravalvular leaks, followed by postoperative gated contrast computerized tomography. After euthanasia, animals underwent necropsy for anatomic evaluation.

Results

All 12 animals had successful valve implantation with no study deaths. Postoperative echocardiographic trans‐valve gradients varied among bioprosthesis manufacturers. The 25‐mm Mitris (5.1 ± 2.7)/(2.6 ± 1.3 torr) had the lowest peak/mean gradient and the 27‐mm Epic bioprosthesis had the highest (9.2 ± 3.7)/(4.6 ± 1.9 torr). Surgical valve opening area (SOA) varied with the 25‐mm Mitris having the largest SOA (2.4 ± 0.15 cm²) followed by the 27‐mm Mosaic (2.04 ± 0.23 cm²) and the 27‐mm Epic (1.8 ± 0.27 cm²) valve. Bench device orthogonal internal diameter measurements did not match manufacturer device size labeling: 25‐mm Mitris (23 × 23 mm), 27‐mm Mosaic (23 × 22 mm), 27‐mm Epic (21 × 21 mm).

Conclusions

Current advertisement/packaging of commercial surgical mitral valves is not uniform. This study demonstrates marked variations in hemodynamics, valve opening area and anatomic dimensions between similar sized mitral bioprostheses. These data suggest a critical need for standardization and close scientific evaluation of surgical mitral bioprostheses to ensure optimal clinical outcomes.

Uniformity in bioprosthetic mitral valve sizing-When will we get there?

Much has changed since the introduction of surgical valve repair in the 1950s, from the introduction bioprosthetic valves to percutaneous approaches to valve repair. Yet, despite substantial advancements in bioprosthetic valve technology, there has been a lack of direct, independent comparison between bioprosthetic mitral valve devices, accompanied by a marked heterogeneity in approaches to the sizing and selection thereof. Wang et al. have hence endeavored to evaluate, head-to-head, the technical successes and biomechanical outcomes associated with three different bioprosthetic mitral valves (Epic; Abbott; Mosaic; Medtronic; Mitris Resilia; Edwards Lifesciences) in a porcine model, under standardized hemodynamic and anatomical conditions. With a robust experimental technique, they have made clear the heterogeneity in both sizing and biomechanical properties between bioprosthetic mitral valves, and have further emphasized the need for a uniform approach to the manufacturing and sizing of bioprosthetic valves.

Initial in-human experience with the conveyor cardiovascular system for the delivery of large profile transcatheter valve devices

OBJECTIVES

To determine the safety and efficacy of the conveyor cardiovascular system (CCS) to facilitate the delivery of large profile transcatheter valve devices.

BACKGROUND

Transcatheter valve devices rely on force provided by the operator to be delivered to their intended position. This delivery may be challenging in a variety of anatomic scenarios. The ability to provide steering from the tip of the device by forming an arterial venous loop may help overcome these challenges.

METHODS

Between May, 2019 and October, 2020, five patients were recruited for delivery of transcatheter valve devices with the CCS. These patients were deemed by the operators to have challenging anatomy which could make conventional valve delivery difficult or impossible. These patients were recruited as part of an FDA approved early feasibility study or through an institutional review board approved compassionate use protocol.

RESULTS

Three patients underwent transcatheter mitral valve replacement with a SAPIEN-3 valve. One patient each underwent transcatheter aortic valve (TAVR) implantation with a SAPIEN 3 and 1 patient underwent TAVR implantation with a Lotus valve. All patients underwent successful implantation of the valve and removal of the CCS and valve delivery systems. There was no more than trivial mitral regurgitation post procedure in any patient and there was no more than trivial paravavular leak. There were no major in-hospital complications.

CONCLUSIONS

The CCS facilitates the delivery of large profile transcatheter valve devices in challenging anatomic scenarios. Further studies are needed with additional valve technologies.

The effect of catheter ablation for ventricular arrhythmias originating from the left ventricular papillary muscles on mitral valve function

BACKGROUND

Ablation of ventricular arrhythmias (VA) originating from the left ventricular (LV) papillary muscles (PM) has the potential to damage the mitral valve apparatus resulting in mitral regurgitation (MR). This study sought to evaluate the effect of radiofrequency (RF) ablation of a PM on MR severity.

