[Conservative treatment of valvular heart disease in adults]

Currently, there is no specific medication approved for the treatment of valvular heart disease per se. Except for secondary mitral valve insufficiency and tricuspid valve insufficiency in pulmonary hypertension, drug therapy for higher-grade valvular heart disease is limited to diuretic therapy for symptom control. Conservative therapy for comorbidities and potential heart failure can be beneficial regardless of the specific valve lesion. In cases of aortic valve stenosis or insufficiency, controlling arterial hypertension is important. Patients with mitral valve stenosis benefit from rhythm and rate control. Diuretics can help reduce regurgitant volume in patients with primary mitral valve insufficiency and tricuspid valve insufficiency. In addition to drug therapy, maintaining functional capacity is crucial for the outcome of patients. Therefore, it is recommended to engage in active physical activity whenever possible, despite the presence of valvular heart disease.

Frailty as a predictor of mortality and readmission rate in secondary mitral regurgitation

INTRODUCTION

Selection in patients with functional mitral regurgitation (MR) to identify responders to interventions is challenging. In these patients, frailty might be used as a multidimensional parameter to summarize the resilience to stressors. Our objective was to evaluate frailty as a predictor of outcome in patients with moderate to severe secondary MR.

METHODS

We conducted a single-center retrospective observational cohort study and included 239 patients with moderate to severe secondary MR aged 65 years or older between 2014 and 2020. Echocardiography was performed at baseline; frailty was evaluated using the clinical frailty scale (CFS). The combined primary endpoint was hospitalization for heart failure and all-cause mortality.

RESULTS

A total of 53% (127) of all patients were classified as CFS 4 (living with mild frailty) or higher. Frail patients had a higher risk for the combined endpoint (hazard ratio, HR 3.70, 95% confidence interval, CI 2.12-6.47; p < 0.001), 1‑year mortality (HR 5.94, 95% CI 1.76-20.08; p < 0.001) even after adjustment for EuroSCORE2. The CFS was predictive for the combined endpoint (AUC 0.69, 95% CI 0.62-0.75) and outperformed EuroSCORE2 (AUC 0.54, 95% CI 0.46-0.62; p = 0.01). In sensitivity analyses, we found that frailty was associated with adverse outcomes at least in trend in all subgroups.

CONCLUSION

For older, medically treated patients with moderate to severe secondary mitral regurgitation, frailty is an independent predictor for the occurrence of death and heart failure-related readmission within 1 year and outperformed the EuroSCORE2. Frailty should be assessed routinely in patients with heart failure to guide clinical decision making for mitral valve interventions or conservative treatment.

Treatment of intracardiac thrombi using ultra-slow low-dose thrombolytic therapy: A case report

A 57-year-old male with previously known severe primary mitral regurgitation was admitted to the intensive care unit (ICU) due to massive venous thromboembolism, associated with right ventricular dysfunction and two large mobile right atrial thrombi. Due to deterioration in his clinical condition despite standard treatment with unfractionated heparin, it was decided to use an ultra-slow low-dose thrombolysis protocol, which consisted of a 24-hour infusion of 24 mg of alteplase at a rate of 1 mg per hour, without initial bolus. The treatment was continued for 48 consecutive hours, with clinical improvement and resolution of the intracardiac thrombi and no complications. One month after ICU admission, successful mitral valve repair surgery was conducted. This case demonstrates that ultra-slow low-dose thrombolysis is a valid bailout treatment option in patients with large intracardiac thrombi refractory to the standard approach.

Iberian experience with PASCAL transcatheter edge-to-edge repair for mitral valve regurgitation

INTRODUCTION AND OBJECTIVES

The PASCAL system is a novel device for transcatheter mitral valve repair based on the edge-to-edge concept. The unique features of this device might have a relevant impact on the repair outcomes. There are few data on clinical outcomes in real-life registries. The aim of this study was to report the early Iberian experience (Spain and Portugal) of the PASCAL system.

METHODS

Procedural and 30-day outcomes were investigated in consecutive patients with symptomatic severe mitral regurgitation (MR) treated with the PASCAL system at 10 centers. Primary efficacy endpoints were technical success and degree of residual MR at discharge. The primary safety endpoint was the rate of major adverse events (MAE) at 30 days.

RESULTS

We included 68 patients (age, 75 [68-81] years; 38% women; EuroSCORE II 4.5%). MR etiology was degenerative in 25%, functional in 65%, and mixed in 10%. A total of 71% of patients were in New York Heart Association (NYHA) functional class≥III. Technical success was achieved in 96% and independent capture was used in 73% of procedures. In the treated population, MR at discharge was≤2+ in 100%, with no in-hospital deaths. At 30 days, the MAE rate was 5.9%, the all-cause mortality rate was 1.6%, 98% were in NYHA functional class≤II, and 95% had MR≤2+ (P<.001).

CONCLUSIONS

Transcatheter mitral valve repair with the PASCAL system was safe and effective, with high procedural success and low rates of MAE. At 30 days, MR was significantly reduced, with a significant improvement in functional status.

Objectively measured preoperative physical activity and sedentary behaviour among Finnish patients scheduled for elective cardiac procedures: baseline results from randomized controlled trial

Background

We investigated preoperative physical activity (PA) and sedentary behaviour (SB) in patients scheduled for elective cardiac procedures and compared them with population-based sample of Finnish adults.

Methods

Cardiac patients (n = 139) undergoing cardiac operations carried a triaxial accelerometer for seven days during the month before the procedure. Patients were categorised into four groups according to the procedure: percutaneous coronary intervention or coronary angiography (PCI-CA), coronary artery bypass grafting (CABG), aortic valve replacement (AVR) and mitral valve surgery (MVS). The raw accelerometer data was analyzed with dedicated algorithms to determine metabolic equivalents (METs, 3.5 mL/kg/min of oxygen consumption) of PA. The intensity of PA was divided into two categories: light (LPA, 1.5–2.9 METs) and moderate-to-vigorous (MVPA, ≥ 3.0 METs), while SB represented intensity < 1.5 MET without movements. SB and PA were described as daily means and accumulation from different bout lengths. Daily standing, steps and mean and peak MET-values were calculated. The results were compared between the patient groups and against the reference group from a population-based study FinFit2017.

Results

Cardiac patients had fewer daily steps than the FinFit population (p = 0.01), and less SB accumulating from < 20 min bouts (p = 0.002) but more from 20 to 60 min bouts (p = 0.002). Particularly, CABG group had less daily MVPA (p = 0.002) and MVPA accumulating from > 10 min bouts (p < 0.001) than the FinFit population.

Conclusions

We found large differences in PA and SB between the patient groups and the FitFit population, CABG group having the worst activity profile. Also, the variation within the patient groups was wide, which should be considered to individualise the rehabilitation programs postoperatively.

Trial registration clinicaltrials.gov (NCT03470246). Registered 19 March 2018, https://clinicaltrials.gov/ct2/show/NCT03470246.

Latent Avulsion of the Posterior Mitral Leaflet Base from the Mitral Annulus Following a Motor Vehicle Accident: A Case Report

Injuries to the heart and great vessels should always be considered after blunt chest trauma. Valvular damage rarely occurs after blunt trauma, but symptoms may be delayed. A 58-year-old woman was referred to our hospital with exertional dyspnea (functional class III) and palpitations for elective transesophageal echocardiography. Her symptoms had exacerbated in the preceding 2 or 3 months. Physical examination showed holosystolic murmurs (IV/VI) at the lower sternal border with extension to the apex. Transesophageal echocardiography revealed avulsion of the base of the posterior mitral valve leaflet (P3) from the annulus. In the past medical history, there was a history of a motor vehicle accident 9 months earlier. The patient was recommended for mitral valve surgery. Mitral valve replacement was performed, and the diagnosis was confirmed by surgery. The patient was discharged without any complications.

