Impact of Tricuspid Regurgitation on Outcomes After Transcatheter Mitral Valve Replacement

Development of functional tricuspid regurgitation (TR) because of chronic mitral disease and subsequent heart failure is common. However, the effect of TR on clinical outcomes after transcatheter mitral valve replacement (TMVR) remains unclear. We aimed to evaluate the impact of baseline TR on outcomes after TMVR. This was a single-center, retrospective analysis of patients who received valve-in-valve or valve-in-ring TMVR between 2012 and 2022. Patients were categorized into none/mild TR and moderate/severe TR based on baseline echocardiography. The primary outcome was 3 years all-cause death and the secondary outcomes were in-hospital events. Of the 135 patients who underwent TMVR, 64 (47%) exhibited none/mild TR at baseline, whereas 71 (53%) demonstrated moderate/severe TR. There were no significant differences in in-hospital events between the groups. At 3 years, the moderate/severe TR group exhibited a significantly increased risk of all-cause death (adjusted hazard ratio 3.37, 95% confidence interval 1.35 to 8.41, p = 0.009). When patients with baseline moderate/severe TR were stratified by echocardiography at 30 days into improved (36%) and nonimproved (64%) TR groups, although limited by small sample size, there was no significant difference in 3-year all-cause mortality (p = 0.48). In conclusion, this study investigating the impact of baseline TR on clinical outcomes revealed that moderate/severe TR is prevalent in those who underwent TMVR and is an independent predictor of 3-year all-cause mortality. Earlier mitral valve intervention before the development of significant TR may play a pivotal role in improving outcomes after TMVR.

Early outcomes following transatrial transcatheter mitral valve replacement in patients with severe mitral annular calcification

OBJECTIVE

Implantation of a transcatheter valve-in-mitral annular calcification (ViMAC) has emerged as an alternative to traditional surgical mitral valve (MV) replacement. Previous studies evaluating ViMAC aggregated transseptal, transapical, and transatrial forms of the procedure, leaving uncertainty about each technique's advantages and disadvantages. Thus, we sought to evaluate clinical outcomes specifically for transatrial ViMAC from the largest multicenter registry to-date.

METHODS

Patients with symptomatic MV dysfunction and severe MAC who underwent ViMAC were enrolled from 12 centers across the United States and Europe. Clinical characteristics, procedural details, and clinical outcomes were abstracted from the electronic record. The primary end point was all-cause mortality.

RESULTS

We analyzed 126 patients who underwent ViMAC (median age 76 years [interquartile range {IQR}, 70-82 years], 28.6% female, median Society of Thoracic Surgeons score 6.8% [IQR, 4.0-11.4], and median follow-up 89 days [IQR, 16-383.5]). Sixty-one (48.4%) had isolated mitral stenosis, 25 (19.8%) had isolated mitral regurgitation (MR), and 40 (31.7%) had mixed MV disease. Technical success was achieved in 119 (94.4%) patients. Thirty (23.8%) patients underwent concurrent septal myectomy, and 8 (6.3%) patients experienced left ventricular outflow tract obstruction (7/8 did not undergo myectomy). Five (4.2%) patients of 118 with postprocedure echocardiograms had greater than mild paravalvular leak. Thirty-day and 1-year all-cause mortality occurred in 16 and 33 patients, respectively. In multivariable models, moderate or greater MR at baseline was associated with increased risk of 1-year mortality (hazard ratio, 2.31; 95% confidence interval, 1.07-4.99, P = .03).

CONCLUSIONS

Transatrial ViMAC is safe and feasible in this selected, male-predominant cohort. Patients with significant MR may derive less benefit from ViMAC than patients with mitral stenosis only.

Challenging in pulmonary thromboembolism diagnosis in patients with disproportionate pulmonary hypertension and severe mitral stenosis: Report of two cases

Key Clinical Message

Before valvular interventions, echocardiography, especially the TEE or the ventilation/perfusion scan, should be performed to detect silent PTE and set a more accurate treatment and surgical plan.

Abstract

Pulmonary hypertension (PH) is a progressive and critical disease that can be caused by mitral stenosis (MS). Some of these patients present with disproportionate PH, which is an uncommon phenomenon and is considered a challenging diagnostic and treatment process. In these patients, other causes may also play a role in developing PH. This report presented two cases with disproportionate PH and severe MS who were scheduled for percutaneous mitral valvuloplasty (PMV). The pre-procedural echocardiography revealed systolic pulmonary artery pressure (sPAP) of 90 and 120 mmHg, mitral valve area of 0.80 and 0.55 cm2 by three-dimensional (3D) planimetry, and diastolic pressure gradient (DPG) of 13 and 18.8 mmHg, respectively. Furthermore, in the first patient, 3D transesophageal echocardiography (TEE) revealed multiple saddle-type organized thrombi in the proximal parts of the right and left pulmonary arteries, extending to the distal branches. In the second patient, 3D TEE revealed a large, relatively fresh, flow-limiting thrombosis in the proximal part of the right pulmonary artery. The diagnosis of pulmonary thromboembolism (PTE) in both patients was confirmed by CT angiography. In both patients, the valves were surgically repaired, while all thrombi were removed from the cardiac chambers and pulmonary vessels during surgery. In addition, patients underwent warfarin therapy orally. They were followed up 6 months after the intervention, and their clinical symptoms had improved significantly.

Impact of mitral stenosis on early and late outcomes of transcatheter aortic valve replacement for aortic stenosis: a single-center analysis

OBJECTIVES

To assess the impact of concomitant mitral stenosis (MS) on early and late outcomes of transcatheter aortic valve replacement (TAVR) for aortic stenosis.

METHODS

This study involved 952 patients undergoing TAVR for severe tricuspid aortic stenosis. The patients were classified into 3 groups: without MS, with progressive MS, and severe MS (mitral valve area ≤ 1.5 cm2). Clinical outcomes between these groups were compared.

RESULTS

The median age of the overall cohort was 82 years, and patients in the progressive (n = 49) and severe (n = 24) MS groups were more likely to be female than those in the no-MS group (n = 879). Periprocedural mortality rate was lowest in the no-MS group (1.8%) compared with the progressive (4.1%) and severe (4.2%) MS groups, which were not significantly different (P = .20). During 5 years of follow-up (median: 27, range: 0-72 months), there was no significant difference in all-cause mortality (log-rank P = .99), a composite of all-cause mortality or rehospitalization for heart failure (log-rank P = .84), or cardiovascular death (log-rank P = .57) between groups. Although crude analysis showed a significant difference in rehospitalization for heart failure in the severe MS group compared with the no-MS group (P = .049), the difference was not significant in the multivariate analysis (adjusted hazard ratio: 1.36 [95% CI, 0.66-2.80], P = .41).

CONCLUSIONS

TAVR can be safely performed in patients with severe tricuspid aortic stenosis and concomitant MS, with early and mid-term outcomes comparable to those in patients without MS.

Assessment of Suitability for Percutaneous Mitral Commissurotomy: A Contemporary Review of Key Anatomical Criteria and Predictive Models

The immediate result of percutaneous balloon mitral commissurotomy (PMC) is largely determined by the anatomy of the mitral valve complex. Several scores and models have been developed to assess anatomical suitability for PMC. Although none has an optimal predictive power, these models look at the valvular apparatus from different perspectives bearing the potential for a complementary role.

