Mapping of the myxomatous mitral valve: The three-dimensional extension of mitral annular disjunction in surgically repaired mitral prolapse

Objectives

This study aimed to describe the heterogeneous extension of mitral annular disjunction (MAD) and assess the hypotesis that different phenotypes of disjunction are not associated with increased surgical challenges.

Background

Mitral regurgitation (MR) is the most common end-stage scenario of degenerative mitral valve disease (DMVD). Few data exist on the three-dimensional extension and geometry of MAD, as well as for its role in valvular dynamic and coaptation.

Methods

A total of 85 consecutive subjects, who underwent elective mitral valve repair (MVR) for MMVD at our Institution between November 2019 and October 2021, were studied retrospectively. The extension and geometry of MAD was assessed using the digitally stored volumetric datasets of real-time 3D transesophageal echocardiography (TEE). Annular phenotypes and surgical repair techniques were analyzed.

Results

Mitral annular disjunction was diagnosed in 50 out of 85 patients (59%) with Barlow disease (BD). A detailed analysis of MAD extension was conducted on 33 patients. Two pattern of disjunction were identified: a bimodal shape was highlighted in 21 patients, while a more uniform distribution of the disjuncted annulus was observed in 12 patients. The bimodal pattern was characterized by lower disjunction distance (DD) at the 140°–220° arch (3.6 ± 2.2 mm), while a more regular DD was measured in the remaining patients. All patients successfully underwent MVR. Triangular leaflet resection was performed in 58% of the cases, neochordae implantation in 9%, and notably a 27% received an isolated annuloplasty.

Conclusion

Rather than a binary feature, MAD should be taken into account in its complex and heterogeneous morphology, where two major phenotypes can be identified. Despite its anatomical complexity, MAD was not associated with an increased surgical challenge; conversely a peculiar subgroup of patient was successfully treated with an isolated annuloplasty.

Kinetics of the Severe Acute Respiratory Syndrome Coronavirus 2 Antibody Response and Serological Estimation of Time Since Infection

BACKGROUND

Infection with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) induces a complex antibody response that varies by orders of magnitude between individuals and over time.

METHODS

We developed a multiplex serological test for measuring antibodies to 5 SARS-CoV-2 antigens and the spike proteins of seasonal coronaviruses. We measured antibody responses in cohorts of hospitalized patients and healthcare workers followed for up to 11 months after symptoms. A mathematical model of antibody kinetics was used to quantify the duration of antibody responses. Antibody response data were used to train algorithms for estimating time since infection.

RESULTS

One year after symptoms, we estimate that 36% (95% range, 11%-94%) of anti-Spike immunoglobulin G (IgG) remains, 31% (95% range, 9%-89%) anti-RBD IgG remains, and 7% (1%-31%) of anti-nucleocapsid IgG remains. The multiplex assay classified previous infections into time intervals of 0-3 months, 3-6 months, and 6-12 months. This method was validated using data from a seroprevalence survey in France, demonstrating that historical SARS-CoV-2 transmission can be reconstructed using samples from a single survey.

CONCLUSIONS

In addition to diagnosing previous SARS-CoV-2 infection, multiplex serological assays can estimate the time since infection, which can be used to reconstruct past epidemics.

Isolated aortic insufficiency valve repair with external ring annuloplasty: a standardized approach

OBJECTIVES

Aortic valve (AV) insufficiency with normal root and ascending aorta is most frequently treated by valve replacement with significant prosthetic-related complications and reduced life expectancy. We compared the outcomes of a new standardized isolated AV repair approach using an external aortic annuloplasty ring at the subvalvular level (single ring annuloplasty) and the role of an additional supravalvular ring at the sinotubular junction (double ring annuloplasty).

METHODS

Single centre data were collected from the Aortic Valve Insufficiency and ascending aorta Aneurysm InternATiOnal Registry (AVIATOR) between 2003 and 2017. A total of 93 patients (56 single ring and 37 double ring) underwent isolated AV repair.