[Transcatheter mitral valve replacement : Indications, options, and techniques as well as important aspects for perioperative care]

Die interventionelle Therapie der Mitralklappe stellt im Gegensatz zur Aortenklappenintervention eine größere Herausforderung dar. Die Therapie mittels Mitra-Clip zur Rekonstruktion der Mitralklappe wurde erstmals im Jahr 2003 durchgeführt und ist seit dem Jahr 2008 in Europa zugelassen. Die erste Implantation der einzig zugelassenen interventionellen Mitralklappe erfolgte im Jahr 2014, die Zulassung in Europa erfolge im Jahr 2020. Es befinden sich zahlreiche andere Klappensysteme in klinischer Prüfung und werden das Portfolio wahrscheinlich erweitern. In diesem Artikel werden die Indikation für diese neue Therapieform, die technische Umsetzung sowie die spezifischen Herausforderungen für die perioperative Betreuung besprochen.

Clinical Predictors of Mortality in Patients with Moderate to Severe Mitral Regurgitation

BACKGROUND

Mitral regurgitation is the most common form of valvular heart disease worldwide, however, there is an incomplete understanding of predictors of mortality in this population. This study sought to identify risk factors of mortality in a real-world population with mitral regurgitation.

METHODS

All patients with moderate or severe mitral regurgitation were identified at a single center from January 1, 2016 to August 31, 2017. Multivariate regression was performed to evaluate variables independently associated with all-cause mortality.

RESULTS

A total of 490 patients with moderate (76.3%) or severe (23.7%) mitral regurgitation due to primary (20.8%) or secondary (79.2%) etiology were identified. The mean age was 66.7 years; 50% were male. At a median follow-up of 3.1 years, the incidence of all-cause mortality was 30.1%, heart failure hospitalization 23.1%, and mitral valve intervention 11.6%. Of 117 variables, multivariate analysis demonstrated 5 that were independently predictive of mortality: baseline creatinine (hazard ratio [HR] 1.2; 95% CI, 1.0-1.3; P = .02), right atrial pressure by echocardiogram (HR 1.3; 95% CI, 1.07-1.55; P = .008), hemoglobin (HR 0.65; 95% CI, 0.52-0.83; P = .001), hospitalization for heart failure (HR 1.6; 95% CI, 1.1-2.4; P = .015), and mitral valve intervention (HR 0.40; 95% CI, 0.16-0.83; P = .049).

CONCLUSION

In this retrospective, pragmatic analysis of patients with moderate or severe mitral regurgitation, admission for heart failure exacerbation, elevated right atrial pressure, renal dysfunction, anemia, and lack of mitral valve intervention were independently associated with increased risk of all-cause mortality. Whether these risk factors may better identify select patients who may benefit from more intensive monitoring or earlier intervention should be considered in future studies.

[ESC/EACTS guidelines 2021 on the management of valvular heart diseases : What are the most important innovations?]

In August 2021 the European Society for Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) updated their guidelines on the management of valvular heart disease. Since the publication of the previous version in 2017 new evidence regarding epidemiology, diagnosis and treatment of valvular heart diseases has been accumulating, which led to reassessment of several recommendations. Most importantly, the critical role of the heart team in treatment decision-making was reemphasized, the criteria for choosing the mode of aortic valve interventions were clarified, the definition of severe secondary mitral regurgitation was revised and the recommendation for transcatheter edge-to-edge mitral valve repair in patients with this condition was upgraded. Additionally, antithrombotic therapeutic regimens in patients with native valvular heart diseases and bioprostheses were reappraised, the indications for early surgery in selected asymptomatic patient groups were expanded and the potential of transcatheter tricuspid valve interventions in inoperable and high-risk patients was acknowledged, although the latter needs to be further evaluated. This review article summarizes the most important recommendations of the new guidelines.

Current devices and interventions in mitral regurgitation

Mitral regurgitation (MR) is the most common valvular disease. With a rising incidence in older age, the prevalence of relevant comorbidities inevitably increases. Considering the constantly aging population with high surgical risk, transcatheter therapy of MR is gaining increasing importance. Interventional therapy of either primary or secondary MR represents an alternative to pure drug or surgical therapy. With mitral valve transcatheter edge-to-edge repair, a well-established treatment has evolved in the past two decades. In addition, direct or indirect annuloplasty and ultimately transcatheter mitral valve implantation further expand the armamentarium. The current broad spectrum of interventional therapy options allows for patient-oriented therapy individually targeting different MR pathologies. This review discusses the current landscape of transcatheter therapies for relevant MR.

Dynamic changes of mitral valve annulus geometry at preprocedural CT: relationship with functional classes of regurgitation

BACKGROUND

We investigated mitral valve annular geometry changes during the cardiac cycle in patients with severe mitral regurgitation (MR) who underwent cardiac computed tomography angiography (CCTA) prior to percutaneous mitral valve replacement or annuloplasty.

METHODS

Fifty-one patients with severe MR and high surgical risk (Carpentier classification: 3 type I, 16 type II, 16 type IIIa, 16 type IIIb) underwent multiphase electrocardiographically gated (0-90%) CCTA, using a second generation dual-source CT scanner, as pre-procedural planning. Twenty-one patients without MR served as controls. The mitral valve annulus was segmented every 10% step of the R-R interval, according to the D-shaped segmentation model, and differences among groups were analysed by t-test or ANOVA.

RESULTS

Mitral annular area and diameters were larger in MR patients compared to controls, particularly in type II. Mitral annular area varied in MR patients throughout the cardiac cycle (mean ± standard deviation of maximum and minimum area 15.6 ± 3.9 cm² versus 13.0 ± 3.5 cm², respectively; p = 0.001), with greater difference between annular areas versus controls (2.59 ± 1.61 cm² and 1.98 ± 0.6 cm², p < 0.001). The largest dimension was found in systolic phases (20-40%) in most of MR patients (n = 27, 53%), independent of Carpentier type (I: n = 1, 33%; II: n = 10, 63%; IIIa: n = 8, 50%; IIIb: n = 8, 50%), and in protodiastolic phases (n = 14, 67%) for the control group.

CONCLUSIONS

In severe MR, mitral annular area varied significantly throughout the cardiac cycle, with a tendency towards larger dimensions in systole.

Mitral valve thrombosis in term pregnancy: A case report and review of the literature

OBJECTIVE

With this case report would like to emphasize the complexity that involves the management of pregnant women with mechanical heart valves. In that sense, an adequate interdisciplinary management of this potentially serious pathology is required for maternal and fetal well-being.

CASE REPORT

A 32-year-old primipara, with a mechanical mitral valve replacement, was admitted to our emergency department at 37⁺¹ weeks of gestation with acute dyspnea and presyncope. The patient was diagnosed with mechanical mitral valve thrombosis and, due to the appearance of hemodynamic instability, the patient underwent an uncomplicated emergency caesarean section and subsequent prosthetic mitral valve replacement. The patient was discharged six days after surgery, without any obstetric complication and with normal valve function.

CONCLUSION

This case report shows that, despite strict control and optimal anticoagulation regimen, pregnant women with mechanical heart valves still have a high risk of developing valve thrombosis.

Standard and emerging CMR methods for mitral regurgitation quantification

BACKGROUND

There are several methods to quantify mitral regurgitation (MR) by cardiovascular magnetic resonance (CMR). The interoperability of these methods and their reproducibility remains undetermined.

OBJECTIVE

To determine the agreement and reproducibility of different MR quantification methods by CMR across all aetiologies.

