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.

[Association of a myxoma of the left atrium and a mitral stenosis : About a case]

Atrial myxoma is a rare and benign clinical entity. It remains common in women and mainly affects the left atrium. Its clinical picture is polymorphic. We report the case of a 53-year-old woman who consulted for dyspnea with cardiac failure's picture. The diagnosis of myxoma of the left atrium was made on echocardiography which also objectified the existence of mitral stenosis. The patient underwent surgical excision and mitral valve replacement with good postoperative outcomes.

Mediastinal Radiotherapy-induced Early-onset Valvulopathy in a 6-Year-old Boy With Hodgkin Lymphoma

Mediastinal radiotherapy for childhood cancers, particularly Hodgkin disease, has numerous potential adverse effects, including coronary artery disease, pericarditis, cardiomyopathy, valvular disease, and conduction abnormalities. The prevalence of valvular stenosis is relatively low, and regurgitation is more common. Mediastinal radiotherapy-induced valvular disease develops more than 10 years after radiotherapy. Here, we present a case of a 6-year-old boy with moderate to significant mitral stenosis + moderate mitral regurgitation and mild aortic regurgitation that appeared 1.5 months after radiotherapy and showed a progressive course.

Segmental and global longitudinal strain measurement by 2-dimensional speckle tracking echocardiography in severe rheumatic mitral stenosis

BACKGROUND

The present study aimed to detect subtle left ventricular (LV) dysfunction in patients with severe rheumatic mitral stenosis (MS) by measuring global and segmental longitudinal strain with a two-dimensional speckle tracking echocardiography (2D-STE) method.

METHODS

In this case-control study, 65 patients with severe rheumatic MS and preserved ejection fraction (EF ≥ 50% measured by conventional echocardiographic methods) were compared with 31 otherwise healthy control subjects. All patients underwent LV strain measurement by the 2D-STE method in addition to conventional echocardiography using a VIVID S60 echocardiography device.

RESULTS

Absolute strain values in myocardial segments 1-8, 10, and 12 (all basal, mid anterior, mid anteroseptal, mid inferior, and mid anterolateral segments) were significantly lower in patients with severe MS compared with the control group (P < 0.05 for all). The absolute global longitudinal strain (GLS) value was higher in the control group (-19.56 vs. -18.25; P = 0.006). After adjustment for age, gender, and systolic blood pressure, the difference in GLS between the two groups was as follows: mean difference=-1.16; 95% CI: -2.58-0.25; P = 0.110.

CONCLUSION

In patients with severe rheumatic MS and preserved EF, the absolute GLS tended to be lower than healthy controls. Furthermore, the segmental strain values of LV were significantly lower in most of the basal and some mid-myocardial segments. Further studies are warranted to investigate the underlying pathophysiology and clinical implications of this subclinical dysfunction in certain segments of patients with severe rheumatic MS.

Supravalvular mitral stenosis in a cat: clinical, diagnostic and pathologic findings

The present case report describes a rare case of a cardiac abnormality diagnosed as Supravalvular Mitral Stenosis in an asymptomatic cat. An 11-years old cat was presented for orthopedic evaluation, and during general clinical examination a heart rate of 180 bpm and left diastolic cardiac murmur grade III-IV/VI, between the mitral and aortic foci, were found. Radiographic, echocardiographic, angiocardiographic and post-mortem (the patient died during anesthesia performed to diagnose the orthopedic condition) magnetic resonance and pathologic findings are reported herein.

Thoracoabdominal aneurysm causing functional mitral valve stenosis after total arch replacement

Large thoracic and thoraco-abdominal aneurysms may compress adjacent mediastinal structures. We present a case of a large thoraco-abdominal aneurysm compressing the left atrium and leading to functional mitral valve stenosis after total aortic arch repair, requiring urgent open thoraco-abdominal aneurysm repair.

Usefulness of Computed Tomography to Predict Mitral Stenosis After Transcatheter Mitral Valve Edge-to-Edge Repair

Multidetector computed tomography (MDCT) can provide valuable information for preprocedural planning of transcatheter mitral valve interventions. However, no data exists on pre-MDCT parameters predicting high transmitral pressure gradient (TMPG) post-MitraClip procedure. We analyzed the preprocedural MDCTs of 156 consecutive patients with mitral regurgitation undergoing MitraClip implantation at our institution. The mean TMPG was assessed by periprocedural transesophageal and pre-discharge transthoracic echocardiography. MDCT-derived mitral annulus area (MAA), anterior-posterior (AP) and medial-lateral (ML) mitral annulus diameters, and mitral valve orifice area (MVOA) were smaller in patients with mean TMPG ≥5 mmHg than those with mean TMPG <5 mmHg after 1-or 2-clip implantation. Small MAA, AP and ML diameters, and MVOA were moderately correlated with high TMPG post-MitraClip, in which MAA and MVOA had the highest degree of correlation after 1-clip (r = -0.46 both), whereas MAA and ML had the strongest degree of correlation after 2-clip (r = -0.39 both) and at discharge (r = -0.38 both). From the receiver-operating-characteristic curve analyses, no significant differences in the area under the curve were observed among these MDCT parameters for low TMPG after MitraClip implantation, except for those between MAA and AP diameter at discharge (p=0.026). For optimal cutoff values, MAA ≥1100 and ≥1300 mm² had positive predictive values of 89% and 91%, while both MAA ≥750 and ≥900 mm² had negative predictive values of 100%, for mean TMPG <5 mmHg after 1-and 2-clip implantation, respectively. In conclusion, in patients undergoing the MitraClip procedure, preprocedural MDCT parameters are useful to predict postprocedural mitral stenosis.