Mitral Annular Calcification-Related Valvular Disease: A Challenging Entity

Mitral valve annular calcification-related valvular disease is increasingly common due to the rising prevalence of age-related mitral annular calcifications. Mitral annular calcification alters the structure and function of the mitral valve annulus, which in turn causes mitral valve regurgitation, stenosis, or both. As it frequently coexists with comorbid conditions and overlapping symptoms, mitral annular calcification-related valvular disease poses significant diagnostic and therapeutic challenges. For instance, left ventricular diastolic dysfunction hinders the assessment of mitral valvular disease. Detection of mitral annular calcifications and assessment of related mitral valve disease hinge on two-dimensional echocardiography. Comprehensive assessment of mitral annular calcifications and related mitral valve disease may require multidetector computed tomography and three-dimensional echocardiography. Invasive hemodynamic testing with exercise helps identify the cause of symptoms in patients with comorbid conditions, and transcatheter interventions have emerged as a viable therapeutic option for older patients. After an outline of the normal mitral annulus, we examine how mitral annular calcifications lead to mitral valve disease and how to accurately assess mitral regurgitation and stenosis. Lastly, we review surgical and transcatheter approaches to the management of mitral annular calcification-related mitral valve regurgitation, stenosis, or both.

Large Left Atrial Thrombus in a Patient With Severe Mitral Stenosis and Atrial Fibrillation Despite Anticoagulant Therapy: A Case Report

This case report highlights a patient with atrial fibrillation, severe mitral stenosis, and left atrial dilatation who developed a large thrombus, despite being on anticoagulant therapy. The complexity of thrombus formation in patients with multiple risk factors is described, emphasising the need for regular echocardiographic assessments to detect and monitor thrombi, even in patients undergoing anticoagulant treatment. The interplay between atrial fibrillation, mitral stenosis, and left atrial dilatation contributes to thrombus formation, requiring a multidisciplinary approach to the management of these patients. Further research is needed to improve our understanding of the optimal treatment strategies for such cases. Timely identification and intervention are critical to mitigate the risk of thromboembolic complications in these high-risk patients.

Camptodactyly-arthropathy-coxa vara-pericarditis syndrome and an unusual association with mitral stenosis

BACKGROUND

Campotodactyly-artrhropathy-coxa vara-pericarditis (CACP) syndrome is a very rare autosomal recessive genetic disorder. It is characterized by flexion contracture of the fifth finger (camptodactyly); noninflammatory arthropathy; decreased angle between the shaft and the head of the femur (coxa vara) and pericarditis. Its association with mitral stenosis has not yet been reported. Hereby we report this unique association with CACP syndrome.

CASE

An eleven-year-old girl presented with non-productive cough, dyspnea, and orthopnea. She was diagnosed CACP syndrome at the age of seven and a biallelic frameshift mutation in the PRG4 gene was determined. The physical examination revealed pectus excavatum, camptodactyly, genu valgum, tachypnea and orthopnea. The functional capacity was NYHA III-IV. She had 2/6 soft pansystolic murmur at 4th left intercostal space and a rumbling diastolic murmur at apex. Echocardiography revealed an enlarged left atrium, severe stenotic mitral valve with a mean diastolic transmitral gradient of 22.5 mmHg, mild mitral regurgitation and mild apical pericardial effusion. The patient had mitral comissurotomy and partial pericardiectomy operation. Her post-operative transmitral gradient decreased to 6.9 mmHg and the pulmonary pressure was 30 mmHg. Her functional capacity increased to NYHA I-II.

CONCLUSIONS

The main defect is the proteoglycan 4 protein which acts like a lubricant in articular and visceral surfaces. Therefore, the leading clinical feature is arthropathy. Cardiac involvement other than clinically mild pericarditis is not usually expected. Three types of proteoglycans (decorin, biglycan, and versican) are present in the mitral valve. This could be the reason of mitral valve involvement in rare cases as like ours. It is important that these patients undergo echocardiographic examination regularly.

Is Concomitant Mitral Stenosis Associated With Worse Outcomes in Patients Who Underwent TAVR? Insights from a National Database

Concomitant mitral stenosis (MS) is present in 10% to 15% of all patients who underwent transcatheter aortic valve replacement (TAVR). Our aim is to assess outcomes of TAVR in patients with MS using a national database. The Nationwide Inpatient Sample database was used to identify patients who underwent TAVR from 2015 to 2020. We created 2 groups, patients with and those without MS. We then compared baseline characteristics, demographics, and in-hospital outcomes of the groups. Primary outcomes were in-hospital mortality, acute respiratory failure, and pacemaker placement. Secondary outcomes were length of stay and in-hospital costs. Our study indicates that patients with MS had greater incidence of acute respiratory failure (8.8% vs 4.89%, p = 0.001), complete heart block (13.54% vs 9.36%, p = 0.01), and permanent pacemaker placement (8.03% vs 6.03%, p = 0.05). In-hospital mortality was greater in the MS group; however, it was not statistically significant (1.32% vs 1.53%, p = 0.679).

National trends in utilization of transatrial transcatheter mitral valve replacement and postoperative outcomes

OBJECTIVE

Transatrial transcatheter mitral valve replacement reduces complexity during mitral valve replacements involving high-risk patients with mitral annular calcification. This study examines trends in transatrial transcatheter mitral valve replacement use and outcomes.

METHODS

Patients in the Society of Thoracic Surgeons database from 2014 to 2021 with mitral annular calcification undergoing transatrial transcatheter mitral valve replacement were included. Exclusion criteria were hypertrophic cardiomyopathy, congenital mitral valve disease, ventricular assist device placement, or prior mitral valve surgery. Primary outcomes were operative mortality and major adverse cardiac events compared between the Early (2014-2017, N = 71) and Recent (2018-2021, N = 151) eras. Parsimonious multivariable regression assessed select possible confounders for trends in major adverse cardiac events.

RESULTS

Overall, 222 transatrial transcatheter mitral valve replacements at 104 hospitals were identified. Annual volume increased from 6 in 2014 to 43 in 2021. Median hospital volume was 1, maximum hospital volume was 17, and 10 or more replacements were performed at 4 hospitals. Mortality and major adverse cardiac events occurred in 10.4% and 22.5% of patients, respectively. Compared with the Early era patients, Recent era patients were more often elective (79.5% vs 64.8%) and were approached via sternotomy (90.1% vs 80.3%, all P < .05). Despite similar predicted risk of mortality (9.6% ± 11.1% vs 11.0% ± 6.0%; P = .61), Recent patients had reduced mortality (3.3% vs 25.4%, P < .001) and major adverse cardiac events (18.5% vs 31.0%; P = .057). On univariate and multivariable analyses, the Recent surgical era was significantly associated with lower mortality (0.10 [0.04-0.29]; P < .001) and lower major adverse cardiac events (0.48 [0.25-0.94]; P = .032), respectively. There were no preoperative characteristics that were significant confounders for the difference in major adverse cardiac events.

CONCLUSIONS

Mortality and major adverse cardiac events after transatrial transcatheter mitral valve replacement have decreased significantly in the contemporary era independent of changes in major patient and operative characteristics. Transatrial transcatheter mitral valve replacement will have a future role in patients with mitral annular calcification.

5-Year Prospective Evaluation of Mitral Valve-in-Valve, Valve-in-Ring, and Valve-in-MAC Outcomes: MITRAL Trial Final Results

BACKGROUND

The MITRAL (Mitral Implantation of Transcatheter Valves) trial is the first prospective trial to evaluate the safety and feasibility of balloon-expandable aortic transcatheter heart valves in patients with failed surgical bioprostheses or annuloplasty rings and severe mitral annular calcification treated with mitral valve-in-valve (MViV), valve-in-ring (MViR), or valve-in-mitral annular calcification (ViMAC).

OBJECTIVES

The aim of this study was to evaluate 5-year outcomes among these patients.