RESULTS

The overall 30-day mortality rate and the need for a permanent pacemaker were 1% and 2%, respectively. The overall survival rate at 6 years was similar for sex- and age-matched members of the general population (89% vs 95%; P = 0.1) and did not differ between the double and single ring groups (82% vs 93%; P = 0.4) at 6 years. There were no thromboembolic or bleeding events in the entire cohort. However, at 6 years, the cumulative incidence of valve-related reintervention was 26% in the single ring annuloplasty group compared to 3% in the double ring annuloplasty (P = 0.02) group. Similarly, at 6 years, the cumulative incidence of moderate-to-severe (>2) aortic insufficiency was 30% in the single ring annuloplasty group compared to 0% in the double ring annuloplasty group (P = 0.007).

CONCLUSIONS

Standardized AV repair with external ring annuloplasty has a survival rate similar to that of the general population. The additional stabilization of the sinotubular junction with a second supravalvular ring (double ring annuloplasty) is associated with better outcomes compared to single subvalvular annuloplasty. It can be considered as a first line intervention for patients with isolated aortic insufficiency and pliable leaflets.

Standardization of bicuspid valve repair with aortic annuloplasty provides similar results to tricuspid aortic valve repair

Background

Bicuspid aortic valves (BAV) represent the main cause of severe dystrophic aortic insufficiency in young patients and are mostly replaced with high rates of valve-related events and altered quality of life in case of mechanical prosthesis. Valve repair is now recommended for root aneurysm and tricuspid aortic valves (TAV) when feasible. However, concerns remain regarding the long-term durability of BAV repair, compared to TAV.

Purpose

Our objective is to compare the long-term results of repair between TAV and BAV, in consecutive patients operated on with a standardized approach according to each phenotype of the dystrophic ascending aorta.

Methods

Data were prospectively collected into the multicenter international AVIATOR registry (AorticValve repair InternATiOnal Registry). Between 2003 and 2019, according to ascending aorta phenotypes, 226 patients with BAV and 309 patients with TAV underwent either isolated valve repair with external ring annuloplasty (26,2%), or root remodeling with external ring (59,4%), or a supra-coronary graft with external ring (14,4%).

Results

Cusp repair was performed in 95,1% patients in the BAV group and in 63,8% in the TAV group. The 30-day operative mortality was 0,93% (n=5). Mean follow-up was 5,5±4,4 years. The actuarial survival rate at 12 years was 93,2% in the BAV group and 87,8% in the TAV group (p=0,14). Freedom from reoperation at 12 years was similar between groups being 94,9% for bicuspid and 93,2% for tricuspid (p=0,75). Freedom from major adverse valve-related events at 12 years was 82,8% and 82,9% in BAV and TAV groups respectively (p=0,17). At 12 years, freedom from AI ≥Grade 2 or ≥Grade 3 was 68,7% and 94,3% for BAV and 76,5% and 94,7% for TAV group, with no significant difference (respectively p=0,16 and p=0,92).

Conclusion

Aortic valve repair with a standardized approach adapted to the aorta phenotype provides excellent long-term results with a low rate of valve-related events. Similar results were achieved between BAV and TAV patients.

freedom from reoperation for BAV and TAV

Funding Acknowledgement

Type of funding source: None

Bicuspid aortic valve repair adapted to aortic phenotype

The bicuspid aortic valve (BAV) is the most common congenital cardiovascular anomaly and may present with differing phenotypes including almost constant annular dilation. We have developed a standardized approach to BAV repair with a systematic adjunct of aortic annuloplasty according to the three phenotypes of the proximal aorta, which include a dilated aortic root, dilated ascending aorta and normal root and ascending aorta. In our cohort of 191 patients, freedom from AV-related re-intervention was 98% for remodeling with annuloplasty (n=100) and 100% for tubular aortic replacement with annuloplasty (n=31) at 8 years. In an isolated aortic insufficiency (AI) group, freedom from AV-related re-intervention varied from 72.4% with a single subvalvular annuloplasty ring (n=31) compared to 100% at 6 years when a double sub- and supra-valvular (STJ) annuloplasty ring was performed (n=29). Restoration of the annulus: sinotubular junction (STJ) ratio is a key factor to ensure longevity of the bicuspid valve repair and freedom from re-intervention.