METHODS

Patients with pre- and postablation transthoracic echocardiograms who underwent PM ablation for treatment of VA were retrospectively identified and compared to similar patients who underwent VA ablation at non-PM sites. MR severity was evaluated pre- and postablation in both groups and graded as none/trace (Grade 0); mild/mild-to-moderate (Grade 1); moderate (Grade 2); moderate-to-severe/severe (Grade 3).

RESULTS

A total of 45 and 49 patients were included in the PM and non-PM groups, respectively. There were no significant baseline demographic differences. The PM group had longer RF ablation times (22.3 vs. 13.3 min, p < .01) compared to the non-PM group. Most patients had low-grade MR in both groups at baseline. Change in pre- versus postablation MR within the PM group was not statistically significant by Wilcoxon rank-sum test (Figure 2, p = .46). MR severity following ablation was also evaluated using logistic regression models. The odds ratio for worsening MR in the PM group compared to non-PM was 0.19 (95% confidence interval: 0.008-4.18, p = .29) after adjusting for comorbidities, LV ejection fraction, and LV internal end-diastolic diameter.

CONCLUSION

RF ablation of VA originating from PM under intracardiac echocardiography guidance did not result in clinically or statistically significant worsening of MR.

Transcatheter Mitral Valve Replacement: An Update on Current Techniques, Technologies, and Future Directions

Growing clinical data support the use of transcatheter therapies for significant mitral valve disease. Currently, edge-to-edge repair is the transcatheter treatment of choice, but many anatomies are not suitable. Transcatheter mitral valve replacement offers several potential advantages over transcatheter repair, most notably a greater and more sustained reduction in mitral regurgitation post-implantation, but also potential disadvantages. To enable the successful treatment of mitral valve disease in a wide range of patients and anatomies, we require an armory of transcatheter devices, including transcatheter mitral valve replacement systems.

Transseptal Puncture Learning Curve for Transcatheter Edge-to-Edge Mitral Valve Repair

OBJECTIVE

This study examined the learning curve for transseptal puncture (TSP) during transcatheter edge-to-edge mitral valve repair (TEER) performed by a dedicated mitral valve structural heart team. Effective TSP is mandatory for TEER but can be time-consuming and associated with complications including pericardial effusion and cardiac tamponade.

METHODS

TSP was performed on 107 consecutive patients (76 ± 1 years, 52% male) undergoing TEER between 2014 and 2019. TSP was performed by each structural heart team member (1 cardiologist, 2 cardiac surgeons) on a rotating case-by-case basis. No team member had prior independent TSP experience. Data collected included total procedure time, TSP time (time elapsed between procedure start and septal crossing), and number of TSP attempts before successful puncture. Cumulative sum (CUSUM) of deviations from the mean across sequential cases were used to examine learning curves.

RESULTS

Median total procedure time was 107 min, and the median TSP time was 14 min. Greater case number was significantly associated with both lower TSP time (r _s = -0.22, P = 0.022) and lower total procedure time (r _s = -0.29, P = 0.003). The majority of patients required only 1 TSP attempt (79%). There was a significant quadratic relationship between case number and the CUSUM for TSP time, with the learning curve peaking at 49 cases.

CONCLUSIONS

TSP for TEER has a substantial learning curve, requiring >50 cases to achieve acceptable efficiency. Even once proficiency is demonstrated, TSP remains a time-consuming component of TEER. Improvements in transseptal access technology may significantly decrease the time needed to master TSP and may improve the safety and precision of the procedure.

Combined Mitral and Aortic Valve Surgery: 17 Years' Experience in a Single Center

Background and objective:

It is not uncommon that patients requiring valve surgery have several simultaneous valvular dysfunctions. Combined aortic and mitral valve surgery is the most common form of double-valve surgery. The aim of this study was to analyze and present the outcomes of simultaneous aortic and mitral valve surgery in a single center in a real-life setting.

