Progressive calcification of bioprosthetic mitral valve observed during pregnancy resulting from in vitro fertilization: a case report.

BACKGROUND: Women with pre-existing cardiac conditions who undergo assisted reproductive technologies (ART) are believed to be at a heightened risk of cardiovascular events during both the treatment and pregnancy phases. An unresolved question within this context pertains to whether the ART procedure itself constitutes a risk factor for individuals with bioprosthetic heart valves (BHV). Additionally, there is ongoing controversy regarding whether pregnancies expedite the process of structural valve degeneration (SVD) in BHV. The purpose of this study is to present the developmental process of BHV calcification, which is considered the primary cause of SVD, during a pregnancy resulting from in vitro fertilization and embryo transfer (IVF-ET), an ART modality, and to elucidate the underlying mechanisms. CASE PRESENTATION: At 7 + 3 weeks of gestation in a twin pregnancy resulting from IVF-ET, a 27-year-old woman with a bioprosthetic mitral valve manifesting severe mitral stenosis and moderate pulmonary arterial hypertension, was suspected of SVD. Despite undergoing fetal reduction, she experienced progressive calcification of the bioprosthetic valve, increasing pulmonary arterial pressure and ultimately deteriorated into heart failure. An elective cesarean section and redo valve replacement was subsequently administered to improve her cardiovascular condition. As a result, a healthy young boy was delivered and the dysfunctional BHV was replaced with a mechanical valve. She did not report any discomfort during the 3-month follow-up. CONCLUSION: The progressive calcification of the BHV was observed during IVF pregnancy, indicating a potential connection between fertility therapy, pregnancy and calcification of BHV. Pregnant women with pre-implanted BHV should be treated with caution, as any medical interventions during ART and pregnancy can have a significant impact on both maternal and fetal outcomes. Thus, involving a multidisciplinary team in decision-making early on, starting from the treatment of the original heart disease, throughout the entire process of ART and pregnancy, is crucial.

Mitral complex geometric changes aggravate mitral stenosis after transcatheter aortic valve replacement.

Severe aortic valve stenosis (AS) often coexists with mitral valve stenosis (MS). MS aggravation after transcatheter aortic valve replacement (TAVR) is common, and its etiology is multifactorial. We hypothesized that geometric changes in the mitral complex (mitral valvular and annular deformities) are adjunctive factors aggravating MS after TAVR, particularly in older adults with a smaller left ventricle (LV). This study aimed to evaluate the mitral complex geometric changes before and after TAVR and to assess the important predictors of MS aggravation after TAVR. This retrospective study enrolled consecutive adult patients who underwent TAVR and surgical AVR (SAVR) for severe AS. The mitral valve area (MVA), the angle between the anterior mitral valve leaflet (AMVL) and left ventricular outflow tract (LVOT), AMVL length, mitral annular diameter, presence of mitral annular calcification, and LV size were evaluated using transthoracic echocardiography. This study included 258 patients who underwent TAVR and SAVR. MVA index decreased from 2.3 ± 0.6 cm² to 1.9 ± 0.5 cm² in the TAVR group. The angle between the AMVL and LVOT was 56.3 ± 9.7° preoperatively and increased to 67.3 ± 11.5° after TAVR. In multivariate analysis, the most important predictive factors of MS aggravation after TAVR were a smaller mitral annular diameter, restricted AMVL mobility, and implantation depth (odds ratio: 4.5, 5.3,3.0; 95% confidence interval: 1.6-14, 1.9-17, 1.0-8.9; and p = 0.005, p = 0.001, p = 0.042, respectively). The reduction in MVA after TAVR was related to the restriction of AMVL opening, depth of implantation and narrowing of the mitral annulus.

[Association of a myxoma of the left atrium and a mitral stenosis : About a case]. / Association d'un myxome de l'oreillette gauche et d'un rétrécissement mitral : à propos d'un cas.

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.

The interplay of cardiac hemodynamics in rheumatic triple valve stenosis.

Rheumatic heart disease is among the common causes of cardiovascular morbidity in developing countries. Here we present the hemodynamic interplay of stenotic rhematic involvement of aortic, mitral, and tricuspid valves in a 35-year-old female. Though noninvasive imaging by echocardiography and doppler has taken the upper hand today, this case illustrates the crucial role of cardiac catheterization in understanding the hemodynamics and patient management of rheumatic multivalvular heart disease.

Spontaneous calcific cerebral embolization revealing a calcified rheumatic mitral stenosis: a case report.