METHODS

Thirty-five patients with MR were recruited (primary MR = 12, secondary MR = 10 and MVR = 13). Patients underwent CMR, including cines and four-dimensional flow (4D flow). Four methods were evaluated: MR_Standard (left ventricular stroke volume - aortic forward flow by phase contrast), MR_LVRV (left ventricular stroke volume - right ventricular stroke volume), MR_Jet (direct jet quantification by 4D flow) and MR_MVAV (mitral forward flow by 4D flow - aortic forward flow by 4D flow). For all cases and MR types, 520 MR volumes were recorded by these 4 methods for intra-/inter-observer tests.

RESULTS

In primary MR, MR_MVAV and MR_LVRV were comparable to MR_Standard (P > 0.05). MR_Jet resulted in significantly higher MR volumes when compared to MR_Standard (P < 0.05) In secondary MR and MVR cases, all methods were comparable. In intra-observer tests, MR_MVAV demonstrated least bias with best limits of agreement (bias = -0.1 ml, -8 ml to 7.8 ml, P = 0.9) and best concordance correlation coefficient (CCC = 0.96, P < 0.01). In inter-observer tests, for primary MR and MVR, least bias and highest CCC were observed for MR_MVAV. For secondary MR, bias was lowest for MR_Jet (-0.1 ml, PNS).

CONCLUSION

CMR methods of MR quantification demonstrate agreement in secondary MR and MVR. In primary MR, this was not observed. Across all types of MR, MR_MVAV quantification demonstrated the highest reproducibility and consistency.

Predictors of moderate to severe ischemic mitral regurgitation after myocardial infarction: a cardiac magnetic resonance study

OBJECTIVES

The purpose of this study is to explore the predictors of moderate to severe ischemic mitral regurgitation (IMR) after myocardial infarction with cardiovascular magnetic resonance (CMR).

METHODS

From January 2016 to September 2018, 109 patients (mean age 60 ± 8 years) with IMR were studied retrospectively. All patients underwent CMR-cine with True-FISP sequence and late gadolinium enhancement (LGE) with a phase-sensitive inversion recovery sequence. The presence of papillary muscle infarction (PMI), global left ventricular (LV) infarcted extent, LV functional parameters, and LV myocardial strain were assessed. Univariate and multivariate analyses were performed to identify factors in the development of moderate to severe IMR.

RESULTS

Mild IMR was present in 61 patients (56%), and moderate to severe IMR was present in 48 patients (44%). PMI was identified in 22 patients (20.1%); 14 of them (63.63%) showed a moderate or severe IMR. Global LV infarcted extent was increased in patients with moderate to severe IMR (p < 0.001). LV functional parameters of patients with moderate to severe IMR were statistically different from those of the patients with mild IMR (all p < 0.001), except the LV SV index (p = 0.142) and LV CI (p = 0.447). The global longitudinal strain (GLS), regional radial strain (RS), and circumferential strain (CS) of the moderate-to-severe IMR group were significantly decreased compared with those of the mild IMR group (p < 0.05). In multivariable analyses, age (OR = 1.11; p = 0.001), global LV infarct extent (OR = 1.14; p = 0.000), and GLS (OR = 1.31; p = 0.000) were associated with moderate-to-severe chronic IMR.

CONCLUSIONS

The incidence of PMI was higher in patients with moderate-to-severe IMR. The extent of global LV infarcted extent and GLS were independent predictors of moderate-to-severe IMR.

KEY POINTS

• Cardiovascular magnetic resonance late gadolinium enhancement and feature-tracking imaging provide reliable information on LV function, myocardial viability, and papillary muscle morphology. • Papillary muscle infarction is not an independent predictor of moderate-to-severe IMR. • The extent of global LV infarction and LV global longitudinal strain were independent predictors of moderate-to-severe chronic IMR.

Left atrial appendage aneurysm: A case report

BACKGROUND

An aneurysm of the left atrial appendage is one of the rare but potentially hazardous heart defects. The risk of lethal complications grows with its size. To date, about 150 cases of this defect have been described in the literature. We present a case of left atrial appendage aneurysm with the deformation of the mitral valve and the left main coronary and circumflex artery, which required mitral valve annuloplasty and bifurcation stenting.

CASE SUMMARY

A 58-year-old man presented to our hospital complaining of shortness of breath, general weakness, dizziness during physical exertion, and fatigue. Based on the results of echocardiography, an aneurysm of the left atrium was suspected. A free-breathing real-time cine magnetic resonance imaging with electrocardiograph synchronization confirmed the diagnosis of left atrial appendage aneurysm. The patient underwent an aneurysmectomy via a median sternotomy with cardiopulmonary bypass. Intraoperative transesophageal echocardiography revealed relative mitral insufficiency that was corrected with an annuloplasty ring. Intraoperative coronary angiogram showed impaired blood flow in the left main coronary and circumflex artery and 60% stenosis. For this reason, bifurcation stenting was performed. The patient had an uneventful postoperative clinical course and was discharged from the hospital on the 10th day in a satisfactory condition.

CONCLUSION

Left atrial appendage aneurysm is a rare and dangerous heart pathology that requires surgery to prevent related complications.

[Anesthesiological implications of minimally invasive valve interventions : Transcatheter aortic valve implantation, clip reconstruction on the mitral and tricuspid valve]

Catheter-guided interventional implantation of cardiac valves is one of the main developments in cardiology over the past 15 years. It is characterized by a close interdisciplinary cooperation in the heart team (H-team), which consists of cardiac anesthesiologists, cardiologists and heart surgeons. This co-responsibility for anesthesia, which is demanded by the legislator (Federal Joint Committee, G‑BA, July 2015), includes not only qualified training for the cardiac anesthesiologist, including transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) but also several years of experience in cardiac anesthesia and correlates with the recommendations of the German Society for Anaesthesiology and Intensive Care Medicine. In accompaniment with the demographic development, the number of heart valve diseases increases with age. More than 50% of all heart operations are performed on patients over the age of 70 years and nearly 20% on patients over the age of 80 years. Minimally invasive procedures are outstanding opportunities for patients who were initially classified as inoperable. Therefore, anesthesiologists must have precise knowledge of the possible complications related to the procedure itself. Additionally, it challenges the anesthesiologist with unconventional situations in the care of older patients who are exposed to a higher risk. The aforementioned risks are organic functional restrictions, increasing number of comorbidities and more severe exposure due to malnutrition and frailty; however, monitoring methods are also being developed aiming for patient-specific anesthesia management and analgesia treatment. This article discusses the interventional procedures of heart valvular diseases as well as the hemodynamic changes associated with the procedures from the anesthesiologist's point of view. To present examples, we have selected transcatheter aortic valve replacement (TAVR) and the interventional procedure of mitral and tricuspid valve insufficiency called MitraClip and TricaClip. A thorough examination of the procedural risk rate shows that despite minimizing the surgical intervention by miniaturizing the devices, the presence of an experienced cardiac anesthesiologist is obligatory.