Methods:

The study population consisted of 150 patients operated in the Kuopio University Hospital from 2004 to 2020. All patients undergoing concomitant mitral and aortic valve surgery were included. Four groups were formed based on either the etiology or pathophysiology of the valvular dysfunction. The most common combination was mitral regurgitation with aortic regurgitation (n = 72, 48%), followed by mitral regurgitation with aortic stenosis (n = 37, 25%), endocarditis (n = 29, 19%), and mitral stenosis with aortic regurgitation or stenosis (n = 12, 8%). Concomitant coronary artery revascularization was performed in 37 (25%) patients and tricuspid valve repair in 26 (17%) patients.

Results:

Operative mortality was 2% and 30-day mortality was 7%. Overall survival was 86%, 78%, and 61% in 3, 5, and 10 years, respectively. Patients with endocarditis were significantly more morbid, and more often than other patients had to undergo an emergency operation. There were no significant differences between the groups in terms of early and late survival. In the overall cohort, the EuroSCORE II value, increased pulmonary artery pressure, decreased glomerular filtration, and length of the operation displayed a negative correlation with survival.

Conclusions:

Despite the challenging nature of multivalvular heart disease, surgery is a safe method of treatment with good short- and long-term outcomes.

Radiofrequency ablation alters the microstructural organization of healthy and enzymatically digested porcine mitral valves

BACKGROUND

Myxomatous mitral valve degeneration is a common cause of mitral regurgitation and is often associated with mitral valve prolapse. With no known targets to pharmacologically treat mitral valve prolapse, surgery is often the only treatment option. Recently, radiofrequency ablation has been proposed as a percutaneous alternative to surgical resection for the reduction of mitral valve leaflet area.

OBJECTIVE

Using an in vitro model of porcine mitral valve anterior leaflet enlargement following enzymatic digestion, we sought to investigate mechanisms by which radiofrequency ablation alters the geometry, microstructural organization, and mechanical properties of healthy and digested leaflets.

METHODS

Paired measurements before and after ablation revealed the impact of radiofrequency ablation on leaflet properties. Multiphoton imaging was used to characterize changes in the structure and organization of the valvular extracellular matrix; planar biaxial mechanical testing and constitutive modeling were used to estimate mechanical properties of healthy and digested leaflets.

RESULTS

Enzymatic digestion increased leaflet area and thickness to a similar extent as clinical mitral valve disease. Radiofrequency ablation altered extracellular matrix alignment and reduced the area of digested leaflets to that of control. Additionally, enzymatic digestion resulted in fiber alignment and reorientation toward the radial direction, causing increased forces during ablation and a structural stiffening which was improved by radiofrequency ablation.

CONCLUSION

Radiofrequency ablation induces radial extracellular matrix alignment and effectively reduces the area of enlarged mitral valve leaflets. Hence, this technique may be a therapeutic approach for myxomatous mitral valve disease and is thus an avenue for future study.

Mitral valve-in-valve and valve-in-ring: tips, tricks, and outcomes

Transcatheter aortic valve implantation is now a mainstay of treatment in patients with aortic stenosis who are considered intermediate, high and prohibitive risk for surgery. Extended use of this innovative platform in treating other conditions has led to its approval in treating degenerated aortic bioprosthesis. Similarly, use of transcatheter devices in treating degenerated mitral bioprosthesis and failed mitral valve repairs with annuloplasty rings has opened a potential alternative to surgery in these patients. Experience in mitral valve-in-valve (MVIV) and valve-in-ring (VIR), while still limited, is on the rise. Although similar in many ways to the aortic VIV, it is different with respect to patient selection, planning and procedural steps. Familiarity with the bioprosthetic properties and dimensions can help an operator choose an appropriate transcatheter device and deploy it in an ideal position. Due to greater variability in construction and properties, mitral rings have led to poorer results compared to mitral valve-in-valve. Understanding the properties of mitral rings is critical and has been simplified by us in a stepwise manner. We also describe steps in patient preparation and procedure, which should help operators in performing this procedure. Certain unique complications, such as left ventricular outflow tract obstruction and risk of embolization, are discussed with tips to address these issues. Once these steps are followed, the procedure can be performed with minimal risk and good outcome.