An unusual case of spontaneous obstructive thrombus complicating rheumatic mitral stenosis

We describe a rare case of native mitral valve thrombosis in a patient with rheumatic mitral valve disease without predisposing thrombophilia. The patient presented in heart failure with a new diagnosis of mitral stenosis. After a period of intravenous diuresis there was a sudden cardiovascular collapse. Trans-oesophageal echocardiogram identified an atrial mass obstructing the mitral valve. The patient proceeded to emergent mitral valve replacement. A coagulopathy was identified in the form of thrombus-induced disseminated intravascular coagulation (DIC). Mitral valve thrombosis is a rare cause of morbidity and mortality in rheumatic heart disease and is not readily identifiable on transthoracic echocardiography.

Lessons from reoperations for mitral stenosis after mitral valve repair

BACKGROUND

The durability of mitral valve repair (MVr) is usually defined by the absence of recurrent significant mitral regurgitation. Postrepair mitral stenosis (MS) is a less frequent and less studied mode of failure of MVr. We analyzed our experience in patients who underwent reoperation for postrepair MS to characterize mechanisms resulting in MS and to summarize reoperative surgical strategies and mid-term outcomes.

METHODS

Using a prospective database, we retrospectively analyzed data on 35 consecutive patients who underwent reoperation for symptomatic moderate to severe MS between January 1, 2011, and February 1, 2020.

RESULTS

The mean patient age was 61.4 ± 11.4 years, and 69% were female. The median annuloplasty ring size used at the initial repair was 28 mm (interquartile range, 26-30 mm). Additional repair techniques at the initial operation included leaflet resection in 12 patients (34%) and commissuroplasty or edge-to-edge repair in 6 patients (18%). At reoperation, the most common mechanism of MS was pannus ingrowth in 20 patients (57%), leaflet calcification in 12 (34%), commissural fusion in 5 (14%), and tunnel effect (functional MS) in 3 (9%). Twenty-two patients (63%) underwent valve replacement, and 13 (37%) underwent valve re-repair. In patients who underwent re-repair, annuloplasty revision was performed in all patients, with 6 patients (46%) converted from complete ring to band, 4 (11%) converted from ring to pericardial annuloplasty, 2 (6%) converted to no annuloplasty, and 1 (8%) with annuloplasty ring upsizing. There were no in-hospital or 1-year mortalities. Survival at the 5-year follow-up was 93.9%.

CONCLUSIONS

MS causing late failure of MVr is frequently associated with smaller ring sizes and inflammatory or calcific changes in the valve. Highly selected patients may be good candidates for mitral valve re-repair.

Comparison between 2D and 3D Echocardiography in Efficient Detection of Commissural Calcification in Rheumatic Mitral Stenosis

Rheumatic heart disease causes a substantial number of morbidity and mortality in Southeast Asia. In Bangladesh prevalence of Rheumatic Fever and Rheumatic heart disease is still high, 0.6 and 0.3 per thousand populations, respectively. Mitral valve mostly involved in the form of mitral stenosis in the rheumatic process. Treatment selections and its success largely depend upon the severity of disease especially the extent and distribution of calcification. Echocardiography has got the key role in determining the pattern, extent and severity of mitral stenosis. Two dimensional and Doppler echocardiography are conventionally used. With the increasing availability of 3D echocardiography, better cardiac imaging is possible now. The heart being a complex three-dimensional structure, the 3D evaluation would definitely offer better imaging for accurate assessment of the severity of mitral stenosis, especially details of commissural involvements. Many scoring systems are available for the assessment of the severity of rheumatic Mintral Stenosis (MS), mostly 2DE based; among them, Wilkins is mostly practiced. This cross-sectional observational study was conducted in University Cardiac Centre, Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh from May 2012 to October 2012. Data were collected from 50 subjects who underwent transthoracic 2D and 3D Echocardiography for the assessment of rheumatic mitral stenosis especially detection of calcification also it's severity, extent, and distribution, furthermore the presence of commissural calcification. Precise measurement of Mitral valvular area is essential in the assessment of severity, which is found similar by both 2DE (0.98±0.24cm²) and 3DE (0.92±0.23cm²). But in identifying calcification and its extent especially commissural involvement is better detected by 3DE (p=0.002). This has paramount importance in therapeutic decision making of chronic rheumatic MS. To make a well-organized management plan and also for the confident prediction of complications, three-dimensional echocardiography has promising prospects in detecting commissural calcification and should be considered as an essential adjuvant to the conventional two-dimensional echocardiography.