METHODS

A multicenter prospective study was conducted among patients at high surgical risk at 13 U.S. sites. Patients underwent MViV (n = 30), MViR (n = 30), or ViMAC (n = 31) and were followed annually for 5 years. Kansas City Cardiomyopathy Questionnaire scores were obtained at baseline and follow-up visits. Echocardiograms were analyzed at independent core laboratories.

RESULTS

A total of 91 patients underwent transcatheter mitral valve replacement (February 2015 to December 2017). The mean age was 74.3 ± 8.9 years. At 5-year follow-up, the lowest all-cause mortality was observed in the MViV group (21.4%), 94.7% of patients were in NYHA functional class I or II, and the mean mitral gradient was 6.6 ± 2.5 mm Hg. The MViR and ViMAC groups had higher all-cause mortality (65.5% and 67.9%), most survivors were in NYHA functional classes I and II (50% and 55.6%), and mean mitral gradients remained stable (5.8 ± 0.1 and 6.7 ± 2.5 mm Hg). Significant improvements in Kansas City Cardiomyopathy Questionnaire scores were observed when all 3 arms were pooled.

CONCLUSIONS

MViV, MViR, and ViMAC procedures were associated with sustained improvement of heart failure symptoms and quality of life among survivors at 5 years. Transcatheter heart valve function remained stable in all 3 groups. Patients treated with MViV had excellent survival at 5 years, whereas survival was lower in the MViR and ViMAC groups, consistent with underlying disease severity. Patients with more residual mitral regurgitation had higher mortality.

Transfemoral Transcatheter Mitral Valve Implantation With a Dedicated Device in a Rheumatic Mitral Stenosis Patient

A 65-year-old obese woman with rheumatic heart disease and restrictive lung disease presented with decompensated heart failure. Evaluation demonstrated severely thickened mitral valve leaflets, severe mitral stenosis, and moderate mitral regurgitation. She underwent successful transfemoral transseptal transcatheter mitral valve replacement with a dedicated valve resulting in improved functional status. (Level of Difficulty: Advanced.).

Mitral facies-a classic feature of chronic mitral stenosis: A case report

Mitral facies is a classical feature of chronic mitral stenosis (MS) that commonly associated with low cardiac output and pulmonary hypertension. A 44-year-old woman presented with 10-year history of refractory right heart failure. We noted distinctive malar rash appearance on her face known as "mitral facies." An echocardiogram revealed severe MS and other significant valve involvement with typical characteristics of rheumatic valvular heart disease. Doppler measurement showed decreased cardiac output and severe pulmonary hypertension in this patient. The mitral facies could be an alarming sign of a more severe and advanced form of MS. It also can be a marker of impaired cardiac output and concomitant severe pulmonary hypertension.

Effect of Dapagliflozin on Patients with Rheumatic Heart Disease Mitral Stenosis

(1) Background: Mitral stenosis is the most common rheumatic heart disease (RHD). Inflammation and fibrosis are the primary pathophysiology, resulting in left atrial stress and dysfunction. Dapagliflozin is a new heart failure treatment with anti-inflammation and anti-fibrosis effects from previous studies. However, the specific role of dapagliflozin in RHD mitral stenosis is unknown. This study aims to investigate (i) the effect of dapagliflozin on biomarkers of fibrosis, NT-pro BNP levels and left atrial function; (ii) the relationship between the changes in fibrosis biomarkers with left atrial function and NT-pro BNP levels. (2) Methods: An open-label randomized study was conducted on 33 RHD mitral stenosis patients divided into a dapagliflozin group which received 10 mg dapagliflozin and standard therapy, and a control group which only received standard therapy. All patients were examined for levels of PICP, MMP-1/TIMP-1 ratio, TGF-β1, NT-proBNP, mitral valve mean pressure gradient (MPG), and net atrioventricular compliance (Cn) pre- and post-intervention. (3) Results: This study found a significant increase in PICP and TGF-β1 and a reduction in the MMP-1/TIMP-1 ratio in the dapagliflozin group and the control group (p < 0.05). In the dapagliflozin group, the levels of NT-pro BNP decreased significantly (p = 0.000), with a delta of decreased NT-pro BNP levels also significantly greater in the dapagliflozin group compared to the control (p = 0.034). There was a significant increase in Cn values in the dapagliflozin group (p = 0.017), whereas there was a decrease in the control group (p = 0.379). Delta of changes in Cn values between the dapagliflozin and control groups also showed a significant value (p = 0.049). The decreased MPG values of the mitral valve were found in both the dapagliflozin and control groups, with the decrease in MPG significantly greater in the dapagliflozin group (p = 0.031). There was no significant correlation between changes in the value of fibrosis biomarkers with Cn and NT-pro BNP (p > 0.05). (4) Conclusions: This study implies that the addition of dapagliflozin to standard therapy for RHD mitral stenosis patients provides benefits, as evidenced by an increase in net atrioventricular compliance and decreases in the MPG value of the mitral valve and NT-pro BNP levels (p < 0.05). This improvement was not directly related to changes in fibrosis biomarkers, as these biomarkers showed ongoing fibrosis even with dapagliflozin administration.

An Infrequently Encountered Cause of Hemoptysis

Mitral stenosis (MS) is not a common entity in modern-day medicine, especially in developed countries, as the most common etiology is still rheumatic fever. MS can present mainly with a wide range of cardiac symptoms. However, infrequently, MS can cause extra-cardiac symptoms as well. We present a case report of a patient with severe bioprosthetic mitral valve stenosis with intermittent hemoptysis and cardiogenic shock. We aim to report this case to remind clinicians about this uncommon but significant cause of hemoptysis. This case report also emphasizes the importance of utilizing a team approach while treating patients with severe MS, especially if they have serious complications that could be life-threatening. We also aim to add to the current literature by reporting this case.

Concurrent valve replacement and caesarean section for rheumatic mitral valve disease with refractory heart failure in late pregnancy

Objective

To assess clinical characteristics and outcomes of women who underwent concurrent valve replacement with caesarean section for severe rheumatic mitral valve disease with refractory heart failure.

Methods

All women admitted to a single centre from 2011 to 2020 with severe rheumatic mitral valve disease, having recurrent episodes of pulmonary edema on optimal medical therapy and contraindication to percutaneous balloon mitral valvotomy, who underwent concurrent valve replacement (for native valve disease) along with caesarean section, were included.

Results

Among 1300 pregnancies with rheumatic heart disease, six underwent the concurrent procedure. All had replacement of mitral valve except one who had both aortic and mitral valve replacements, between 33 and 39 weeks of gestation. There were no maternal deaths, and there was one neonatal loss from late-onset sepsis.

Conclusion

Pregnant women with severe rheumatic mitral valve disease with refractory heart failure, unsuitable for minimal access interventions, can be considered for a concurrent valve replacement with caesarean section.

Giant left atrium and management modalities (surgical vs. conservative): a case report from Mauritania

Introduction and importance

Giant left atrium (GLA) is a rare condition often associated with rheumatic heart disease and can lead to cardiac and extracardiac complications. In this case report, the authors present a rare case of GLA with extracardiac complications, highlighting the importance of prompt diagnosis and management.

Case presentation

A 54-year-old woman with a 25-year history of mitral stenosis caused by rheumatic heart disease presented with symptoms of dyspnea, orthopnea, and palpitations. Diagnostic tests revealed an enlarged left atrium, pleural effusion, severe pulmonary hypertension, and tricuspid regurgitation. The patient was treated with diuretics and ACE (angiotensin-converting enzyme) inhibitors and is currently on a medication regimen with regular follow-up appointments.

Clinical discussion

GLA can cause cardiac and extracardiac complications, and conservative treatment and surgery are both involved in the management plan. The reduction of left atrial size by surgery may eliminate symptoms, reduce postoperative complications, and increase the probability of regaining sinus rhythm.