Hemodynamics rounds: Hemodynamics of mitral valve interventions

Mitral valvulopathy presents as regurgitation, stenosis, or mixed disease and can occur in both native and prosthetic valves. Such disease develops in conjunction with pathophysiologic changes in the left atrium (LA) and drives changes in LA compliance, pressure, and thus clinical syndromes. With advances in the understanding and treatment of structural heart disease and in the setting of higher-risk patient populations, less-invasive transcatheter approaches have become increasingly commonplace in the treatment of mitral valve disease. Over time, transcatheter mitral valve interventions have evolved to include paravalvular leak closure, mitral valve repair, and mitral valve replacement. Parallel to this evolution, advances in invasive intracardiac pressure monitoring, particularly at the level of the LA, have also occurred. These advances emphasize the unique interplay between mitral valve disease and LA function; account for limitations of noninvasive assessment; and guide beneficial outcomes in each area of transcatheter mitral valve intervention. As a result, continuous transseptal LA pressure monitoring has developed into an indispensable instrument in successful percutaneous mitral valve intervention, complementing traditional noninvasive assessment.

Transcatheter Mitral Valve Replacement With the Transseptal EVOQUE System

OBJECTIVES

The aim of this study was to examine the initial experience with a novel transseptal transcatheter mitral valve replacement (TMVR) system.

BACKGROUND

Transseptal TMVR may offer a less invasive option than surgery for mitral regurgitation (MR) with greater efficacy and fewer anatomic limitations than transcatheter repair.

METHODS

Patients were treated with the EVOQUE TMVR system from September 2018 to October 2019. Key inclusion criteria were moderate or greater MR, New York Heart Association functional class ≥II, and high or prohibitive surgical risk. The primary outcome was technical success, defined by Mitral Valve Academic Research Consortium criteria.

RESULTS

Fourteen patients were treated, all with at least moderate to severe MR. The median age was 84 years, and the median Society of Thoracic Surgeons score was 4.6%. MR was degenerative in 4 (28.6%), functional in 3 (21.4%), and mixed in 7 (50%). Technical success was achieved in 13 patients (92.9%), and 1 patient was converted to surgery. At 30 days there was 1 noncardiovascular mortality (7.1%), 2 strokes (14.3%), no myocardial infarctions, and no rehospitalizations. Two patients (14.3%) underwent paravalvular leak closure. One patient (7.1%) underwent alcohol septal ablation for left ventricular outflow tract obstruction. Including the 2 patients with paravalvular leak closure, MR was mild or less in all implanted patients at 30 days, with no MR in 10 (83.3%). Mean mitral gradient was 5.8 mm Hg (median). New York Heart Association functional class improved to ≤II in 9 patients (81.8%).

CONCLUSIONS

This first-in-human experience has demonstrated the feasibility of the transseptal EVOQUE TMVR system. Further clinical studies are required to establish safety and clinical outcomes.

Iatrogenic Coronary Artery Compromise Post Non-Coronary Cardiac Surgery in Patients With Normal Coronaries

BACKGROUND

Unexpected events in cardiac surgery may increase morbidity and mortality. We present rare complications related to coronary arteries in non-coronary cardiac surgery in adults and pediatrics.

PATIENTS AND METHODS

We retrospectively reviewed our surgical left-sided valve procedures and aortic root reconstruction for patients with documented coronary ostial injury or left circumflex artery (LCX) between January 2012 and December 2019. Preoperative echocardiography was the standard investigation for all cases and other specific work ups were ordered, according to each case. Management by surgical or non-surgical intervention was planned, according to each complication. Postoperative hemodynamics and mortality rate were the outcomes of interest.

RESULTS

Seven patients were found to have coronary artery compromise post left-sided valve procedures and aortic root reconstruction in adults and children. The details are shown in Table 1. The complications were in 2 patients post-mitral valve (MV) repair, 3 patients post-aortic (AV) replacement, 2 pediatric patients, 1 post-aortic homograft, and the other post-repair of anomalous single coronary arising from the pulmonary artery (ASCAPA). Six patients were hemodynamically unstable. Five patients had intraoperative ischemic changes on electrocardiogram and echocardiography, while ventricular arrhythmias were documented in 3 patients. Two patients were treated with percutaneous coronary intervention to LCX and right coronary artery (RCA), while 4 patients required immediate surgery to graft the obtuse marginal branch of the LCX artery (1) and RCA (3). No revision to valvular procedure was done. With the exception of one, all patients survived.