[Mitral stenosis and acute hemolytic anemia after mitraclip]

Mitraclip corrects mitral regurgitation in a less invasive way than cardiac surgery. These procedures are becoming widespread with the emergence of new complications. We report a rare case of mitral stenosis associated with acute hemolytic anemia after mitraclip treatment in an 82-year-old patient. The cause of this stenosis in our case is linked to the placement of two clips and an increase gradient in post-procedure. The mechanism of hemolysis could be due to the persistence of mitral leaks resulting in strong collisions against the clip.

Patterns of Rheumatic Heart Disease and Treatment Practices at Tertiary Care Center in Nepal: A Descriptive Cross-sectional Study

Introduction:

Rheumatic heart disease is a sequel of rheumatic fever which causes heart valve damage. This study was conducted to look at the pattern of valve lesions and treatment practices in patients with rheumatic heart disease.

Methods:

A cross-sectional study conducted at the tertiary care center with a diagnosis of rheumatic heart disease from July 2018 to January 2020 by convenient sampling. Ethical clearance was obtained from the Institutional Review Committee (ref no. 55/2018). Data were analyzed by using Statistical package for social sciences version 20.

Results:

Out of 600 patients, 428 (71.3%) were female. The mean age was 44.24±14.24 years. The isolated mitral valve was affected in 280 (46.6%). Dual involvement of mitral and aortic valve was present in 294 (49%). Only 14 (2.3%) had involvement of isolated aortic valve involvement. Overall, mitral stenosis was the most common abnormality 508 (84.6%) followed by mitral regurgitation 418 (69.6%), aortic regurgitation 320 (53.3%), and aortic stenosis 63 (10.5%). Assessment of the severity of lesions showed that 247 (41.2%) patients had severe mitral stenosis, 119 (19.8%) severe mitral regurgitation, 14 (2.3%) severe aortic stenosis, and 11 (1.8%) severe aortic regurgitation. Majority 493 (82.2%) were treated with medical therapies. Surgical procedures were performed in 51 (8.5%). The use of anticoagulation was in 212 (35.3%) of eligible patients.

Conclusions:

Mitral valve was affected commonly both in isolation and combination. The majority of patients who were eligible for cardiac interventions were treated medically with suboptimal use of anticoagulation and secondary prophylaxis.

Minimally Invasive Hybrid Approach to High Risk Mitral Disease With Severe Mitral Annular Calcification

Severe circumferential mitral annular calcification (MAC) remains a significant challenge, complicating surgical treatment of mitral valve disease. Transcatheter treatment options are attractive; however, they remain fraught with risks of annular fixation, paravalvular leak, atrioventricular-groove disruption, and left-ventricular outflow tract obstruction. We describe a novel minimally invasive hybrid technique of transcatheter mitral valve replacement in a patient with severe circumferential MAC.

Reverse-Loop Technique for Percutaneous Transvenous Mitral Commissurotomy in a Patient With Huge Left Atrium

A 34-year-old man was referred for percutaneous transvenous mitral commissurotomy (PTMC); he had undergone 2 PTMC attempts at another institute, but both attempts failed because of inability to cross the mitral valve with the balloon. We present an alternative reverse-loop technique for PTMC in patients with large left atrium.

Non-Rheumatic Mitral Annular Calcification as a Cause of Late-Onset Mitral Stenosis

While 'senile' calcific mitral stenosis is a rare cause of mitral stenosis as compared with rheumatic heart disease worldwide, it is thought to be more common in developed nations. Due to differences in the mechanism of dysfunction compared to rheumatic mitral stenosis, treatment options for senile calcific mitral stenosis are more limited and technically challenging. We describe a case of symptomatic severe mitral stenosis that was managed by surgical bioprosthetic valve replacement.

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

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

Long-Term Follow Up After Successful Percutaneous Balloon Mitral Valvuloplasty

BACKGROUND

Percutaneous balloon mitral valvuloplasty (PMV) is the cornerstone of rheumatic mitral stenosis treatment in suitable patients. Previous studies have reported low rates of technical failure and few major complications, with good long-term results after successful PMV. The study aim was to assess the very long-term outcome in patients after PMV performed at a single tertiary center.

METHODS

Between 1991 and 2010, a total of 213 consecutive patients underwent PMV at the authors' center. The criteria used to define successful procedure were post-procedural mitral valve area ≥1.5 cm2 and mitral regurgitation less than grade III, without in-hospital major cardiac or cerebrovascular events. The primary endpoint evaluated during the follow up period was the occurrence of cardiovascular death and need for mitral reintervention (percutaneous or surgical). Kaplan-Meier curves were generated to determine event rates, and predictors of major cardiac events in patients with successful PMV were determined using Cox regression analysis.