Conclusion

Observational data on managing GLA is limited, and mortality can be high. Cardiovascular surgeons should carefully consider surgical options, and screening and follow-up are essential for early detection and management in patients with long-standing rheumatic heart disease.

Left Atrial Thrombus in the Setting of Mitral Stenosis

A 56-year-old man with no significant past medical history presented with exertional shortness of breath. Echocardiogram, cardiac magnetic resonance, and computed tomography showed mitral stenosis and a left atrial thrombus. Left atrial thrombus formation is a well-known complication of severe mitral stenosis that can lead to systemic thromboembolism. The patient underwent mitral valve replacement, left atrial thrombus resection, and left atrial appendage closure that resulted in significant improvement in breathing.

Pulmonary Hypertension in Left Ventricular Valvular Diseases: A Comprehensive Review on Pathophysiology and Prognostic Value

Left ventricular (LV) valvular diseases, make up one of the most common etiologies for pulmonary hypertension (PH), and it is not well understood how and at which degree it affects prognosis. The aim of the present study was a comprehensive review of the pathophysiologic mechanism of PH in patients with LV valvular diseases and the prognostic value of baseline and post-intervention PH in patients undergoing interventional treatment. The pathophysiology of PH in patients with LV valvular diseases involves gradual elevation of left ventricular filling pressure and left atrial pressure, which are passively transmitted to the pulmonary circulation and raise pulmonary artery systolic pressure (PASP). A long-lasting exposure to elevated PASP progressively leads to initially functional and thereafter irreversible structural changes in the pulmonary vasculature, leading up to high pulmonary vascular resistance. Surgical treatment of severe LV valvular diseases is highly effective in patients without resting PH or those with exercise-induced PH (EIPH) before intervention. In the case of pre-operative PH, successful interventional therapy decreases PASP, but the post-operative cardiac and all-cause mortality remain higher compared to patients without pre-operative PH. Hence, it is of paramount importance to detect patients with severe LV valvulopathies before the development of PH, since they will get greater benefits from early intervention.

An Overview of Sport Participation and Exercise Prescription in Mitral Valve Disease

The incidence of heart valve disease (HVD) has been rising over the last few decades, mainly due to the increasing average age of the general population, and mitral valve (MV) disease is the second most prevalent HVD after calcific aortic stenosis, but MV disease is a heterogeneous group of different pathophysiological diseases. It is widely proven that regular physical activity reduces all-cause mortality rates, and exercise prescription is part of the medical recommendations for patients affected by cardiovascular diseases. However, changes in hemodynamic balance during physical exercise (including the increase in heart rate, preload, or afterload) could favor the progression of the MV disease and potentially trigger major cardiac events. In young patients with HVD, it is therefore important to define criteria for allowing competitive sport or exercise prescription, balancing the positive effects as well as the potential risks. This review focuses on mitral valve disease pathophysiology, diagnosis, risk stratification, exercise prescription, and competitive sport participation selection, and offers an overview of the principal mitral valve diseases with the aim of encouraging physicians to embody exercise in their daily practice when appropriate.

Cesarean section of a patient with combined severe mitral and aortic stenosis: a case report

Cardiovascular diseases during pregnancy are rare but account for complications that pose risks to the mother as well as the child. In patients with fixed cardiac output due to stenotic valvular lesion(s), the physiological changes during pregnancy carry high risk of morbidity and mortality.

Case Presentation

Our patient was diagnosed with severe mitral and aortic stenosis at her first antenatal visit at 24 weeks of gestation. She was also diagnosed with intrauterine growth restriction and was therefore planned to be operated on at a gestational age of 34 weeks. After careful selection of monitoring and anesthetic regime, the patient was managed without any intraoperative or postoperative complications.

Clinical Discussion

This case reports how the anesthetists, obstetricians, and cardiac surgeons devised a well-designed plan to operate on a patient with a relatively rare disease manifestation. Our patient had coexisting severe stenotic lesions of both mitral and aortic valves and posed a clinical dilemma regarding the choice of anesthesia and perioperative management. Regardless of the anesthetic technique, goals for a patient with the combined valvular disease include maintenance of adequate preload, systemic vascular resistance, cardiac contractility, sinus rhythm and avoidance of tachycardia, bradycardia, aortocaval compression, and anesthetic or surgery-induced hemodynamic changes.

Conclusion

The course of management would give clinicians an idea of how to manage a patient with combined stenotic valvular lesions for cesarean section, ensuring a smooth course and a safe postoperative period.

Transcatheter Mitral Valve Replacement in Patients with Mitral Annular Calcification: A Review

Mitral annular calcification (MAC) is a progressive degenerative calcification of the mitral valve (MV) that is associated with mitral stenosis, regurgitation or both. Patients with MAC are poor candidates for MV surgery because of technical challenges and high peri-operative mortality. Transcatheter MV replacement (TMVR) has emerged as an option for such high surgical risk patients. This has been described with the use of the SAPIEN transcatheter heart valve (valve-in-MAC) and dedicated TMVR devices. Careful anatomic assessment is important to avoid complications of TMVR, such as left ventricular outflow tract obstruction, valve migration, embolization and paravalvular mitral regurgitation. In this review, we discuss the pathology, importance of preprocedural multimodality imaging for optimal patient selection, clinical outcomes and complications associated with TMVR in patients with MAC.

What Is the Hypoplastic Left Heart Syndrome?

As yet, there is no agreed definition for the so-called "hypoplastic left heart syndrome". Even its origin remains contentious. Noonan and Nadas, who as far as we can establish first grouped together patients as belonging to a "syndrome" in 1958, suggested that Lev had named the entity. Lev, however, when writing in 1952, had described "hypoplasia of the aortic outflow tract complex". In his initial description, as with Noonan and Nadas, he included cases with ventricular septal defects. In a subsequent account, he suggested that only those with an intact ventricular septum be included within the syndrome. There is much to commend this later approach. When assessed on the basis of the integrity of the ventricular septum, the hearts to be included can be interpreted as showing an acquired disease of fetal life. Recognition of this fact is important to those seeking to establish the genetic background of left ventricular hypoplasia. Flow is also of importance, with septal integrity then influencing its effect on the structure of the hypoplastic ventricle. In our review, we summarise the evidence supporting the notion that an intact ventricular septum should now be part of the definition of the hypoplastic left heart syndrome.

Lutembacher syndrome in a middle-aged woman in Ghana with an extremely large atrial septal defect

Lutembacher syndrome (LS) is a rare heart disorder characterized by a congenital or acquired combination of the atrial septal defect (ASD) and mitral stenosis. In LS, patients may be asymptomatic for years, but early detection and treatment result in a better prognosis. In contrast, the prognosis is usually poor, with conservative treatment if the diagnosis is late and the patient develops heart failure and pulmonary hypertension. Although rheumatic heart disease (RHD) and congenital heart disease are prevalent in Ghana, cases of LS are not reported. Here, we report the case of a 45-year-old woman with rheumatic mitral valve stenosis and an exceptionally large ASD with bidirectional flow who was diagnosed with LS and treated conservatively for heart failure at a cardiology clinic in Ghana.

Assessment of Right Ventricular Systolic Function with 3-Dimensional Speckle Tracking Echocardiography in Isolated Mild Mitral Stenosis

BACKGROUND

In rheumatic severe mitral stenosis, right ventricular mechanics deteriorate with the increasing severity of mitral stenosis. Therefore, we aimed to investigate right ventricular mechanics in patients with mild mitral stenosis using 3-dimensional speckle tracking echocardiography.