[Coronary artery bypass grafting surgery in left ventricular dysfunction patients complicated with mitral regurgitation]

Objective: To evaluate the efficacy of coronary artery bypass grafting (CABG) surgery in left ventricular dysfunction patients complicated with different degrees of ischemic mitral regurgitation (IMR). Methods: The clinical data of 525 patients (428 males and 97 females) undergoing CABG in Fuwai Hospital Chinese Academy of Medical Sciences Shenzhen, and Tianjin Medical University General Hospital between January 2015 and December 2018 were collected. The average age was (61±7) years old. Among them, the patients with moderate to serve IMR and left ventricular ejection fraction(LVEF)≤40% were further selected, and the outcomes of CABG were analyzed. Results: In total, 67 patients (48 males and 19 females) with moderate to severe IMR and LVEF≤40% were enrolled, among which 52 patients had moderate IMR, with a LVEF of 38%(35%, 40%). Transesophageal echocardiography (TEE) of 52 cases displayed no damage of papillary muscles, and ventricular wall motion was improved after CABG. Therefore, no treatment on the mitral valve was performed in this group. Six patients were with moderate-severe mitral insufficiency, with a LVEF of 38%(35%, 39%). After surgery, TEE found that the ventricular wall motion and regurgitation were improved, and the mitral valve structures were well. Thus, mitral valves were not treated in these patients. Nine patients were with severe mitral regurgitation, with a LVEF of 38%(35%, 39%). Two of them received valve repair because the papillary muscle function and the ring were well. Another 7 patients received valve replacements because the valve ring was dilatated and the leaflet was prolapsed. All patients recovered well. The LVEF increased significantly at 6 months after surgery [47%(45%, 48%) vs 38%(35%, 39%), P=0.024], and the left ventricular end diastolic diameter also became smaller [57(56, 59) mm vs 61(59, 64) mm, P=0.002]. Conclusions: For patients suffered from left ventricular dysfunction complicated with IMR, TEE is crucial to evaluate the valve function. To those with moderate-severe regurgitation, if papillary muscle function and the ring were seriously affected by ischemia, the valve replacement could facilitate the improvement of postoperative cardiac function.

Dynamic computed tomographic assessment of the mitral annulus in patients with and without mitral prolapse

OBJECTIVES

To obtain 3D CT measurements of mitral annulus throughout cardiac cycle using prototype mitral modeling software, assess interobserver agreement, and compare among patients with mitral prolapse (MP) and control group.

BACKGROUND

Pre-procedural imaging is critical for planning of transcatheter mitral valve (MV) replacement. However, there is limited data regarding reliable CT-based measurements to accurately characterize the dynamic geometry of the mitral annulus in patients with MV disease.

METHODS

Patients with MP and control subjects without any MV disease who underwent ECG-gated cardiac CT were retrospectively identified. Multiphasic CT data was loaded into a prototype mitral modeling software. Multiple anatomical parameters in 3D space were recorded throughout the cardiac cycle (0-95%): annular circumference, planar-surface-area (PSA), anterior-posterior (A-P) distance, and anterolateral-posteromedial (AL-PM) distance. Comparisons were made among the two groups, with p < 0.05 considered statistically significant. Interobserver agreement was assessed on ten patients using intraclass correlation coefficient (ICC) among 4 experienced readers.

RESULTS

A total of 100 subjects were included: 50 with MP and 50 control. Annular dimensions were significantly higher in the MP group than control group, with circumference (144 ± 11 vs. 117±8 mm), PSA (1533 ± 247 vs. 1005 ± 142 mm²), A-P distance (38 ± 4 vs. 32±2 mm), and AL-PM distance (47 ± 4 vs. 39±3 mm) (all p < 0.001). Substantial size changes were observed throughout the cardiac cycle, but with maximal and minimal sizes at different cardiac phases for the two groups. The interobserver agreement was excellent (ICC≥0.75) for annular circumference, PSA, A-P- and AL-PM distance.

CONCLUSION

A significant variation in the mitral annular measures between different cardiac phases and two groups was observed with excellent interobserver agreement.

Outcome for Conservative Surgery for the Correction of Severe Mitral Valve Regurgitation in Children: A Single-Center Experience

Evolving reconstructive techniques have progressively become the preferred approach for treatment of pediatric mitral valve regurgitation. We present our experience in a cohort of patients undergoing surgical correction for severe mitral regurgitation. Fifty-five patients (age 1 month-18 years; median 5 years) were included in the present analysis. Different surgical techniques were used (posterior leaflet augmentation in 25, isolated cleft closure in 12, Alfieri-type procedure in 10, annuloplasty in 5, with artificial chordae in 2, and quadrangular resection with chordal transposition in 1). Follow-up time ranged from 1 to 192 months (median 38[IQR 12-54] months). Operative and follow-up mortality was 0%. Reintervention in the whole population occurred in 31% of patients. However, when first surgery was performed under 2 years of age (no = 17), reintervention reached nearly 50%. The degree of residual mitral regurgitation at follow-up remained stable after surgery, while a significant increase in mean transmitral gradient was observed over time (paired t test = 0.03). In multivariable Cox-regression analysis, post-surgical transmitral gradient was the only independent predictor for reintervention (p = 0.017; HR 2.4; 95%CI 1.2-5.1), after correcting for differences in age at surgery, type of reintervention, mitral annulus dimension, and BSA at the first surgery. ROC curve demonstrated that a post-surgical transmitral mean gradient value > 5 mmHg, was predictive for reintervention (AUC = 0.89; Youden index = 0.44). Our study suggests that the use of conservative technique strategy achieves satisfactory functional results in infants and children with severe MR, although the rate of reoperation in younger patients remains substantial. Post-operative moderate mitral stenosis was the strongest predictor for reoperation.

Percutaneous mitral valve repair in recurrent severe mitral valve regurgitation after mitral annuloplasty : MitraClip-in-the-ring as a complementary strategy

BACKGROUND

Patients with reduced left ventricular (LV) function undergoing coronary artery bypass graft surgery or/and aortic valve replacement occasionally show severe mitral valve (MV) regurgitation and thus also undergo surgical mitral annuloplasty. Over time, further deterioration of LV function and additional ischemic events cause recurrence of severe MV regurgitation due to the Carpentier IIIb morphology of the MV that is not adequately addressed by the previously implanted annuloplasty ring.

METHODS

Seven patients (Society of Thoracic Surgeons score: 7.5 ± 1.5%) with Carpentier type-IIIb recurrent severe MV regurgitation, having undergone prior cardiothoracic surgery (median: 40 months) including mitral annuloplasty, were treated with the MitraClip device.

RESULTS

MitraClip implantation resulted in significantly reduced MV regurgitation and improved New York Heart Association functional state, translating into an increased exercise capability and improved cardiac biomarkers. The morphology of the MV was adequately addressed without causing relevant MV stenosis, while the MV annulus area remained unaltered. The procedure was safe with a 30-day mortality rate of 0%.

CONCLUSION

MitraClip-in-the-ring is feasible and in principle safe for treating Carpentier type IIIb severe MV regurgitation after surgical MV repair using mitral annuloplasty. MitraClip-in-the-ring resulted in immediate amelioration of clinical symptoms and increased physical exercise capacity.

[Valvular heart disease in patients with chronic kidney disease]

Valvular heart disease is a common comorbidity in patients with impaired renal function, especially in those with end-stage renal disease undergoing dialysis. Sclerosis and calcification of the heart valves and the valve ring are particularly relevant in the etiology of the diseases. These typically occur at the aortic and mitral valves and can lead to both insufficiency and stenosis of the affected valve. In the current guidelines of the European Society for Cardiology published in 2017, surgical treatment remains the standard of care for most forms of severe valvular heart disease; however, the presence of chronic kidney disease impairs clinical outcomes and is associated with higher mortality rates when compared to patients with preserved renal function. Catheter-based treatment options have emerged as an effective and safe alternative for patients >75 years and/or with increased surgical risk. Consequently, in patients with appropriate anatomy and elevated risk, interventional treatment options should also be discussed in the heart team.

[Edge-to-edge repair : What has changed compared to the position paper in 2013?]

This short review article aims to explain the changes in the treatment strategies of interventional care designed to treat secondary mitral valve regurgitation with edge-to-edge repair in comparison to the position paper published in 2013 by the German Society of Cardiology and the German Society of Thoracic and Cardiovascular Surgery. To this end the current data situation with respect to the European Society of Cardiology (ESC) guidelines from 2017, the intraprocedural assessment of mitral valve regurgitation and new technical developments are discussed.

Moderate ischemic mitral incompetence: does it worth more ischemic time?