RESULTS

A total of 190 patients (89%) underwent a successful PMV; 88% of these are currently being followed up at the authors' center. During a mean follow up of 11.2 ± 7.3 years, at least one major adverse cardiac event occurred in 25.1% of patients (6.6% all-cause death, 6.6% repeated PMV, 21% required mitral valve surgery). Cumulative event-free survival at 20 years was 54.7 ± 6.3%. On univariate analysis, the echocardiographic score [hazard ratio (HR) = 1.25 (1.00-1.70), p <0.05], left atrial diameter [HR = 1.06 (1.01-1.11), p <0.05] and mean mitral valve gradient soon after the procedure [HR = 1.25 (1.02-1.55), p <0.05] were predictors of events. On multivariate analysis, the echocardiographic mitral valve score before PMV was the only independent predictor of primary outcome [HR=1.75 (1.16-2.64), p<0.01].

CONCLUSIONS

Up to 20 years after successful PMV, a sizeable proportion of patients remained event-free, which confirmed the late efficacy of PMV. Among the present patient cohort, echocardiographic score before PMV was the only independent predictor of long term events.

Mitral Valve Malignant Primary Tumor as a Surgical Emergency: Case Report

Malignant primary tumors of the heart are among the most unusual forms of cancer. Cardiac malignancy accounts for about 20% of all primary cardiac tumors, with most arising from the atria and less frequently the ventricles; very unusual locations include the great vessels and the cardiac valves. A rare case is presented of a young female that arrived at the authors' emergency room in pulmonary edema and circulatory collapse secondary to a true tumor of the mitral leaflets that caused severe mitral valve stenosis. On pathological examination this proved to be a mitral leaflet angiosarcoma.

Clinicopathological Spectrum of Mitral Valve Myxoma

Cardiac myxomas are the most common primary tumors of the heart. Although these tumors have been reported in all cardiac chambers, myxomas arising from heart valves are extremely rare. Here, the details are described of a patient with mitral valve myxoma, and a review is provided of 99 cases reported in the literature. Mitral valve myxomas most often occur in middle-aged patients, with a slight female predominance. Most of the tumors arise in an isolated fashion on the atrial side of the anterior mitral valve leaflet. Embolic events were the most frequent manifestation, followed by obstructive symptoms. Unlike atrial wall myxomas, these tumors have a lower incidence of constitutional manifestations. Tumor resection with valve preservation is the usual method of surgical treatment in isolated tumors, while most patients with multiple valve myxomas underwent valve replacement. Mitral valve myxomas should be considered in the differential diagnosis of mitral valve tumors, with an awareness of a relatively high risk of embolic events. This location should not raise suspicion for a heritable myxoma syndrome. Prompt surgical resection is warranted to reduce complications.

Acute Severe Mitral Stenosis Immediately After Transcatheter Aortic Valve Implantation

An 86-year-old female patient was referred for treatment of symptomatic severe aortic stenosis. The heart team decided to perform transfemoral transcatheter aortic valve implantation. A 25 mm transcatheter aortic valve was implanted, but the valve migrated low into the left ventricular outflow tract. The subsequent removal and replacement procedures are described.

Development and Validation of a Teaching Module for Echocardiographic Scoring of Rheumatic Mitral Stenosis

BACKGROUND

The Wilkins score and commissural calcification scores predict outcomes after percutaneous balloon mitral valvuloplasty. However, many cardiologists are inadequately trained in their application-both in the United States where the incidence of rheumatic heart disease has fallen and in rheumatic heart disease endemic countries where training infrastructure is weak.

OBJECTIVES

This study sought to develop a computer-based educational module teaching 2 scoring systems for rheumatic mitral stenosis and to validate the module among cardiology fellows in the United States and Uganda.

METHODS

We developed a module organized into 3 sets of 10 echocardiograms each. The module was completed by 13 cardiology fellows from 2 academic centers in the United States and 1 in Uganda. Subject answers were compared with a score assigned by 2 experts in echocardiography. The primary outcome was change in subjects' accuracy from set 1 to set 3, measured by mean absolute deviation from expert scores. Secondary outcomes included change in interoperator variability and individual subject bias from set 1 to set 3.

RESULTS

The mean absolute deviations from expert scores in sets 1 and 3 were 2.09 and 1.82 for the Wilkins score (possible score range 0 to 16) and 1.13 and 0.94 for the commissural calcification score (possible score range 0 to 4). The change from set 1 to set 3 was statistically significant only for 1 of the Wilkins component scores (leaflet calcification, p < 0.001.) No change was seen in the interoperator variability. Individual subject bias in assigning the total Wilkins score was reduced from set 1 to set 3.

CONCLUSIONS

Use of this module has the potential to enhance the training of cardiologists in the echocardiographic assessment of mitral stenosis. Modified versions of this module or similar ones should be tested in targeted populations of cardiology trainees with the most exposure to mitral stenosis interventions.

Redo Scoring for Prediction of Success of Redo-Percutaneous Balloon Mitral Valvuloplasty in Patients with Mitral Restenosis

BACKGROUND

Echocardiographic predictors of redo-percutaneous balloon mitral valvuloplasty (redo-PBMV) have not been well studied, and indications are based mainly on Wilkins score. The study aim was to evaluate the immediate results of redo-PMBV and to introduce a simplified redo-score to predict the success of redo-PBMV.