[Cardiac papillary fibroelastoma and stroke during pregnancy: Case report]

Stroke occurring during pregnancy is linked to high mortality. Stroke may be directly related to pregnancy (e.g. eclampsia, cerebral venous thrombosis), but all the other causes of stroke are possible. Brain magnetic resonance imaging that is not contraindicated during pregnancy remains the reference in this context. We report the case of a woman with severe headache associated with visual disturbances, without hypertension or proteinuria at 32 weeks of pregnancy. MRI revealed multiple recent cerebral vascular accidents. An echocardiogram detected a papillary fibroelastoma of 5mm. Maternal fetal experts determined it safe to continue the pregnancy. Childbirth at 39 weeks was normal uneventful for the newborn and mother. In the postpartum, despite the theoretical operative indication to resect the small residual papillary fibroelastoma, the patient was followed expectantly because of the stable neuro-cardiologic state. A fibroelastoma can be revealed by a stroke during pregnancy. In the postpartum period, an expectant attitude can be reasonably chosen in case of small size of the fibroelastoma.

Mitroflow LXA structural deterioration following aortic valve replacement: a single-center experience

BACKGROUND

Concerns have been previously raised regarding the potential early degeneration of the Mitroflow (Sorin Group Italia, Saluggia, Vercelli, Italy) bioprostheses. We aimed to evaluate our clinical experience with the Mitroflow LXA prosthesis for aortic valve replacement.

METHODS

We prospectively analyzed data from 227 consecutive patients (133 males, mean age 73.9±9.2 years) implanted with the Mitroflow LXA between February 2007 and October 2011. Follow-up data were obtained by contacting the referring cardiologists. Kaplan-Meier curves were constructed for all-cause mortality, valve related mortality and structural valve degeneration (SVD). Multivariable analysis was conducted to identify SVD predictors.

RESULTS

Median follow-up time was 54.2±37.9 months and completeness of follow-up was 95%. Overall mortality in the entire series was at 31% (N.=71) and mortality from cardiac or unknown causes at 20% (N.=46). SVD occurred in 24 patients (10%) (median delay between implantation and diagnosis: 62.6 (36.5) months). Reintervention was required in 20 cases (13 redo surgery, 7 percutaneous transcatheter valve intervention). The 8 years actuarial global survival was 54.7±4.9%, freedom from valve related mortality 67.5±4.9% and freedom from SVD 72±8%. The estimated freedom from SVD was significantly (P=0.007) longer in larger prosthesis (diameter >21 mm, 77±11%) compared to the smaller devices (≤21 mm, 59±13%.). Multivariate analysis identified smaller prostheses and age at implantation as independent predictors of SVD.

CONCLUSIONS

The Mitroflow LXA showed evidence of early SVD in this cohort. A close follow-up of these patients is strongly advised.

[Surgery of 56 patients having a partial atrioventricular septal defect]

Between January 1991 and December 2006, 56 patients having a partial atrioventricular septal defect (AVSD) were operated. The purpose of this retrospective study is to analyze the immediate and long-term results of the surgery by granting of the importance to two main problems which are the disturbances of the rhythm and the conduction and the residual mitral regurgitation (MR). The mean age of our patients is of 10 and a half years with a net feminine ascendancy. Ninety-three percent of the patients were in regular sinus rhythm. No case of complete atrioventricular block (AVB) was noted. The MR was of grade I in 28.5% of the cases, grade II in 60% of the cases and grade III and IV in 7.5% of the cases. The MR was mild in 4% of the cases. The correction was made under cardiopulmonary bypass (CPB) and consisted of a suture of the mitral cleft in most of the cases with lock of the ostium primum by a patch of pericardium. The perioperative mortality was 1,8% of the cases. The disturbances of the rhythm and the conduction were noted in 34% of the cases. All the patients were controlled with a mean follow-up of six years and seven months. The secondary mortality was nil. The MR, at mid-term follow-up, was mild in 78% of the cases. The partial AVSD is a congenital heart disease, the spontaneous evolution of which can be burdened by complications, notably the disturbances of the rhythm and the conduction, as well as the heart failure. This justifies a premature surgical repair.

[Human immunodeficiency virus and pregnancy: a retrospective study of 124 women]

The objective is to describe medical and obstetrical prenatal care of 124 HIV-infected pregnant women in the Hôpital Delafontaine, Saint-Denis, France, between 1995 and 2001.Demographic, clinical and biological characteristics of study population were retrospectively collected. Three (2,4%) children were infected.