OBJECTIVES

Ischemic mitral regurgitation (IMR) is a common finding following myocardial infarction or ischemia. Management of moderate IMR is still a hot topic. Adding mitral valve repair (MVr) to coronary artery bypass grafting (CABG) is questionable. The goal of this study was to assess and compare short-term clinical and echocardiographic results of moderate IMR treated by CABG alone versus another group of patients treated by CABG plus MVr.

METHODS

Eighty consecutive patients with ischemic heart disease (IHD) and moderate IMR were divided randomly into two equal groups: group I (40) had only CABG and group II (40) had CABG plus MVr. Patients were evaluated at 1-week, 3-months and 1-year intervals postoperatively.

RESULTS

After 1-year follow-up, our study revealed statistically significant improvement in the grade of mitral regurgitation (MR) in group II than group I. The mean value for effective regurgitant orifice area (EROA) was 0.22 ± 0.13 for group I versus 0.03 ± 0.03 for group II (P = 0.001) and for vena contracta (VC), it was 3.8 ± 2.24 for group I versus 0.4 ± 0.49 for group II (P = 0.000). There was also a significant reduction in the New York Heart Association (NYHA) functional class in both groups.

CONCLUSIONS

MVr can be performed safely and concomitantly with CABG in patients having moderate IMR, and its addition to CABG have significant short-term impact on clinical or echocardiographic outcome of patients.

Is the MitraClip® procedure profitable in a high-volume French hospital?

BACKGROUND

Mitral regurgitation is the second most frequent valvulopathy managed by surgery in Europe. For patients who have a contraindication to surgery or a high surgical risk, the percutaneous MitraClip® implantation procedure has emerged as a favourable alternative approach, but elevated procedural costs are a medicoeconomic concern.

AIM

The objective of this study was to evaluate whether the MitraClip® procedure is profitable in a high-volume French hospital.

METHODS

Patients eligible for mitral valve repair with a MitraClip® device, and covered by the French National Health Service, were included retrospectively in this single-centre study between September 2016 and June 2018. Subgroups were considered based on medicoeconomic severity level. The study primary endpoint was the difference between hospital costs and revenues, calculated for each patient. Secondary endpoints included profit based on severity level, breakdown of costs and adverse events during hospitalization.

RESULTS

Twenty-two patients were included in the study. The mean hospital cost and revenue were €30,039±2476 and €30,331±2720 per patient, respectively, resulting in a profit of €292±2039 per patient. The total estimated profit was €6429 for the whole study period. The largest benefits were observed for patients assigned to the higher medicoeconomic severity levels (levels 2 and 3). Profit increased following a reduction in the device cost (€1136±2415 per patient). The price of the device represented 78% of the total costs.

CONCLUSIONS

Percutaneous MitraClip implantation is a financially neutral procedure for a French university hospital, but this depends on patient severity level.

[MITRA-FR and COAPT : Why are the results so different and what are the consequences for the daily routine?]

Percutaneous mitral valve repair with the MitraClip in the COAPT study significantly reduced overall mortality and hospitalization in patients with at least moderate to severe mitral valve regurgitation, in comparison to guideline-compliant drug treatment alone. Consequently, the assumption that secondary mitral regurgitation is more a consequence than the cause of systolic heart failure needs to be revised; however, data from the simultaneously published MITRA-FR study showed no prognostic benefits for patients with advanced heart failure and severely enlarged left ventricle; therefore, MitraClip treatment should only be performed after careful patient selection and heart team decision. With respect to future patient selection further studies are needed to better define cut-offs for treatment or exclusion criteria and to identify patients who profit the most from treatment. Also, new catheter-based techniques and alternative approaches to treat functional mitral regurgitation need to be investigated.

Global longitudinal strain to predict left ventricular dysfunction in asymptomatic patients with severe mitral valve regurgitation: literature review

The optimal treatment strategy for asymptomatic patients with severe mitral valve regurgitation (MR) and preserved left ventricular (LV) function is challenging. This manuscript reviews the available literature on the value of left ventricular global longitudinal strain (LV-GLS) in predicting LV dysfunction after mitral valve surgery in these patients and discusses its current place in the treatment strategy. Studies were identified from Cochrane Library, SCOPUS, PubMed and Web of Science up to February 2018. The domain used was MR. The determinant was LV-GLS; other methods of deformation imaging were excluded. The examined outcome was LV dysfunction after surgery. A total of 144 articles were retrieved, of which 11 publications met the inclusion criteria, including a total of 2415 patients. Ten studies showed a significant correlation between preoperative LV-GLS and LV dysfunction postoperatively; one study reported a negative correlation. These studies suggest that LV-GLS is a predictor of LV dysfunction after surgery in asymptomatic patients with chronic MR. Hence, incorporation of LV-GLS for clinical decision-making in these patients might be of additional value. Further research is needed to confirm the role of LV-GLS in postoperative patients, and additionally in asymptomatic MR patients during a ‘watchful waiting’ strategy.

[Cardioband®: Where do we stand, who are suitable patients?]

Functional mitral regurgitation (FMR) is characterized by a dilatation of the mitral valve annulus resulting in an insufficient adaptation of the anterior and posterior mitral valve leaflets and/or severe tethering of the leaflets due to dilatation of the left ventricle. The Cardioband® system was introduced in 2015 and is a catheter-based direct mitral valve annuloplasty procedure for treatment of FMR. In the European CE approval study 60 patients with moderate or severe FMR were analyzed per protocol. There were no device or procedure-related deaths. The technical success rate of the procedure, defined as successful implantation and tightening was 97%. At 1 year, the overall survival and survival free of hospital readmission for heart failure were 87% and 66%, respectively. Currently, various interventional treatment procedures are available, such as the edge-to-edge technique as well as direct and indirect annuloplasty. In summary, patients with FMR as a result of a dilatation of the mitral valve annulus appear to be suitable for direct annuloplasty with the Cardioband® system.

Concomitant aortic valve replacement, mitral valve replacement, and coronary artery bypass grafting for aortic stenosis and mitral regurgitation in a patient with relapsing polychondritis

Relapsing polychondritis is a rare multi-system disease characterized by inflammation in cartilaginous structures and other connective tissues. Cardiovascular complications occur in 10-51% of the patients. We report a case of concomitant aortic valve replacement, mitral valve replacement, and coronary artery bypass grafting in a patient with relapsing polychondritis. A 71-year-old female with relapsing polychondritis on prednisolone (5 mg/day) for 15 years presented at our hospital for further evaluation of valvular disease. Severe aortic stenosis and severe mitral regurgitation were diagnosed. We performed aortic and mitral valve replacement. During surgery, we found connective tissue surrounding the intima of the sinus of Valsalva and stenosis of the right coronary artery ostium, which was not noted on preoperative coronary angiography. We removed the tissue and performed bypass grafting to the right coronary artery. Postoperative recovery was uneventful, and she was discharged 27 days after surgery.

Thoracoscopic retrieval of an atrial appendage occlusion device after embolization into the left ventricular outflow tract and damaging the mitral valve requiring replacement

Embolization of a percutaneous left atrial appendage occlusion device is a rare, but potentially life-threatening, complication. In this report, we present the case of an embolization of such a device into the left ventricular outflow tract causing extensive damage to the mitral subvalvular apparatus and requiring mitral valve replacement. We also describe the first thoracoscopic removal of such a device from the left ventricular outflow tract.

[Cardiomyopathy in a 22-year-old man with a long history of methamphetamine abuse]

This article presents the case of a 22-year-old male patient with cardiomyopathy associated with a long history of methamphetamine abuse. Echocardiography revealed a dilated cardiomyopathy with highly reduced systolic pump function and severe mitral valve regurgitation. Inotropic treatment and MitraClip® (Abbott Vascular, Santa Clara, CA, USA) implantation resulted in enhancement of hemodynamics. The rising prevalence of methamphetamine abuse should give reason to raise awareness for the diagnostic work-up and patient history particularly in cases of unexplained cardiomyopathy in young patients.