METHODS

Two cohorts of symptomatic patients (derivation group, n = 218; validation group, n = 100) who had undergone redo-PBMV at a mean of 8.1 ± 2.9 years after a first successful PBMV were enrolled in the study. The mean Wilkins scores were 8.5 ± 1.7 in the derivation group and 8.4 ± 1.8 in the validation group. PBMV was performed using a multi-track technique. Independent echocardiographic predictors of outcome were assigned a points value: mitral valve area ≤1.0 cm2 (2 points), posterior mitral valve leaflet length (PMVL)/anterior mitral valve leaflet length (AMVL) ratio ≤1/2 (2 points), doming distance ≤12 mm (3 points), mitral annular calcification (mild = 1 point; moderate = 2 points; severe = 3 points), commissural status (no fusion = 0 points; uni-fusion = 2 points; bi-fusion = 3 points) and chordal length ≤10 mm (2 points).

RESULTS

The minimum score was 5 and the maximum was 13. A receiver operating curve analysis showed the redo score to be highly significant in predicting redo-PBMV immediate results. The cut-off value of redo score to predict a favorable outcome was ≤8, with a sensitivity of 96% and specificity of 85% in the derivation cohort, and a sensitivity of 95% and specificity of 83% in the validation cohort. A Wilkins score ≤8 had a sensitivity of 71% and a specificity of 59% in the derivation cohort, while sensitivity was 70% and specificity 62% in the validation cohort.

CONCLUSIONS

The described scoring system was significantly more predictive than the Wilkins score, and was particularly valuable in predicting outcome in patients with a prior PBMV. It may serve as a satisfactory scoring system for correctly selecting patients with mitral restenosis for PBMV.

Randomised trial of mitral valve repair with leaflet resection versus leaflet preservation on functional mitral stenosis (The CAMRA CardioLink-2 Trial)

BACKGROUND

The gold-standard treatment of severe mitral regurgitation (MR) due to degenerative disease is valve repair, which is surgically performed with either a leaflet resection or leaflet preservation approach. Recent data suggest that functional mitral stenosis (MS) may occur following valve repair using a leaflet resection strategy, which adversely affects patient prognosis. A randomised comparison of these two approaches to mitral repair on functional MS has not been conducted.

METHODS AND ANALYSIS

This is a prospective, multicentre randomised controlled trial designed to test the hypothesis that leaflet preservation leads to better preservation of mitral valve geometry, and therefore, will be superior to leaflet resection for the primary outcome of functional MS as assessed by 12-month mean mitral valve gradient at peak exercise. Eighty-eight patients with posterior leaflet prolapse will be randomised intraoperatively once deemed by the operating surgeon to feasibly undergo mitral repair using either a leaflet resection or leaflet preservation approach. Secondary end points include comparison of repair strategies with regard to mitral valve orifice area, leaflet coaptation height, 6 min walk test and a composite major adverse event end point consisting of recurrent MR ≥2+, death or hospital readmission for congestive heart failure within 12 months of surgery.

ETHICS AND DISSEMINATION

Institutional ethics approval has been obtained from all enrolling sites. Overall, there remains clinical equipoise regarding the mitral valve repair strategy that is associated with the least likelihood of functional MS. This trial hopes to introduce high-quality evidence to help surgical decision making in this context.

TRIAL REGISTRATION NUMBER

NCT02552771.

Oncostatin M was associated with thrombosis in patients with atrial fibrillation

The mechanism underlying thrombosis in atrial fibrillation (AF) is not yet clearly understood. Oncostatin M (OSM), as a member of IL-6 family, is involved in atherosclerosis-mediated thrombosis. The present study hypothesizes that OSM and its downstream factors play a role in thrombogenesis in AF.The specimens of left atrial appendages collected from patients with rheumatic mitral stenosis who underwent valve replacement were divided into 3 groups: sinus rhythm, AF(+)/thrombus(-), and AF(+)/thrombus(+) group. The macrophage infiltration in atrial tissue was assessed by immunohistochemistry, and the amount of OSM, tissue factor (TF), and tissue factor pathway inhibitors (TFPIs) was detected by Western blot.The infiltration of the M1 macrophages was significantly increased in the AF with thrombus group compared with the sinus rhythm group (P = .03). Moreover, the expression of OSM and TF was much higher in the AF with thrombus group compared with the sinus rhythm group (P = .02, .009, respectively) while the TFPI was decreased in the AF with thrombus group (P = .04).OSM might be correlated with thrombosis in patients with AF mediated by TF and TFPI.

Autoimmune Disease with Cardiac Valves Involvement: Libman-Sacks Endocarditis

This case study aim to evaluate the response of steroid treatment for autoimmune endocarditis. Valvular heart disease is relatively rising in both congenital and acquired cases, but the autoimmune endocarditis remains rare. In this case, a 34 year old woman with clinical manifestation resembling systemic lupus erythematosus (SLE) is diagnosed with Libman-sacks Endocarditis. After six months of steroid treatment, her clinical manifestations and heart structure improved.

Mitral Valve Diverticulum Presenting with Severe Mitral Stenosis: Case Report

The case is presented of a non-infectious anterior mitral valve leaflet diverticulum, which appeared as symptomatic mitral stenosis. Unlike previous reports, there was no histological myxomatous degeneration of the valve. To the authors' knowledge, this is the first time a mitral valve diverticulum resulting in severe mitral stenosis has been reported in the literature.