METHODS

In total, 40 patients with mild mitral stenosis and 36 age- and gender-matched healthy controls were included. Conventional echocardiographic examination was performed and 3-dimensional data sets were acquired for strain analysis. Besides conventional echocardiographic parameters, right ventricular volume and function and 3-dimensional speckle tracking echocardiography-derived right ventricular free wall longitudinal strain were compared between patients with mild mitral stenosis and healthy controls.

RESULTS

Although 3-dimensional right ventricular volumes and ejection fraction were similar between the groups, 3-dimensional speckle tracking echocardiography-derived right ventricular free wall longitudinal strain was significantly lower in patients with mild mitral stenosis than in controls (25.57 ± 4.39% vs. 27.90 ± 4.71%, P =.028). Significant correlations were observed between right ventricular free wall longitudinal strain and mitral valve area and estimated systolic pulmonary artery pressure (r = 0.597, P <.001; r = -0.508, P =.003, respectively). Another significant positive correlation was observed between planimetric mitral valve area and 3-dimensional speckle tracking echocardiography-derived right ventricular free wall longitudinal strain (r = 0.597, P <.001).

CONCLUSION

The degree of severity of mild mitral stenosis in terms of mitral valve area can help in the early detection of subclinical right ventricular systolic function impairment which can be easily detected by 3-dimensional speckle tracking echocardiography. Right ventricular contractile performance could decrease even in mild mitral stenosis.

Successful Resuscitation and Management of Cardiac Arrest in Pregnancy Due to Undiagnosed Severe Mitral Stenosis: A Case Report

Maternal collapse is a rare, potentially fatal event with associated feto-maternal morbidity and mortality. We report a case of severe mitral stenosis without any prior symptoms, that presented as acute cardiac decompensation leading to maternal collapse and cardiac arrest. A 35-year-old female in her 28th week of gestation presented to the emergency room with a four-hour history of per-vaginal discharge and leaking of amniotic fluid. Her past history, physical examination, and laboratory workup were unremarkable. An initial diagnosis of pre-term premature rupture of membranes (PPROM) was made and she was managed conservatively. Within four hours of the presentation, she developed shortness of breath, which gradually worsened, and the anesthesia team was requested to assess the patient. Upon arrival, the patient was in severe respiratory distress. She collapsed soon after and started frothing copiously from the mouth. Pulse was absent and cardio-pulmonary resuscitation (CPR) commenced. Endotracheal intubation was performed and the obstetric team was asked to prepare for a perimortem cesarean section, which was completed four minutes after the commencement of CPR and the baby was delivered alive and well with an APGAR score of 7 and 8 at one minute and five minutes of birth, respectively, and birth weight of 1.1 kg. CPR continued for 16 minutes after which a return of spontaneous circulation was achieved. Due to the unavailability of an ICU bed, the patient was shifted to OR where she stayed for the next five hours for further resuscitation. After a two-month-long ICU course, the patient was discharged in stable condition; her baby was discharged after a month of hospital stay. The expertise of anesthesiologists as resuscitators and peri-operative physicians helped in successful resuscitation, saving not just one but two lives in the process.

Valvular Heart Disease: New Concepts in Pathophysiology and Therapeutic Approaches

This review discusses recent advancements in the field of valvular heart disease. Topics covered include recognition of the impact of atrial fibrillation on development and assessment of valvular disease, strategies for global prevention of rheumatic heart disease, understanding and management of secondary mitral regurgitation, the updated classification of bicuspid aortic valve disease, recognition of heightened cardiovascular risk associated with moderate aortic stenosis, and a growing armamentarium of transcatheter therapies.

The Outcomes of PBMV in Pregnancy, and When is the Best Time?

Background

Percutaneous balloon mitral valvuloplasty (PBMV) is considered the most suitable option for managing symptomatic severe mitral valve stenosis (MS) during pregnancy with favorable anatomy. We do not know the best time to perform PBMV during pregnancy to achieve the best maternal and fetal outcomes. Therefore, we conducted this study to clarify the best procedure timing.

Methods

This prospective, observational, single-center study involved 44 pregnant patients suffering from symptomatic MS who underwent PBMV from May 2017 to May 2020. A detailed history is taken, full clinical examination, laboratory assessment, 2 D echocardiography, and follow-up during the hospital stay and monthly until labor.

Results

We found that the mean mitral valve area (MVA) had significantly increased from 1.12 ± 0.24 to 2.09 ± 0.46 cm² (P < 0.001). The mean pressure gradient across the mitral valve reduced from 17.22 ± 5.55 to 8.94 ± 3.75 mmHg (P < 0.001). The procedures were successful in 91% of the patients. Regarding obstetric outcomes, the incidence of preterm labor, fetal death, and composite adverse outcomes was significantly lower in patients who had the procedure during the second trimester than those who had the procedure during the third trimester. All preterm deliveries and intrauterine fetal deaths occurred at least 21 days after PBMV. The patients showed a statistically significant improvement in NYHA functional classification.

Conclusion

We can conclude that PBMV performed in pregnant patients is an effective and safe treatment modality, and we observed better obstetric outcomes achieved with early intervention during the second trimester.

Whats new in ESC Guidelines for the management of valvular heart disease?

The article summarize the most important changes regarding the management of valvular heart disease, which have been made in the ESC Guidelines 2021. Based on the randomized clinical study data, which were recently published, the most frequent changes were done in terms of the choice of mode of intervention in the aortic and mitral valves as well as in the management of the antithrombotic therapy.

Parachute Mitral Valve in an Adult

Two-dimensional transthoracic echocardiography images for a 49-year-old female with a history of ventricular septal defect status post repair, type 2 diabetes mellitus, and hyperlipidemia whose evaluation of her lower extremity edema showed parachute mitral valve.

Novel Oral Anticoagulants in Patients With Atrial Fibrillation and Moderate to Severe Mitral Stenosis: A Systematic Review

The use of novel oral anticoagulants (NOAC) in patients with moderate to severe mitral stenosis (MS) and atrial fibrillation (AF) is not recommended. We aimed to evaluate the efficacy and safety of NOAC usage compared to vitamin K antagonist (VKA) in patients with moderate to severe MS and AF. We conducted a systematic review to identify articles that compared warfarin to NOAC in patients with moderate to severe MS and AF. Only four studies (two observational studies and two trials) met our search criteria and reported a total of 7529 patients with MS and AF with MS and AF, 4138 of them treated with NOAC. In both observational studies, the severity of MS was not determined, and there was heterogeneity in MS etiology. Nevertheless, both studies showed a positive signal toward the efficacy and safety of NOAC compared to VKA in this population. A randomized pilot trial (n=40) was done on patients with moderate to severe MS, and it showed further acceptable efficacy and safety for rivaroxaban use. However, a larger randomized controlled trial (n=4531) disclosed that VKA (warfarin) led to a significantly lower rate of a composite of cardiovascular events or mortality than rivaroxaban, without a higher rate of major bleeding but not fatal bleeding. Our systematic review provides exploratory information on NOAC safety and effectiveness in patients with MS; it also discourages using NOACs for patients with moderate to severe MS and supports the current treatment guidelines. However, more dedicated clinical trials evaluating the use of NOACs in moderate to severe MS are underway. They will categorically establish the safety profile and clinical effectiveness of NOAC in this high-risk population.