Surgical Treatment of Degenerative Mitral Valve Regurgitation in the Elderly: Comparison of Early and Long-Term Outcomes Using Propensity Score Matching Analysis

Background

It is unclear whether mitral valve (MV) repair for degenerative mitral regurgitation (MR) provides the same advantages in the elderly that it does in the general population.

Methods

From 1994 to 2016, 188 elderly patients (mean age, 68.3±5.50 years) underwent MV repair (n=153) or MV replacement (n=35) for primary degenerative MR. Early and long-term outcomes were compared before and after propensity score matching (PSM).

Results

Before PSM, there was a significant difference in operative mortality (p=0.011). Overall survival and freedom from cardiac-related death (CRD) at 5, 10, and 15 years were significantly higher in patients who underwent MV repair (p=0.039 and p=0.007, respectively). In the multivariable analysis, MV replacement was an independent risk factor of CRD. After PSM, operative mortality was not significantly lower in patients who underwent MV repair (p=0.125). Overall survival and freedom from CRD at 5, 10, and 15 years showed no significant difference between the 2 groups in the PSM cohort (p=0.207, p=0.47, respectively). There was no significant difference in freedom from reoperation before or after PSM (p=0.963 and p=0.575, respectively).

Conclusion

MV repair for primary degenerative MR might be a valid option in the elderly population if successful repair is possible.

Virtual downsizing for decision support in mitral valve repair

PURPOSE

Various options are available for the treatment of mitral valve insufficiency, including reconstructive approaches such as annulus correction through ring implants. The correct choice of general therapy and implant is relevant for an optimal outcome. Additional to guidelines, decision support systems (DSS) can provide decision aid by means of virtual intervention planning and predictive simulations. Our approach on virtual downsizing is one of the virtual intervention tools that are part of the DSS workflow. It allows for emulating a ring implantation based on patient-specific lumen geometry and vendor-specific implants.

METHODS

Our approach is fully automatic and relies on a lumen mask and an annulus contour as inputs. Both are acquired from previous DSS workflow steps. A virtual surface- and contour-based model of a vendor-specific ring design (26-40 mm) is generated. For each case, the ring geometry is positioned with respect to the original, patient-specific annulus and additional anatomical landmarks. The lumen mesh is parameterized to allow for a vertex-based deformation with respect to the user-defined annulus. Derived from post-interventional observations, specific deformation schemes are applied to atrium and ventricle and the lumen mesh is altered with respect to the ring location.

RESULTS

For quantitative evaluation, the surface distance between the deformed lumen mesh and segmented post-operative echo lumen close to the annulus was computed for 11 datasets. The results indicate a good agreement. An arbitrary subset of six datasets was used for a qualitative evaluation of the complete lumen. Two domain experts compared the deformed lumen mesh with post-interventional echo images. All deformations were deemed plausible.

CONCLUSION

Our approach on virtual downsizing allows for an automatic creation of plausible lumen deformations. As it takes only a few seconds to generate results, it can be added to a virtual intervention toolset without unnecessarily increasing the pipeline complexity.

Advances in Mitral Valve Surgery

Mitral valve (MV) insufficiency, classified as primary and secondary mitral regurgitation (MR), is a common cause of morbidity and mortality. In industrialized countries, degenerative forms are the predominant cause of MR; however, an increasing number of patients present with secondary MR (Iung et al. EHJ 24:1231-1243, 2003). During the last decades, MV surgery experienced substantial advancements. Alain Carpentier pioneered the field of reconstructive valve surgery in the beginning of the 1970s and, since then, a plethora of innovations have led to today's landscape of MV surgery. Modern MV repair techniques including minimally invasive approaches represent the gold standard for primary MR with reconstruction rates of > 97% in high-volume reference centers (Castillo et al. JTCS 144(2):308-312, 2012). Although there is a clear strategy for treatment of primary MR with established high-quality results, the optimal course for treatment of secondary MR remains controversial. Results for a variety of MV repair techniques for secondary MR have been uniformly disappointing and there has been a recent resurgence in interest for MV replacement surgery. Innovations in equipment and imaging have led to the development of new techniques for patients with MV disease. High-risk patients who are poor candidates for surgery have been the focus for most of these techniques, usually within the construct of a multidisciplinary heart team. Efforts have been predominantly focused on less invasive strategies, usually transcatheter technologies, in these high-risk patients. This article aims to give an overview about current surgical treatment options for primary and for secondary MR with special focus on new surgical and transcatheter developments.

Surgical antegrade transcatheter valve implantation and heavily calcified heart

It is well known that a heavily calcified mitral valve significantly increases the perioperative and postoperative risks of mitral valve surgery. A 71-year-old woman was referred to our department with severe mitral valve disease. Cardiac imaging revealed extremely severe calcification of the entire left heart. Surgery was performed through a median sternotomy with standard cardiopulmonary bypass. After dilating the mitral orifice with a balloon, we replaced the valve with a transcatheter Edwards Sapiens 3 aortic valve under direct vision. Seven months after the procedure, the patient was doing well and no longer suffered from dyspnea.

[Improving outcomes of patients with heterotaxy and functional single ventricle: a 10-year follow-up of 70 cases in a single institution]

Objective: To review current-era palliation outcomes of patients with heterotaxy and functional single ventricle in a single institution. Methods: The clinical data of 70 consecutive patients with heterotaxy undergoing multistage single ventricle palliation in Guangzhou Women and Children's Medical Center from January 2008 to December 2017 were retrospectively reviewed, and the prognosis factors for mortality were analyzed. There were 53 male and 17 female patients.The median age was 13.3 months (range: 6 days to 150 months). Single ventricle multistage palliation included 1(st) stage palliation surgery, 2(nd) bidirectional Glenn shunt, and 3(rd) stage modified Fontan.The Kaplan-Meier method was used to estimate the probability of survival. Multivariate analysis was performed by Cox regression model. Results: Sixty-two patients had right atrial isomerism while eight had left atrial isomerism. Eighteen patients (25.7%) required the first stage palliation. Fifty-five patients received the Glenn shunt, and the Fontan procedure was completed in 27 patients. Overall, mortality occurred in 17 patients (24.3%) including 9 after the first stage palliation, 6 after the Glenn shunt, and 2 following the Fontan procedure. Survival estimates for the entire cohort following surgery were 81% (95%CI: 72% to 90%), 74%(95%CI: 64% to 85%), and 74% (95%CI: 64% to 85%) at 1 year, 5 years and 10 years, respectively. Survival estimates following the first stage palliation were 56% (95%CI: 33% to 79%) and 49% (95%CI: 26% to 73%) at 1 year and 5 years, respectively. Multivariate Cox regression analysis revealed that total anomalous pulmonary venous connection (TAPVC) (HR=6.16, 95%CI: 1.65 to 22.95, P=0.007), atrioventricular valve regurgitation more than moderate (HR=3.81, 95%CI: 1.32 to 10.94, P=0.013) and required the first palliation surgery (HR=4.58, 95%CI: 1.34 to 15.72, P=0.016) were prognosis factors for overall mortality. Conclusions: The management of heterotaxy patients with functional single ventricle remains challenging, and the outcomes are continously improving in china. TAPVC, atrioventricular valve regurgitation more than moderate and required the first palliation surgery still are prognosis factors for overall mortality in heterotaxy syndrome.