Serum Levels of IL-17 and IL-23 in Patients With Rheumatic Mitral Stenosis

Rheumatic mitral valve stenosis (RMS) is a complication of rheumatic heart disease (RHD) and leads to significant morbidity and mortality. RHD is a chronic inflammatory and autoimmune disease that is associated with cytokine activities. The etiology of RMS is not fully understood yet. Interleukin (IL)-17 and IL-23 have a key role in development of the autoimmunity. The expression of these cytokines in RMS remains unclear. In this study, we investigated the serum levels of IL-17 and IL-23 in RMS patients compared to healthy subjects.A total of 35 patients admitted to cardiology outpatient clinic between December 2014 and May 2015 who were diagnosed with RMS formed the study group. Age- and gender-matched 35 healthy subjects were included as the control group. Statistical analyses were performed using SPSS 18.0 and P value <0.05 was considered as statistically significant.The patients with RMS had higher WBC count, hsCRP, systolic pulmonary artery pressure (PAPs), left atrial diameter (LAD), IL-17, and IL-23 levels compared to the control subjects. The levels of IL-17 (P = 0.012) and IL-23 (P = 0.004) were significantly higher in the RMS group. Correlation analysis revealed that IL-17 and IL-23 levels had a significant correlation with each other and with hsCRP and LAD.We demonstrated that serum levels of IL-17 and IL-23 are significantly higher in patients with RMS compared to those of healthy subjects. IL-17 and IL-23 expression may have a possible role in inflammatory processes that result in RMS development.

A case of familial calcific aortic and mitral stenosis in association with hereditary sclerosing poikiloderma

Hereditary sclerosing poikiloderma is a rare, familial disease with the primary clinical features being dermatologic. Widespread poikiloderma, as well as linear hyperkeratotic and sclerotic bands, tends to be the most common sign of this disease. It has been suggested that cardiac involvement may represent an important element of this disorder; however, this has not been well studied. We confirm here a case of hereditary sclerosing poikiloderma in a patient and his family with significant cardiac involvement characterized by heavily calcified stenotic aortic and mitral valves on echocardiography. Due to the patient's symptomatic severe valvular disease, he underwent simultaneous aortic and mitral valve replacement. Histopathologic analysis of the valves confirmed severe calcification of the aortic and mitral valve leaflets, suggesting a potential common mechanism between the cardiac and skin pathology of this disease. Multiple other family members had presented with similar cardiac and skin manifestations. Further research is needed to better understand the cardiac pathophysiology of this disease.

Proportion of patients in the Uganda rheumatic heart disease registry with advanced disease requiring urgent surgical interventions

INTRODUCTION

Since the establishment of the Uganda Rheumatic Heart Registry, over 900 patients have been enrolled. We sought to stratify the patients in the registry according to disease severity and optimal management strategy.

METHODS

We reviewed data of 618 patients who had enrolled in the Registry between March 2010 and February 2013. The 67 patients who had died were excluded leaving 551 patients who were recruited. The optimum management strategy was determined according to the 2012 European Society of Cardiology guidelines on the management of valvular heart disease.

RESULTS

Out of the 551 patient's records evaluated, 398 (72.3%) required invasive intervention, with 332(60.3%) patients requiring surgery and 66 (12.0%) requiring percutaneous mitral commissurotomy (PMC). This leaves only 27.7% of patients who required only medical management. Currently, majority of the patients (498, 90.4%) in the registry are on medical treatment. Of the 60.3% requiring surgical intervention, only 8.0% (44 patients) underwent valvular surgery and 5(1.0%) patients of the 66 (12.0%) underwent PMC successfully.

CONCLUSION

There is a high proportion of patients with severe disease that require surgical treatment yet they cannot access this therapy due to absence of local expertise.

Mitral Valve Stenosis Progression Due to Severe Calcification on Glutaraldehyde-Treated Autologous Pericardium: Word of Caution for an Attractive Repair Technique

A 42-year-old woman presented with a 6-month history of palpitations and progressive dyspnea on exertion. She had undergone aortic and mitral valve repair using glutaraldehyde-treated autologous pericardium for active infective endocarditis 5 years prior. Transthoracic echocardiography showed mitral valve stenosis with limited movement of the anterior leaflet. At redo surgery, severe calcification of the glutaraldehyde-treated pericardial patch on the anterior mitral leaflet was observed. Double valve replacement was performed with pulmonary vein isolation. Pathologic examination showed calcification of the glutaraldehyde-treated autologous pericardium. The patient was discharged on postoperative day 11 with oral anticoagulant therapy.

Mitral and Aortic Valvulitis in Primary Chronic Septic Endocarditis

Results of long-term prospective follow-up of patients with early stages of mitral and aortic valvulitis and primary chronic septic endocarditic are presented. Clinical diagnostics of the diseases is described and the key role is assigned to pathognomic (absolute) clinical symptoms. The tendency to progressive fibrosis of endocardial structures with subsequent gradual development of valve dysfunction and stenosis (especially for the mitral valve) is revealed. It is shown that early treatment increases the effective valve area and promotes reversion of mitral stenosis. The possibility of early diagnostics of primary chronic septic endocarditis in combination with adequate etiopathogenetic therapy provide the basis for prevention of acquired valvular disease.