CONCLUSION

A high index of suspicion is required to diagnose and rescue coronary complications post-valvular surgery and aortic root reconstruction.

Initial Feasibility Study of a New Transcatheter Mitral Prosthesis: The First 100 Patients

BACKGROUND

Transcatheter mitral valve replacement (TMVR) is a rapidly evolving therapy. Follow-up of TMVR patients remains limited in duration and number treated.

OBJECTIVES

The purpose of this study was to examine outcomes with expanded follow-up for the first 100 patients who underwent TMVR with the prosthesis.

METHODS

The Global Feasibility Study enrolled symptomatic patients with either primary or secondary mitral regurgitation (MR) who were at high or prohibitive surgical risk. The present investigation examines the first 100 patients treated in this study. Clinical outcomes through last clinical follow-up were adjudicated independently.

RESULTS

In the cohort (mean age 75.4 ± 8.1 years; 69% men), there was a high prevalence of severe heart failure symptoms (66%), left ventricular dysfunction (mean ejection fraction 46.4 ± 9.6%), and morbidities (Society of Thoracic Surgeons Predicted Risk of Mortality, 7.8 ± 5.7%). There were no intraprocedural deaths, 1 instance of major apical bleeding, and no acute conversion to surgery or need for cardiopulmonary bypass. Technical success was 96%. The 30-day rates of mortality and stroke were 6% and 2%, respectively. The 1-year survival free of all-cause mortality was 72.4% (95% confidence interval: 62.1% to 80.4%), with 84.6% of deaths due to cardiac causes. Among survivors at 1 year, 88.5% were New York Heart Association function class I/II, and improvements in 6-min walk distance (p < 0.0001) and quality-of-life measurements occurred (p = 0.011). In 73.4% of survivors, the Kansas City Cardiomyopathy Questionnaire score improved by ≥10 points.

CONCLUSIONS

In this study of TMVR, which is the largest experience to date, the prosthesis was highly effective in relieving MR and improving symptoms, with an acceptable safety profile. Further study to optimize the impact on long-term survival is needed.

Transaortic repair of concomitant mitral insufficiency in patients with critical aortic stenosis undergoing aortic valvular replacement

Background

In this study, we present operation technique and outcomes of transaortic mitral valve repair in high-risk patients undergoing aortic valve replacement due to severe aortic stenosis.

Methods

Between January 2005 and March 2016, a total of 11 patients (7 females, 4 males; mean age 71.2±4.1 years; range, 65 to 77 years) with severe aortic valve stenosis (aortic valve area <1 cm2 or aortic valve area index <0.6 cm2/m2) and concomitant moderate or severe mitral regurgitation (non-ischemic, regurgitant jet origin between A2-P2 portions) secondary to left ventricular dysfunction (EuroSCORE logistic score >5%, left ventricular ejection fraction <30%) who were operated were retrospectively analyzed. Aortic valve replacement and transaortic mitral edge-to-edge repair was applied to all patients. Operations were performed through sternotomy, cardiopulmonary bypass, and bicaval venous return. Transesophageal echocardiography was used to evaluate mitral valve before surgery and valve functions after surgery. Postoperative course of all patients was monitored, and postoperative complications were recorded.

Results

The mean preoperative ejection fraction was 24.5±4.1% and the mean transaortic pressure gradient was 35.8±4.8 mmHg. The mean aortic cross-clamp time was 62.09±10.1 (range, 43 to 76) min and the median cardiopulmonary bypass time was 90.1±11.9 (range, 66 to 114) min. No hospital mortality was observed. In the postoperative period, two patients experienced renal insufficiency. Hemofiltration was initiated in these patients and no dialysis was required at two weeks. One patient had postoperative atrial fibrillation and one patient had pericardial effusion leading to cardiac tamponade and this patient underwent reoperation. The patients were followed up for a mean of four years and control echocardiography didn"t detect increase in mitral regurgitation degree.

Conclusion

Transaortic edge-to-edge mitral valve repair can be used in high-risk patients undergoing aortic valve replacement. This technique is feasible with shorter cross-clamp time and can reduce mortality and morbidity in selected high-risk patients.