Pulmonary venous varix associated with mitral regurgitation mimicking a mediastinal mass: A case report and review of the literature

Pulmonary vein varix is an unusual cause of a mediastinal mass on a chest radiograph. It may be found as an isolated malformation or as a sequela of pulmonary venous hypertension. We encountered a case presenting with left hemiparesis and a past medical history of rheumatic heart disease. The chest radiograph revealed a well-defined mediastinal mass that turned out to be a hugely dilated pulmonary vein on contrast enhanced computed tomography of the chest. The computed tomography of the brain and upper abdomen revealed bilateral cerebral infarction and splenic infarction. In the literature, one-third of the reported cases of pulmonary vein varix are acquired secondary to mitral valve disease.

Congenital mitral regurgitation with Down syndrome

A 19-year-old man with Down syndrome had congenital mitral regurgitation. He had slight mental retardation and difficulty in performing independent oral drug administration. We planned mitral valve plasty to avoid postoperative anticoagulant therapy. The mitral valve lesions were complicated. A prolapsed anterior mitral leaflet, shortened posterior leaflet, abnormal cleft, abnormal papillary muscle, and enlarged annulus were observed. Successful mitral valve plasty was performed using several techniques. The postoperative course was uneventful, and no significant mitral regurgitation was found.

Early Surgery in Valvular Heart Disease

The burden of valvular heart disease (VHD) is increasing with age, and the elderly patients with moderate or severe VHD are notably common. When to operate in asymptomatic patients with VHD remains controversial. The controversy is whether early surgical intervention should be preferred, or a watchful waiting approach should be followed. The beneficial effects of early surgery should be balanced against operative mortality and long-term results. Indications of early surgery in each of the VHD will be discussed in this review on the basis of the latest American and European guidelines.

[Surgical treatment and early-mid follow-up results of complete atrioventricular septal]

Objective: To discuss the surgical treatment and early-mid follow-up results of complete atrioventricular septal defect (CAVSD). Methods: The clinic data of 235 cases of CAVSD underwent surgical treatment at Department of Cardiac Surgery, Guangdong General Hospital from June 2009 to June 2016 was analyzed retrospectively (104 male and 131 female patients). The patients were aged 18 days to 58 years (mid age 8.9 months) at surgery, and 2 cases of newborns (0.9%), 24 cases of 1 to 3 months (10.2%), 56 cases of 4 to 6 months (23.8%), 66 cases of 7 to 12 months (28.1%), 36 cases of 1 to 3 years (15.3%), 37 cases of 4 to 18 years (15.7%), and 14 cases above 18 years (6.0%). There were 129 cases of Rastelli type A (54.89%), 16 cases of type B (6.8%), 25 cases of type C (10.6%) and 65 cases of transitional type (27.7%). The patients were combined with 7 cases of unroofed coronary sinus syndrome, 5 cases of coarctation of aorta, 4 cases of tetralogy of Fallot, 3 cases of double outlet right ventricle, 1 case of transposition of the great arteries, 1 case of multiple ventricular septal defect, 1 case of pulmonary artery sling. The CAVSD correction operations were performed in 199 cases with modified single patch technique (84.7%), 26 cases with two patch technique (11.1%), 10 cases with conventional single patch technique (4.3%), and the corrective surgeries of other anomalies were performed in the meantime. Generalized Estimated Equation was used to statistical analysis of postoperative regurgitation level of mitral valve and tricuspid valve. Results: Followed-up for 1 to 7 years, 18 cases (7.7%) died overall and 15 cases (6.4%) died within 30 days post-operation.The mortality of little infant (operation age ≤3 months) was much highest(26.9%). The mortality of different operation age had significant difference(P=0.007). There was no difference among the mortality with three techniques. Seven cases (3.0%) suffered from the re-operation for severe mitral regurgitation. A total of 217 patients survived more than 1 year after initial surgery, and there were 11 cases (5.1%) with severe mitral regurgitation and 7 cases (3.2%) with severe tricuspid valve regurgitation at 1 year post-operation.The degree of mitral regurgitation after operation decreased at 1 week to 6 months, and slightly higher after 1 year postoperatively.The ratios of severe mitral regurgitation in different operative age group was statistically significant difference(P=0.017), mainly from 3 months group and 1 to 3 years group.The degree of tricuspid regurgitation decreased significantly after operation, and decreased gradually in the follow-up period. The ratio of postoperative residual severe tricuspid regurgitation was the highest in surgical aged >18 years old, less in 3 years group, the lowest in 3 to 18 years group. Conclusions: The mortality and the ratio of patients with serious mitral regurgitation were higher in infants less 3 months than elder patients. The infants need more frequently follow-up and medicine treatment after operation. The modified one patch technique is effective for all age groups.

MitraClip and mitral annuloplasty device as a bridge to transplantation

A 42-year-old man with dilated cardiomyopathy and endstage heart failure was evaluated for heart transplantation. He received a MitraClip and Carillon annuloplasty device for functional mitral regurgitation as palliation for his heart failure. Subsequently, he underwent successful heart transplantation.

Acute reverse annular remodeling during MitraClip® therapy predicts improved clinical outcome in heart failure patients: a 3D echocardiography study

Background

Transcatheter mitral valve repair (TMVR) has been shown to have acute effects on mitral valve geometry in patients with functional mitral regurgitation (FMR). This study investigates the impact of MitraClip^® therapy-induced annular remodeling on clinical outcome and mitral regurgitation in heart failure patients.

Methods

TMVR was performed successfully in 45 patients with FMR. In this study, mitral valve datasets were obtained before and directly after MitraClip^® implantation using three-dimensional (3D) transesophageal echocardiography, and were analyzed offline retrospectively using dedicated 3D reconstruction software. Patients underwent clinical and echocardiographic evaluation at baseline and after 6 months. At follow-up, the patients were allocated into two groups according to their improvement in New York Heart Association (NYHA) functional class: a Low Responder group with ΔNYHA <1.5 (n = 25); and a High Responder group with ΔNYHA ≥1.5 (n = 20).

Results

At 6-month follow-up, data analysis revealed that while mitral regurgitation was reduced significantly in both groups, only the High Responder group had experienced significant downsizing of the 3D circumference (137 ± 14 mm to 126 ± 13 mm; p < 0.01) and the anterior-to-posterior diameter (33 ± 5 mm to 29 ± 4 mm; p < 0.01) of the mitral annulus during the intervention. Furthermore, only the High Responder group with reverse annular remodeling as shown had substantial advances in quality of life (Minnesota living with heart failure questionnaire: 55 ± 10 to 34 ± 14 points; p < 0.01) and functional status (6-min walk distance: 290 ± 104 m to 462 ± 111 m; p = 0.07).

Conclusion

Our study demonstrates that instantaneous left ventricular annular remodeling during MitraClip^® implantation is associated with improved clinical outcome of heart failure patients with functional mitral regurgitation.

Trial registration The study was approved by the local ethics committee (Study Number 4497R, Registration ID: 2013121585). Trial registration: NCT02033811 Retrospectively registered January 9, 2014.

[MitraClip® for treatment of tricuspid valve insufficiency]

Tricuspid valve regurgitation is frequently found as a result of right ventricular remodeling due to advanced left heart diseases. Drug treatment is limited to diuretics and the cardiac or pulmonary comorbidities. Due to the high risk only a small percentage of patients are amenable to surgical treatment of tricuspid regurgitation in those who undergo left-sided surgery for other reasons. Catheter-based procedures are an attractive treatment alternative, particularly since the strong prognostic impact of tricuspid regurgitation suggests an unmet need of treatment, independent of the underlying heart disease. A vast amount of clinical experience exists for the MitraClip system for treatment of mitral regurgitation. A first case series shows that the application for treatment of tricuspid regurgitation is technically feasible, seems to be safe and the degree of valve regurgitation can be reduced. In this review the background of tricuspid regurgitation treatment is summarized and first experiences and perspectives with the MitraClip system are assessed.