Concurrent Transcatheter Aortic Valve Implantation and Percutaneous Transvenous Mitral Commissurotomy for Totally Percutaneous Treatment of Combined Severe Rheumatic Aortic and Mitral Stenosis

Transcatheter aortic valve implantation (TAVI) is a new promising therapeutic option for patients with symptomatic severe calcific aortic valve stenosis (AS) who are inoperable or at high risk for conventional cardiac surgery. Percutaneous transvenous mitral commissurotomy (PTMC) is performed routinely in patients with severe mitral stenosis (MS) having a favorable anatomy. Although concurrent TAVI and PTMC is a theoretically possible approach in the treatment of patients with severe AS and MS who are unsuitable for conventional surgery, no cases have yet been reported in which this combined technique is used. For patients with severe AS and MS, the standard therapy is replacement of both the mitral and aortic valves. Herein are presented the details of a 52-year-old woman with urethral carcinoma, in whom simultaneous TAVI and PTMC was the chosen technique to treat combined severe rheumatic AS and MS in a single procedure.

Sleep Apnea in Patients with Rheumatic Mitral Stenosis

BACKGROUND AND AIM OF THE STUDY

It was hypothesized that sleep disorders might be present due to functional heart failure in patients with mitral stenosis (MS), and might be accompanied by obstructive-type sleep disorders. To examine this hypothesis, non-smoker and non-obese patients with rheumatic MS and without concomitant diseases were investigated for sleep disorders.

METHODS

Patients admitted to the cardiology outpatient clinic at the authors' institution for rheumatic MS during a one-year period were included in the study. Patients were evaluated using the Epworth sleepiness scale, apnea-hypopnea index (AHI), and echocardiographic examination. The relationship between echocardiographic findings and AHI was assessed.

RESULTS

Eighteen patients were included in the study. All patients had sinus rhythm and normal electrocardiography recordings, with no coronary artery disease or concomitant cardiac disease. Obstructive sleep apnea (OSA) was determined in 16 patients. AHI was positively correlated with the mean apnea duration, mean gradient, rapid eye movement (REM)-AHI and non-REM-AHI. AHI, pulmonary artery pressure, mitral valve area, mean gradient, left ventricular end-systolic diameter, left ventricular end-diastolic diameter and mean REM-AHI differed significantly according to the degree of MS. AHI was shown to be increased as the degree of MS increased.

CONCLUSION

The frequency of OSA was found to be significantly higher in patients with MS. In addition to cardiac problems, these patients need to be evaluated also for sleep problems and treated appropriately.

Progression of degenerative mitral stenosis: insights from a cohort of 254 patients

BACKGROUND AND AIM OF THE STUDY

Degenerative mitral stenosis (DMS) is an increasingly common echocardiographic finding, yet the clinical and biological behavior and rate of progression of the condition are unknown.

METHODS

A total of 254 patients was identified from the authors' echocardiographic database with DMS, defined as severe mitral annular calcification with extension into the mitral leaflets resulting in transmitral flow acceleration with a mean diastolic gradient of >2 mmHg in the absence of commissural fusion. Each patient required paired echocardiograms to have been recorded at least three months apart. Clinical, biochemical and pharmacological data were collected from each patient and related to the annualized rate of increase in mean diastolic mitral gradient and stenosis severity on a scale of 0 to 3.

RESULTS

The characteristics of the patients were as follows: mean age 71 +/- 15 years; female gender 73%; and left ventricular ejection fraction 66 +/- 13%. Diabetes was present in 50% of patients, renal insufficiency in 40%, and coronary artery disease in 50%. Over a follow up period of 2.6 +/- 2.2 years, the mean gradient was increased by 0.8 +/- 2.4 mmHg (range: 0-15 mmHg) per year, while the stenosis grade was increased by 0.18 +/- 0.5 (range: 0-3) per year. The rate of progression was faster in patients with lesser degrees of stenosis (p = 0.01) and low serum albumen levels (p = 0.04), and slower in those receiving beta-blockers (p = 0.01). Milder stenosis, diabetes mellitus and lack of beta-blocker use were independent predictors of faster DMS progression.

CONCLUSION

DMS progression is highly variable, but generally slow; its progression is accelerated in the presence of diabetes mellitus, but is retarded by beta-blocker use. DMS may be an active biological process offering potentially modifiable targets for intervention.

Robotic mitral valve replacement

Robotic surgical techniques allow surgeons to perform mitral valve surgery. This procedure has gained acceptance, particularly for mitral valve repair in degenerative mitral disease. However, mitral repair may not always be possible, especially in severely calcified mitral valve of rheumatic origin. This study demonstrates the basic concepts and technique of robotic mitral valve replacement for valve pathologies that are not suitable for repair.