Echocardiography protocol: A tool for infrequently used parameters in mice

Echocardiography is frequently used to evaluate cardiac function in rodent models of cardiovascular disease. Whereas methods to acquire the commonly used echocardiography parameters are well-described in published protocols or manuals, many important parameters are ill-defined and often open to subjective interpretation. Such lack of uniformity has engendered conflicting interpretations of the same parameters in published literature. In particular, parameters such as mitral regurgitation, mitral stenosis, pulmonary regurgitation, and aortic regurgitation that are required to define more esoteric etiologies in rarer mouse models often remain equivocal. The aim of this methods paper is to provide a practical guide to the acquisition and interpretation of infrequently used echocardiography parameters and set a framework for comprehensive analyses of right ventricle (RV), pulmonary artery (PA) pulmonary valve (PV), left atrium (LA), mitral valve (MV), and aortic valve (AoV) structure and function.

Mitral stenosis in a teenager after rheumatic mitral valve regurgitation valve repair: A case report

Introduction

Mitral stenosis (MS) is a widely known complication of mitral valve repair for non-rheumatic mitral regurgitation (MR). Few reports are available on the occurrence of MS after mitral valve repair for rheumatic MR in young populations.

Case summary

A 14-year-old girl presented with orthopnea, abdominal distension, and bilateral lower-limb edema. She was cachectic, with a high-pitched holosystolic murmur best heard at the cardiac apex, bilateral basal crackles, tender hepatomegaly, pitting pedal edema, and jugular venous distension. Antistreptolysin O (ASO) titer was elevated. Transthoracic echocardiography (TTE) revealed the loss of central coaptation of the mitral valve with leaflet restriction and MR, annular dilatation of the tricuspid valve, and tricuspid regurgitation (TR). She had AHA/ACC stage D mitral and TR s. Tricuspid annuloplasty and mitral valve repair for rheumatic MR were performed using Carpentier Edwards numbers 30 and 34, respectively. Following surgery, the weight and body mass index (BMI) rapidly normalized. The patient also developed progressive MS.

Discussion

Previous studies in adults have described the etiopathogenesis of MS after non-rheumatic mitral valve repair. There is a paucity of reports describing the development of MS over the span of months after rheumatic MR valve repair in early pubescent children.

Conclusion

Growth spurts during puberty can potentially affect MR repair, as the mitral valve prosthesis based on the preoperative Body Surface Area (BSA) is outgrown. There is a need for research on planning, prognostication, and development of an optimal, individualized, and adaptable approach to MR intervention in early pubescence.

Correlation between mitral valve area and left atrial function in rheumatic mitral valve stenosis patients

BACKGROUND

Rheumatic heart disease (RHD) continues to be one of the leading causes of cardiovascular morbidity and mortality. The mitral valve frequently develops mitral stenosis (MS), and it is the most prevalent valve lesion in patients with chronic RHD. Left atrial (LA) functional impairment is associated with rheumatic MS.

AIM

The aim of this study was to evaluate the association between LA function and mitral valve area (MVA) in rheumatic MS patients, and to assess the echocardiographic parameters in sinus rhythm and atrial fibrillation (AF) patients.

METHODS

This was a cross-sectional, descriptive study that involved patients with rheumatic MS. Patients underwent a standard 12-lead electrocardiogram and echocardiographic examination. MVA was assessed and correlated with LA function. Comparison was made between sinus rhythm and AF patients.

RESULTS

Eighty-one patients with rheumatic MS were included in this study, with 71.6% of them having associated MR. MVA showed a statistically highly significant positive correlation with LA and right ventricular (RV) function, and a statistically significant/highly significant negative correlation with their dimensions. A higher percentage of patients with severe MS was in AF (58.1%).

CONCLUSIONS

There was a positive correlation between LA function and MVA in rheumatic MS patients. AF was related to the severity of MS.

Procedural complications associated with percutaneous mitral balloon valvotomy: A systematic review

BACKGROUND

As Percutaneous mitral balloon valvotomy (PMBV) remains the keystone in treating mitral stenosis, we conducted this review to elucidate the cumulative frequency and predictors of complications following PMBV and their occurrence in various patient populations.

AREAS COVERED

We searched digital databases for relevant studies covering complications of PMBV and retrieved articles using the Medical Subject Heading (MeSH) keywords.

EXPERT OPINION

A total of 37 articles (8 RCTs, 7 nonrandomized clinical trials, 22 observational studies) were selected for qualitative analysis. A total of 11,803 patients undergoing PMBV among 37 studies were included, with a mean success rate of 84.54%. The most common complication was mitral regurgitation (8.2%) followed by an atrial septal defect (2.4%). Other relevant complications like stroke, pericardial tamponade, rupture of mitral leaflets, and conduction abnormalities were present in <1% of the patients.

Effects of percutaneous balloon mitral valvuloplasty in patients with mitral stenosis and atrial fibrillation: a systematic review and meta-analysis

OBJECTIVE

The study aimed to systematically review the existing literature and assess the effects of percutaneous balloon mitral valvuloplasty (PBMV) in patients with mitral stenosis and atrial fibrillation (AF) as opposed to sinus rhythm (SR).

METHODS

Eligible studies were identified from six electronic databases before June 2021. The primary outcome was mitral valve area (MVA), and secondary outcomes were hemodynamic measurements, in-hospital complications, and long-term outcomes. Relative risks (RRs) or weighted mean differences (WMDs) with 95% confidence intervals (CIs) were used as effect sizes.

RESULTS

Fifteen studies were included involving 6351 patients. For the primary outcome, the AF group obtained less favourable changes in MVA (WMD: -0.10, 95%CI: -0.14, -0.06) and a significantly smaller postoperative and long-term MVA (WMD: -0.13, 95%CI: -0.18, -0.08 and WMD: -0.10, 95%CI: -0.17, -0.03, respectively) compared to the SR group. For secondary outcome, the AF group was associated with suboptimal outcomes as following (WMD/RR, [95%CI]): higher LAP (1.37, [0.86, 1.87]), more embolism (2.85, [1.44, 5.63]), lower event-free survival (0.89, [0.80, 1.00]), higher incidences of mitral valve replacement (2.20, [1.40, 3.46]), re-PBMV (2.28, [1.63, 3.19]), and mortality (3.28, [2.42, 4.44]). No significant differences were found in other outcomes.

CONCLUSIONS

The currently available evidence suggests that PBMV may be less effective in patients with AF than in those with SR. However, early treatment and appropriate management of AF patients undergoing PBMV may benefit the immediate and long-term outcomes.

Evaluation of midterm outcomes after Shone's complex surgery: Analysis of reoperation and mortality risk factors

OBJECTIVE

The midterm results of patients who underwent biventricular repair surgery for Shone's complex were examined, and mortality and reoperation risk factors were evaluated.

METHODS

This retrospective study included 34 patients with Shone's complex who underwent mitral valve (MV) surgery between 2005 and 2020.

RESULTS

A total of 19 patients (56%) had coarctation, 10 (29%) patients had subaortic stenosis, 9 (26.5%) patients had a hypoplastic aortic arch (AA), and 9 (26.5%) patients had aortic valve (AV) stenosis. Twenty-four (70.6%) patients had bileaflet AV. Associated left-sided in-flow stenotic lesions included parachute MV in 19 (56%) patients and supramitral ring in 18 (53%) patients. The estimated freedom from reoperation rate on the 6th month, 1 year and 2 years after surgery was 84.4%, 79.5%, and 71.5%, respectively. The overall mortality rate was 20.6% (seven patients) with a median follow-up of 10 months (0-41). The estimated survival rate on the 6th month, 1 year, and 3 years after surgery was 83.8%, 79.4%, and 79.4 respectively. Bicuspid aortic valve (p = .017) (HR (95% CI) = 0.130 (0.025-0.695) and hammock mitral valve (p = .038) (HR (95% CI) = 11,008 (1,146->100) were associated with mortality.

CONCLUSION

The presence of a bicuspid aortic valve hammock mitral valve might have an effect on negative effect on the outcome.