Management of thrombocytopenia in a patient with a mechanical mitral valve undergoing autologous hematopoietic stem cell transplantation: case report and review of literature

Mechanical mitral valves require life-long anticoagulation with Vitamin K Antagonists (VKA), targeted to an international normalized ratio (INR) of 2.5-3.5. While complications, including valve thrombosis and bleeding, are well known, there is a paucity of data on the management of mechanical mitral valves in patients with thrombocytopenia. Due to an increased bleeding risk, the presence of a mechanical mitral valve is considered by some providers as an exclusion criterion for autologous hematopoietic stem-cell transplantation (HSCT). Presented here is a case of a patient with multiple myeloma who successfully underwent autologous HSCT with simultaneous alterations in VKA therapy for continued anticoagulation in the setting of an underlying mechanical mitral valve.

What is the safety and efficacy of the use of automated fastener in heart valve surgery?

INTRODUCTION

Cor-Knot automated fastener has been used as an adjunct in heart valve surgery to eliminate the need for manual tying during valve implantation. Although reduced operative time and facilitation for minimally invasive surgery are clear benefits, whether their use translates to improved patient outcome remains debatable. This study aims to review the safety and efficacy of automated fasteners in heart valve surgeries.

METHOD

Specific searches were conducted via online medical databases (Pubmed, Embase, Ovid) between 1950 and June 2019. Longitudinal studies were included that provided operative parameters.

RESULTS

The initial literature search identified 3773 articles, but only eight met the inclusion criteria and were used for analysis: four studies related to aortic valve replacement (AVR), four related to mitral valve (MV) intervention (total n = 810). The meta-analysis revealed the significantly shorter aortic cross-clamp time in the Cor-knot group compared to manual tying, both in AVR and MV surgeries (P < .05). Cardiopulmonary bypass time was significantly shorter in the Cor-knot group when analyzing studies in MV surgery (weighted mean difference [WMD]: 110.0; 95% confidence interval: 12.3-207.7; P = .027) The use of Cor-Knot did not increase the risk of permanent pacemaker implantation, paravalvular leak, and 30-day mortality. The majority of studies reported no change in the length of intensive unit care and total hospital stay.

CONCLUSION

We confirmed that the majority of existing literatures indicated the safety and intraoperative efficacy with automated fastener application. Nevertheless, there is currently no evidence to support automated fastened sutures can translate its intraoperative advantages to improved patient outcome.

Gemella endocarditis: A case report and a review of the literature

Infective endocarditis (IE) remains a prevalent disease with a high rate of morbidity and mortality. Recent changes have been noted in the profile of causative microorganisms. In this report, we describe a case of Gemella-related endocarditis and review the related literature. Our patient was an 81-year-old man who presented with dyspnea and fatigue. His initial examination revealed a new systolic murmur. Echocardiogram revealed moderate mitral regurgitation with 1-cm mass on the anterior mitral leaflet, and blood cultures grew Gemella haemolysans. Penicillin and gentamicin were initiated, and workup for possible source was positive for a colonic polyp with high-grade dysplasia. The patient subsequently developed cardiogenic shock and severe pulmonary edema. Comfort care measures were initiated, and he passed away thereafter. We reviewed PubMed for cases of Gemella-related endocarditis. We found 65 documented cases and added our patient's case to the analysis. Seventy-two percent of the cases occurred in men. The mean age was 51 years and 42% of the patients were older than 60 years. Fever was the most common presenting symptom and most of the cases presented subacutely. The mitral valve was the most affected site and 50% of the patients required surgical intervention. G. morbillorum was the most common subtype and a total of four cases were found to be associated with colorectal neoplasm. As a conclusion, Gemella species rarely cause IE. The absence of a clear source of bacteremia warrants further evaluation for a gastrointestinal source. The infection can be destructive and must be promptly treated to avoid complications.

The role of the left atrial function in the surgical management of aortic and mitral valve disease

The right management of both mitral and aortic disease can be challenging, especially in asymptomatic patients. The current guidelines recommend valve repair or replacement when symptoms arise or when there is an evident left ventricular dysfunction. However, deciding the optimal surgical timing can be very difficult, since the line between the absence of symptoms and being minimally symptomatic, especially in the elderly, is blurred. Another relevant issue regards the second surgical criterion: operating on a patient with a reduced left ventricular ejection fraction or with a dilated left ventricle might jeopardize the possibility of a fully reverse remodeling of the heart after surgery. In this scenario, the left atrium might play an important role. In particular, left atrial deformation might be a very useful tool to detect early ultrastructural alterations, and help or support guiding a patient-tailored treatment at an early stage, optimizing the outcome in the long term.