[Acute abdominal aortic occlusion in a patient with a giant thrombus in the left atrium and mitral stenosis; report of a case]

The patient was a 69-year-old male who had had percutaneous transvenous mitral commissurotomy (PTMC) 15 years ago, and had stopped taking warfarin after PTMC. He was transferred to our emergency room( ER) because of sudden severe pain in his both lower legs. We recognized pulselessness in his both femoral arteries, and pallor, paresthesia and poikilothermia in his lower extremities. Electorocardiogram(ECG) showed arterial fibrillation, and computed tomography( CT) showed occlusion of the abdominal aorta just below inferior mesenteric artery( IMA) and both common iliac arteries. By echocardiography, a giant thrombus was detected in the left atrium with severe mitral stenosis. Thrombectomy and angioplasty were performed at about 5 hours after the onset of occlusion, and revascularization was successful. Three days after the operation, we excised the giant thrombus in the left atrium and performed mitral valve replacement because we considered that myonephropathic metabolic syndrome (MNMS) had been prevented. The postoperative course was uneventful and he was discharged on the 27th postoperative day.

[Caseous calcification of the mitral annulus, variable and revealing clinical picture, and the contribution of cardiac tomodensitometry to the diagnosis: report of two cases]

Caseous calcification of the mitral annulus (CCMA) is a rare variant of mitral annular calcification and a common echocardiographic finding. CCMA discovery is mostly incidental, considered as benign tumor and may be unrelated to patient symptoms. Multimodality imaging may have an additional value for the diagnosis of CCMA. We report the cases of two CCMA revealed by acute pulmonary oedema and stroke, respectively. The aims of this presentation are: to illustrate the variety of cardiac symptoms that led to the diagnosis of CCMA; and to highlight the usefulness of thoracic multisliced computed tomography for the diagnosis of CCMA.

[Mitral stenosis]

This paper deals with mitral stenosis in the light of current knowledge. Currently, defect is in developed countries very rare (about 10% of defects). Its etiology has changed over the period of time mainly due to decline in rheumatic fever. Review discusses clinical, echocardiographic and catheterization findings, as well as treatment and prognosis.

Recurrent native and prosthetic mitral valve thrombosis in idiopathic hypereosinophilic syndrome

Hypereosinophilic syndrome (HES) is defined as a prolonged, unexplained peripheral eosinophilia. Endomyocardial fibrosis and mural thrombus formation are common occurrences such that patients are exposed to lethal thromboembolic complications. The valvular damage described is mainly related to iterative valve thromboses that are amenable to surgery. Here, the case is reported of a 39-year-old woman suffering from HES with mitral valve thrombosis and mechanical prosthetic mitral valve replacement, in whom a new thrombosis of the inserted prosthesis occurred one month postoperatively, concomitant with severe hypereosinophilia and despite adequate anticoagulation. The patient had received a new bioprosthetic mitral valve replacement, and her eosinophil count had been normalized after treatment with corticosteroids. Oral anticoagulation with warfarin was maintained. Subsequently, no recurrent thromboembolic events were reported, and echocardiography performed at the one-year follow up showed the bioprosthesis to have a normal hemodynamic profile.

Severe bioprosthetic mitral valve stenosis in pregnancy

A 21-year-old woman in the 16th week of pregnancy was admitted due to acute presentation of severe exertional dyspnea. She had undergone mitral valve replacement (MVR) with bioprosthetic valve for infective endocarditis 2 years ago. She developed congestive heart failure from mitral bioprosthetic valve stenosis due to early structural valve deterioration. She also had severe pulmonary hypertension and underwent a redo MVR using a mechanical valve prosthesis with good maternal outcome but fetal demise. This report brings up the debate about what type of valve should be used in women in reproductive age, and discusses the management of severe mitral stenosis and stenosis of a bioprosthetic valve during pregnancy. Surgical options can almost always be delayed until fetal maturity is achieved and a simultaneous cesarean section can be performed. However, under certain circumstances when the maternal welfare is in jeopardy the surgical intervention is mandatory even before the fetus reaches viability.

Percutaneous transvenous mitral commissurotomy: a modified over-the-wire technique for difficult left ventricle entry

Percutaneous transvenous mitral commissurotomy (PTMC) is an acceptable and preferred alternative to surgical commissurotomy in suitable patients with severe rheumatic mitral stenosis. Various over-the-wire techniques have been described in the past for difficult left ventricle (LV) entry during PTMC. Here, we report two cases of successful PTMC with difficult LV entry with a new modified over-the-wire technique. After several failed attempts using classical steps of Inoue PTMC technique, an AR-1 diagnostic catheter was introduced in the left atrium. The AR-1 has a favorable shape when faced end-on to the critically stenosed mitral orifice, hence facilitating LV entry by 0.035″ hydrophilic glidewire. The hydrophilic wire was then exchanged with a 0.035″ Amplatz super-stiff guidewire, which was coiled in vitro to make small loops of its floppy portion. This extra-stiff wire provided enough support to track the Inoue PTMC catheter to the LV cavity and small loops didn't caused any arrhythmia during the procedure. Thus, this technique may help in reducing procedural failure for "difficult LV entry" situations in critically stenosed mitral valves.