[Efficacy of mitral valve repair versus replacement in severe ischemic mitral regurgitation]

Objective: To compare the mortality, survival rate and the therapeutic efficacy between mitral valve repair and replacement as treatment for severe ischemic mitral regurgitation (IMR), and explore the middle- and long-term outcomes. Methods: Between January 2000 and January 2016, 378 patients with severe IMR underwent coronary artery bypass grafting (CABG) combined with mitral valve repair (n=162) or mitral valve replacement (n=216) in the Department of Cardiovascular Surgery of Nanjing First Hospital. Clinical data, in-hospital morbidity and mortality of patients were retrospectively reviewed. The patients were followed up for the long term survival rate, heart function and re-admission. Results: No statistically significant differences of baseline data and operation details were found between the two groups except for left ventricular end-diastolic diameter[(61.3±10.2)mm in replacement group vs (56.2±9.0)mm in repair group, P<0.001]. Seven patients died during the perioperative period, with a total operation mortality of 1.9%.No significant difference of mortality was found between the two groups (5 cases in the replacement group and 2 cases in the repair group). The early outcome after the surgery showed that the rate of low cardiac output and ventricular arrhythmia of patients were significantly higher in the replacement group compared with the repair group (both P<0.05). The mortality of patients received mitral valve replacement was better than who received mitral valve repair when left ventricular end-diastolic diameter was over 65 mm (5.9% vs 10.0%, P=0.036). No significant differences were observed between the two groups in the middle- and -long term survival rate (87% for replacement group vs 85% for repair group, P=0.568). The follow-up time was 1-85 (52.8±21.5) months and the follow-up rate was 93%. The rate of valve-related complications was significantly higher in the repair group compared with the replacement group (8.82% vs 3.82%, P=0.003). Conclusions: We should choose the surgical methods carefully (replacement or repair) for severe IMR patients according to degree of left ventricular remodeling and pathological changes of mitral valve. Mitral valve replacement with preservation of the subvalvular apparatus is a safe and effective surgical alternative for mitral valve repair, especially for patients with complications or complex reflux.

[Real-time 3D echocardiography for estimation of severity in valvular heart disease : Impact on current guidelines]

Besides providing spatial anatomic information on heart valves, real-time three-dimensional echocardiography (3DE) combined with color Doppler has the potential to overcome the limitations of flow quantification inherent to conventional 2D color Doppler methods. Recent studies validated the application of color Doppler 3DE (cD-3DE) for the quantification of regurgitation flow based on the vena contracta area (VCA) and the proximal isovelocity surface area (PISA) methods. Particularly the assessment of VCA by cD-3DE led to a change of paradigm by understanding of the VCA as being strongly asymmetric in the majority of patients and etiologies. This review provides a comprehensive description of the different concepts of cD-3DE-based flow quantification in the setting of different valvular heart diseases and their presentation in recent guidelines.

[Imaging in structural heart disease : Impact on interventional therapy]

For the treatment of structural heart disease, current options in the catheterization laboratory include MitraClip® implantation for treating severe mitral regurgitation, transcatheter aortic valve implantation (TAVI), closure of a patent foramen ovale (PFO) and occlusion of the left atrial appendage (LAA). These treatment options are based on a precise diagnosis provided by modern cardiac imaging, which is indispensable for treatment recommendations. Its importance for supporting the invasive procedures in the catheterization laboratory is less well known. Due to enhanced soft tissue characterization, it complements fluoroscopy and invasive angiography and thus enormously improves the safety of the procedures. In addition, it allows individualized follow-up care. The current article gives an overview of the clinically most frequently used procedures.

[Interdisciplinary differential treatment of structural heart disease : When operation and when catheter-based intervention?]

The demographic changes in society lead to an increasing number of patients with aortic valve stenosis and mitral regurgitation. Simultaneously the higher age of patients is associated with an increase in multimorbidity with a high surgical risk so that they cannot be referred to surgery. Besides the current gold standard of surgery, minimally invasive therapeutic options are increasingly becoming established for these patients. For the differentiated indications and therapeutic success, a multidisciplinary heart team assumes an important role. The next generation of transcatheter aortic valve implantation (TAVI) systems will lead to improvement in the results, lower complication rates and mortality and as a result there is a general trend towards expanding the indications. New innovative minimally invasive mitral valve devices are still undergoing clinical trials and will define future therapy options.

Mitral valve repair using a semirigid ring: patient selection and early outcomes

BACKGROUND

Commonly used complete mitral annuloplastic rings include saddle-shaped and semirigid rings, with no clear indication for either type. A semirigid ring may be preferred in patients whose native mitral saddle shape is well maintained. We present our experience of using semirigid rings for mitral valve repair.

METHODS

We routinely measured the annular height-to-commissural width ratio by 3-dimensional transesophageal echocardiography prior to mitral repair. We generally chose a semirigid (Memo 3D) ring in patients whose annular height-to-commissural width ratio was normal (≥ 15%). The same semirigid ring with an additional chordal guiding system (Memo 3D ReChord) was selected for patients with anterior leaflet or bileaflet pathology. Over an 18-month period, 66 patients with severe degenerative (n = 60) or functional (n = 6) mitral regurgitation had Memo 3D (n = 32) or Memo 3D ReChord (n = 34) rings implanted.

RESULTS

Postoperative 3-dimensional transesophageal echocardiography was completed in all patients (mean follow-up 7 ± 5 months). The majority of patients had no or mild residual mitral regurgitation; only two had moderate (2+) mitral regurgitation. There was no mortality at 30-days or on midterm follow-up.

CONCLUSIONS

Our series represents the first Asian clinical experience using the Memo 3D ReChord ring. Although the long-term durability of mitral repair with this type of semirigid annuloplastic ring warrants further validation, our current clinical data are encouraging.

Dumb-bell in the heart: rare case of biatrial myxoma with mitral regurgitation

Cardiac myxomas are rare intracardiac tumors, and the majority are benign myxomas involving the left atrium. We report a case of the very rare occurrence of biatrial myxoma associated with mitral regurgitation, which was successfully treated.

Predicting Left Ventricular Dysfunction after Surgery in Patients with Chronic Mitral Regurgitation: Assessment of Myocardial Deformation by 2-Dimensional Multilayer Speckle Tracking Echocardiography

Background and Objectives

The development of postoperative left ventricular (LV) dysfunction is a frequent complication in patients with chronic severe mitral valve regurgitation (MR) and portends a poor prognosis. Assessment of myocardial deformation enables myocardial contractility to be accurately estimated. The aim of the present study was to evaluate the predictive value of preoperative regional LV contractile function assessment using two-dimensional multilayer speckle-tracking echocardiography (2D MSTE) analysis in patients with chronic severe MR with preserved LV systolic function.

Subjects and Methods

Forty-three consecutive patients with chronic severe MR with preserved LV systolic function scheduled for mitral valve replacement (MVR) or MV repair were prospectively enrolled. Serial echocardiographic studies were performed before surgery, at 7 days follow-up, and at least 3 months follow-up postoperatively. The conventional echocardiographic parameters were analyzed. Global longitudinal strain (GLS) was obtained quantitatively by 2D MSTE.

Results

The mean age of patients was 51.7±14.3 years and 25 (58.1%) were male. In receiver-operating characteristic curve analysis, the most useful cutoff value for discriminating postoperative LV remodeling in severe MR with normal LV systolic function was -20.5% of 2D mid-layer GLS. Patients were divided into two groups by the baseline GLS -20.5%. Preoperative GLS values strongly predicted postoperative LV remodeling or LV dysfunction. The postoperative degree of decrease in LV end-diastolic dimension might be an additive predictive factor.

Conclusion

STE can be used to predict a decrease in LV function after MVR in patients with chronic severe MR. This promising method could be of use in the clinic when trying to decide upon the optimum time to schedule surgery for such patients.