A giant and double-walled left atrial ball thrombus complicating a mitral stenosis: case report-a truck tire into the heart

BACKGROUND

High thromboembolic risk associated with rheumatic mitral stenosis has been well established, especially in concomitant atrial fibrillation; however, the presence of left atrium ball thrombus is an uncommon finding.

CASE SUMMARY

A 75-year-old woman with a history of mild rheumatic mitral stenosis was admitted to Emergency Department with cardiogenic shock and high ventricular rate atrial fibrillation. Emergency electrical cardioversion was performed-before trans-oesophageal echocardiography (TOE)-due to haemodynamic deterioration which restored sinus rhythm.Transthoracic echocardiography (TTE) revealed severe reduction of left ventricular ejection fraction (LVEF: 15%), severe rheumatic mitral stenosis and a large, perfectly rounded mass, situated at the ostium of left upper pulmonary vein. Due to the persistence of haemodynamic instability and acute pulmonary oedema the patient was intubated and mechanically ventilated and treated with intravenous administration of inotropes and high doses of diuretics. During the stay in Intensive Care Unit, a TOE confirmed a spherical and double-walled mass suggesting a working diagnosis of left atrial ball thrombus (LABT). The case was discussed in Heart Team and considering the poor haemodynamic status in the contest of refractory cardiogenic shock with evidence of multi-organ failure, emergency surgical thrombectomy and mitral valve replacement was deemed prohibitive. Patient developed cardiac arrest and emergency TTE showed left atrial mass engaged into the mitral valve totally obstructing the left ventricle inflow tract. The autopsy and histologic examination confirmed the thrombotic nature of the mass.

DISCUSSION

A free-floating ball thrombus in the left atrium is an unusual occurrence in rheumatic mitral stenosis and it may cause fatal systemic embolization or acute left ventricular inflow obstruction, resulting in syncope, pulmonary congestion, and sudden cardiac death. When possible, emergency surgical thrombectomy and mitral valve replacement can be life-saving.

Machine learning methods for predicting major types of rheumatic heart diseases in children of Southern Punjab, Pakistan

Objective

Rheumatic heart disease (RHD) is a major health problem in the world, particularly in developing countries. This study aimed to predict mitral regurgitation (MR) and mitral stenosis (MS) RHD among children with RHD.

Methodology

Data was collected from the Pediatric Cardiology Department at Chaudhry Pervaiz Elahi Institute of Cardiology Multan, Pakistan from March to October 2019. A sample of 561 children aged 4–14 years, who were diagnosed with RHD of either MR or MS, were recruited from the hospital’s outpatient department. The presence of multivariate outliers was detected, and different machine learning methods, including subset logistic regression, subset logistic regression after deletion, stepwise winsorized logistic regression, robust logistic regression, subset deep neural network, and random forest models were compared using the area under receiver operating characteristics (ROC) curve, sensitivity, and specificity. Parsimony was also considered in model selection.

Results

Out of 561 patients in this study, 75.94% had RHD MR and 24.06% had RHD MS. The average age of study participants was 9.19 ± 2.45 years and of them 55.43% were male. Among the male participants, 58.6 and 45.2% had MR and MS, respectively; and among female participants, those were 70.4 and 29.6%, respectively. Subset logistic regression after deletion appeared as competitive with a discrimination power of 90.1% [95% CI 0.818–0.983]. The sensitivity and specificity of this model were 85.1 and 70.6%.

Conclusion

The best predictive model was subset logistic regression after deletion. The predicted method will be used in the decision-making process, which helps early diagnosis of the disease and leads to prevention. The study findings provide the proper guideline for earlier diagnosis of the RHD MR and MS cases among children with RHD in Pakistan.

Left atrial size predicts long-term outcome after balloon mitral valvuloplasty

BACKGROUND

The treatment of choice for severe rheumatic mitral stenosis is balloon mitral valvuloplasty (BMV). Numerous predictors of immediate and long-term procedural success have been described. The aims of this study were to describe our experience with BMV over the last decade and to evaluate predictors of long-term event-free survival.

METHODS

Medical records were retrospectively analyzed of patients who underwent BMV between 2009 and 2021. The primary outcome was a composite endpoint of all-cause mortality, mitral valve replacement (MVR), and repeat BMV. Long-term event-free survival was estimated using Kaplan-Meier curves. Logistic regression was used to create a multivariate model to assess pre-procedural predictors of the primary outcome.

RESULTS

A total of 96 patients underwent BMV during the study period. The primary outcome occurred in 36 patients during 12-year follow-up: one (1%) patient underwent re-BMV, 28 (29%) underwent MVR, and eight (8%) died. Overall, event-free survival was 62% at 12 years. On multivariate analysis, pre-procedural left atrial volume index (LAVI) > 80 mL/m2 had a significant independent influence on event-free survival, as did previous mitral valve procedure and systolic pulmonary arterial pressure above 50 mmHg.

CONCLUSIONS

Despite being a relatively low-volume center, excellent short and long-term results were demonstrated, with event-free survival rates consistent with previous studies from high-volume centers. LAVI independently predicted long-term event-free survival.

Immediate maternal and fetal outcome following percutaneous mitral valve balloon commissurotomy: a 6-year single-center experience from sub-Saharan Africa

BACKGROUND

Mitral stenosis is the most common valvular heart disease during pregnancy. When severe, it leads to significant maternal and fetal morbidity and mortality. Percutaneous mitral valve balloon commissurotomy can be performed during pregnancy, and the present study aimed to describe the immediate maternal and fetal outcomes after percutaneous mitral valve balloon commissurotomy was done in a cohort of 23 pregnant patients with severe mitral stenosis in Addis Ababa, Ethiopia.

METHODS

Included in the current study were all pregnant mothers who had severe rheumatic mitral valve stenosis and who underwent percutaneous mitral valve balloon commissurotomy at the Cardiac Center of Ethiopia over 6-year period. Data were collected through chart abstraction using a structured proforma and then analysed using STATA version 13.0.

RESULT

Median gestational age was 22 weeks and percutaneous mitral valve balloon commissurotomy was successful resulting in a significant increase in the mean mitral valve area of the group from 0.78 ± 0.20 cm² to 1.89 ± 0.31 cm² (p < 0.001). The mean mitral valve inflow gradient of the group was 23.95 ± 6.27 mmHg and 6.80 ± 2.44 mmHg, respectively, before and after the percutaneous mitral valve balloon commissurotomy procedure (p < 0.001). Post-procedure, there was no significant increment in mitral valve incompetence. The mean pulmonary artery pressure of the group decreased from 77.68 ± 23.19 mmHg to 42.31 ± 9.95 mmHg (p < 0.001). There was no fetal or maternal death following the procedure. Pregnancy ended at term gestation for 19/23 (82.6%) of the mothers and the mean birth weight of the neonates was 2800 g.

CONCLUSION

Percutaneous mitral valve balloon commissurotomy procedure can safely be done for severe symptomatic rheumatic mitral stenosis in pregnancy in our setting.