ACVIM consensus guidelines for the diagnosis and treatment of myxomatous mitral valve disease in dogs

This report, issued by the ACVIM Specialty of Cardiology consensus panel, revises guidelines for the diagnosis and treatment of myxomatous mitral valve disease (MMVD, also known as endocardiosis and degenerative or chronic valvular heart disease) in dogs, originally published in 2009. Updates were made to diagnostic, as well as medical, surgical, and dietary treatment recommendations. The strength of these recommendations was based on both the quantity and quality of available evidence supporting diagnostic and therapeutic decisions. Management of MMVD before the onset of clinical signs of heart failure has changed substantially compared with the 2009 guidelines, and new strategies to diagnose and treat advanced heart failure and pulmonary hypertension are reviewed.

Fluid-structure interaction assessment of blood flow hemodynamics and leaflet stress during mitral regurgitation

The aim of this study is to simulate the Mitral Regurgitation (MR) disease progression from mild to severe intensity. A Fluid Structure Interaction (FSI) model was developed to extract the hemodynamic parameters of blood flow in mitral regurgitation (MR) during systole. A two-dimensional (2D) geometry of the mitral valve was built based on the data resulting from Magnetic Resonance Imaging (MRI) dimensional measurements. The leaflets were assumed to be elastic. Using COMSOL software, the hemodynamic parameters of blood flow including velocity, pressure, and Von Mises stress contours were obtained by moving arbitrary Lagrange-Euler mesh. The results were obtained for normal and MR cases. They showed the effects of the abnormal distance between the leaflets on the amount of returned flow. Furthermore, the deformation of the leaflets was measured during systole. The results were found to be consistent with the relevant literature.

50 years of decoding olfaction

The identification, in the late 20th century, of unexpectedly large families of G-protein-coupled chemosensory receptors revolutionised our understanding of the olfactory system. The discovery that non-selective olfactory sensory neurons express a single olfactory receptor type and project to a specific glomerulus in the main olfactory bulb provided fundamental insight into the spatial pattern of odour representation in the main olfactory bulb. Studies using head-fixed awake mice and optogenetics have revealed the importance of the timing of glomerular input in relation to the sniff cycle and the role of piriform cortex in odour object recognition. What in the 1970s had appeared to be a relatively simple dichotomy between odour detection by the main olfactory system and pheromone detection by the vomeronasal system has been found to consist of multiple subsystems. These mediate innate responses to odours and pheromones and to substances as diverse as O₂, volatile urinary constituents, peptides and proteins.

Early experience with the Intrepid system for transcatheter mitral valve replacement

Severe mitral regurgitation is common and results in a poor prognosis in patients with either symptoms or severe ventricular dilatation. While mitral regurgitation has traditionally necessitated surgical repair or replacement, new transcatheter methods, such as the IntrepidTM transcatheter mitral valve replacement, has recently emerged. The Intrepid system is a circular, self-expanding, tri-leaflet bovine pericardial prosthesis housed within a nitinol frame. In early feasibility studies, the Intrepid prosthesis has been found to be effective for relief of mitral regurgitation and associated with functional improvement in the majority of survivors.

Rheumatoid nodule on the anterior mitral valve leaflet

Symptomatic cardiac rheumatoid nodules are a rare but recognized manifestation of rheumatoid arthritis. We describe the surgical management of a rheumatic nodule involving the anterior leaflet of the mitral valve.

Aortic and mitral valve repair for anterior mitral leaflet perforation caused by severe aortic regurgitation

A 23-year-old man presented with acute onset of dyspnea on exert. Preoperative echocardiography showed a severe regurgitation of the bicuspid aortic valve (due to prolapse of the fused cusp) creating a jet directed through the defect in the anterior leaflet of the mitral valve. Both valves were repaired. Endocarditis was excluded with cultures and polymerase chain reaction (PCR). Postoperative course was uneventful.