Management of mitral stenosis: a systematic review of clinical practice guidelines and recommendations

A number of guidelines exist with recommendations for diagnosis and management of mitral stenosis (MS). We systematically reviewed existing guidelines for diagnosis and management of MS, highlighting their similarities and differences, in order to guide clinical decision-making. We searched national and international guidelines in MEDLINE and EMBASE (5/4/2011-5/9/2021), the Guidelines International Network, Guideline Library, National Guideline Clearinghouse, National Library for Health Guidelines Finder, Canadian Medical Association Clinical Practice Guidelines Infobase, and websites of relevant organizations. Two independent reviewers screened titles and abstracts, and the full text of potentially relevant articles where needed. Selected guidelines were assessed for rigor of development; only guidelines with Appraisal of Guidelines for Research and Evaluation II instrument score >50% were included in the final analysis. Four guidelines were retained for analysis. There was consensus for percutaneous mitral balloon commissurotomy as first-line treatment of symptomatic severe rheumatic MS with suitable anatomy. In patients with unfavourable anatomy, surgical intervention should be considered. Exercise testing is indicated if discrepancy exists between symptoms and echocardiographic measurements. There was no clear divide between rheumatic MS and degenerative MS for their respective diagnoses and management. Pregnancy in severe MS is discouraged and the stenosis should be treated before conception. Long-term antibiotic prophylaxis is recommended for patients with rheumatic MS. Recommendations for the management of patients with mixed valvular diseases are lacking.

Incidence of Acute Cerebrovascular Events in Patients with Rheumatic or Calcific Mitral Stenosis: A Systematic Review and Meta-analysis

BACKGROUND

Patients with mitral stenosis (MS) may be predisposed to acute cerebrovascular events (ACE) and peripheral thromboembolic events (TEE). Concomitant atrial fibrillation (AF), mitral annular calcification (MAC) and rheumatic heart disease (RHD) are independent risk factors. Our aim was to evaluate the incidence of ACEs in MS patients and the implications of AF, MAC, and RHD on thromboembolic risks.

METHODS

This systematic review was registered on PROSPERO (CRD42021291316). Six databases were searched from inception to 19th December 2021. The clinical outcomes were composite ACE, ischaemic stroke/transient ischaemic attack (TIA), and peripheral TEE.

RESULTS

We included 16 and 9 papers, respectively, in our qualitative and quantitative analyses. The MS cohort with AF had the highest incidence of composite ACE (31.55%; 95%CI 3.60-85.03; I²=99%), followed by the MAC (14.85%; 95%CI 7.21-28.11; I²=98%), overall MS (8.30%; 95%CI 3.45-18.63; I²=96%) and rheumatic MS population (4.92%; 95%CI 3.53-6.83; I²=38%). Stroke/TIA were reported in 29.62% of the concomitant AF subgroup (95%CI 2.91-85.51; I²=99%) and in 7.11% of the overall MS patients (95%CI 1.91-23.16; I²=97%). However, the heterogeneity of the pooled incidence of clinical outcomes in all groups, except the rheumatic MS group, were substantial and significant. The logit-transformed proportion of composite ACE increased by 0.0141 (95% CI 0.0111-0.0171; p<0.01) per year of follow-up.

CONCLUSION

In the MS population, MAC and concomitant AF are risk factors for the development of ACE. The scarcity of data in our systematic review reflects the need for further studies to explore thromboembolic risks in all MS subtypes.

In-hospital and Readmission Outcomes With Percutaneous Balloon Mitral Valvuloplasty

BACKGROUND

Percutaneous balloon mitral valvuloplasty (PBMV) is primarily performed for rheumatic mitral stenosis (MS). Therefore, limited data exist on PBMV in countries with a low incidence of rheumatic disease.

METHODS

Using the Nationwide Readmission Database, we examined trends in in-hospital mortality and 30-day readmission among patients who received PBMV for rheumatic and non-rheumatic MS. We also examined the change in 90-day hospitalization rate before vs. after PBMV.

RESULTS

Between 2016 and 2019, there were 1109 hospitalizations in which patients received PBMV for rheumatic (n= 955, 86.1%) vs non-rheumatic MS (n=154, 13.9%). The all-cause in-hospital mortality for rheumatic and non-rheumatic MS did not change over time (0.9% → 2.0%, p=0.94, and 5.9% → 9.5%, p=0.09 respectively). Similarly, the 30-day readmission for patients with rheumatic and non-rheumatic MS did not change over time (12.4% → 9.9%, p=0.26, and 4.4% → 10.5%, p=0.30, respectively). The 90-day all-cause hospitalization rate remained the same before vs after PBMV for rheumatic and non-rheumatic MS (25.5% → 21.8%; p=0.14, and 24.0% → 33.7%; p=0.19, respectively).

CONCLUSIONS

Although no statistically significant change was noted over time for trends in in-hospital mortality, 30-day readmission, or even in the change in 90-day all-cause hospitalizations before and after PBMV for both types of MS, among those with non-rheumatic MS, there was a signal of an increase in the in-hospital mortality, and 30-day readmission, even more, there was 29% relative increase in 90-day hospitalizations after PBMV. Future studies are needed to examine the role of PBMV in patients with non-rheumatic MS.

Mitral Valve Dysfunction in Patients With Annular Calcification: JACC Review Topic of the Week

Mitral annular calcification (MAC) is a common clinical finding and is associated with adverse clinical outcomes, but the clinical impact of MAC-related mitral valve (MV) dysfunction remains underappreciated. Patients with MAC frequently have stenotic, regurgitant, or mixed valvular disease, and this valvular dysfunction is increasingly recognized to be independently associated with worse prognosis. MAC-related MV dysfunction is a distinct pathophysiologic entity, and importantly much of the diagnostic and therapeutic paradigm from published rheumatic MV disease research cannot be applied in this context, leaving important gaps in our knowledge. This review summarizes the current epidemiology, pathophysiology, diagnosis, and classification of MAC-related MV dysfunction and proposes both an integrative definition and an overarching approach to this important and increasingly recognized clinical condition.

Clinical and Hemodynamic Factors Associated with Low Gradient Severe Rheumatic Mitral Stenosis

Discrepancy between narrowed mitral valve area and transmitral gradient is not uncommon, suggesting the presence of low gradient (LG)-severe mitral stenosis (MS). Some clinical and hemodynamic factors are believed to associate with LG-severe MS. Transthoracic echocardiography reports were reviewed retrospectively to evaluate the association of all clinical and hemodynamic parameters with LG-severe MS. A 36% of total 322 patients was in the LG-severe MS group. In multivariate analysis, atrial fibrillation (95% confidence interval [CI] 4.60-16.71, odds ratio [OR] 8.77), net atrioventricular compliance > 4 mL/mm Hg (95% CI 3.96-14.25, OR 7.51), tricuspid regurgitation maximal velocity (TR Vmax) > 3.4 m/s (95% CI 0.13-0.48, OR 0.25), stroke volume index ≤ 35 mL/m ² (95% CI 1.49-6.25, OR 3.05), female gender (95% CI 1.30-5.33, OR 2.63), and severe tricuspid regurgitation (95% CI 1.04-5.50, OR 2.39) were found to be associated with LG-severe MS. Atrial fibrillation, net atrioventricular compliance, TR Vmax, stroke volume index, female gender, and severe TR were associated with low transmitral gradient in patients with severe MS.

Transhepatic balloon mitral valvotomy in mitral stenosis with interrupted inferior vena cava

A 38-year-old female was found to have severe mitral stenosis, severe pulmonary arterial hypertension with moderate tricuspid regurgitation, dilated right atrium, persistent left superior vena cava, and hugely dilated coronary sinus. The scheduled balloon mitral valvotomy via trans-femoral approach was abandoned after the venogram revealed the presence of left-sided inferior vena cava with hemi-azygos continuation draining into coronary sinus via left-sided superior vena cava. Balloon mitral valvotomy was attempted from the right trans-jugular route, but we were unable to puncture the inter-atrial septum due to the hugely dilated coronary sinus and right atrium. A transhepatic approach was used and balloon mitral valvotomy was successfully done with a standard balloon of 24 mm size without any complication. In patients with inferior vena cava anomalies or interruption, a percutaneous transhepatic approach is a feasible alternative for performing balloon mitral valvotomy.