BACKGROUND: Cerebral cardiac embolism accounts for an increasing proportion of ischemic strokes and transient ischemic attacks. Calcified cerebral emboli are rare and mostly iatrogenic secondary to heart or aorta catheterization. However, spontaneous cerebral calcified embolism in the case of calcified aortic valve is very rare and there are less than 10 case reports in the literature. And a more interesting fact is that such an event, in the context of calcified mitral valve disease, has never been reported, at least to our knowledge. We are reporting a case of spontaneous calcified cerebral embolism revealing a calcified rheumatic mitral valve stenosis. CASE PRESENTATION: We report a case of a 59 year-old Moroccan patient, with a history of rheumatic fever at the age of 14 and no history of recent cardiac intervention or aortic/carotid manipulation, who was admitted to the emergency department after a transient ischemic attack. Physical examination at admission found normal blood pressure of 124/79 mmHg and heart rate of 90 bpm. A 12-lead electrocardiogram showed an atrial fibrillation, no other anomalies. Unenhanced cerebral computed tomography imaging was performed, revealing calcified material inside both middle cerebral arteries. Transthoracic echocardiography was performed, showing severe mitral leaflets calcification with a severe mitral stenosis, probably due to rheumatic heart disease. Cervical arteries Duplex was normal. A vitamin K antagonist (acenocoumarol) was prescribed, targeting an international normalized ratio of 2-3 and mitral valve replacement surgery was performed using mechanical prosthesis. Short- and long-term health, with a 1-year follow-up, were good and the patient did not experience any stroke. CONCLUSION: Spontaneous calcified cerebral emboli secondary to mitral valve leaflet calcifications is an extremely rare condition. Replacement of the valve is the only option to prevent recurrent emboli and outcomes are still to be determined.

Medição automática de valva mitral a partir de ecocardiograma utilizando processamento digital de imagens / Automatic measurement of the mitral valve based on echocardiography using digital image processing

Fundamento: A avaliação da área valvar mitral por meio da reconstrução multiplano na ecocardiografia tridimensional é restrita a softwares específicos e à experiência dos ecocardiografistas. Eles precisam selecionar manualmente o frame do vídeo que contenha a área de abertura máxima da valva mitral, dimensão fundamental para a identificação de estenose mitral. Objetivo: Automatizar o processo de determinação da área de abertura máxima da valva mitral, por meio da aplicação de Processamento Digital de Imagens (PDI) em exames de ecocardiograma, desenvolvendo um algoritmo aberto com leitura de vídeo no formato avi. Método: Este estudo piloto observacional transversal foi realizado com vinte e cinco exames diferentes de ecocardiograma, sendo quinze com abertura normal e dez com estenose mitral reumática. Todos os exames foram realizados e disponibilizados por dois especialistas, com autorização do Comitê de Ética em Pesquisa, que utilizaram dois modelos de aparelhos ecocardiográficos: Vivid E95 (GE Healthcare) e Epiq 7 (Philips), com sondas multiplanares transesofágicas. Todos os vídeos em formato avi foram submetidos ao PDI através da técnica de segmentação de imagens. Resultados: As medidas obtidas manualmente por ecocardiografistas experientes e os valores calculados pelo sistema desenvolvido foram comparados utilizando o diagrama de Bland-Altman. Observou-se maior concordância entre valores no intervalo de 0,4 a 2,7 cm². Conclusão: Foi possível determinar automaticamente a área de máxima abertura das valvas mitrais, tanto para os casos advindos da GE quanto da Philips, utilizando apenas um vídeo como dado de entrada. O algoritmo demonstrou economizar tempo nas medições quando comparado com a mensuração habitual. (AU)

Background: The evaluation of mitral valve area through multiplanar reconstruction in 3-dimensional echocardiography is restricted to specific software and to the experience of echocardiographers. They need to manually select the video frame that contains the maximum mitral valve opening area, as this dimension is fundamental to identification of mitral stenosis. Objective: To automate the process of determining the maximum mitral valve opening area, through the application of digital image processing (DIP) in echocardiography tests, developing an open algorithm with video reading in avi format. Method: This cross-sectional observational pilot study was conducted with 25 different echocardiography exams, 15 with normal aperture and 10 with rheumatic mitral stenosis. With the authorization of the Research Ethics Committee, all exams were performed and made available by 2 specialists who used 2 models of echocardiographic devices: Vivid E95 (GE Healthcare) and Epiq 7 (Philips), with multiplanar transesophageal probes. All videos in avi format were submitted to DIP using the image segmentation technique. Results: The measurements obtained manually by experienced echocardiographers and the values calculated by the developed system were compared using a Bland-Altman diagram. There was greater agreement between values in the range from 0.4 to 2.7 cm². Conclusion: It was possible to automatically determine the maximum mitral valve opening area, for cases from both GE and Philips, using only 1 video as input data. The algorithm has been demonstrated to save time on measurements when compared to the usual method. (AU)

Independent Clinical and Echocardiographic Predictors of Restenosis After Percutaneous Mitral Balloon Commissurotomy in a Large, Consecutive Cohort Followed for 24 Years.

OBJECTIVE: To enlighten preprocedural risk factors of mitral valve restenosis in a large, single-center cohort of patients submitted to percutaneous mitral balloon commissurotomy (PMBC) for the treatment of mitral stenosis (MS) secondary to rheumatic heart disease. METHODS: This is a database analysis of a single-center, high-volume tertiary institution involving all consecutive PMBC procedures performed in the mitral valve (MV). Restenosis was diagnosed when MV area was <1.5 cm² and/or loss of 50% or more of the immediate procedural result aligned with the return/worsened symptoms of heart failure. The primary endpoint was to determine the preprocedural independent predictors of restenosis after PMBC. RESULTS: Among a total of 1921 PMBC procedures, 1794 consecutive patients without previous intervention were treated between 1987 and 2010. Throughout 24 years of follow-up, MV restenosis was observed in 483 cases (26%). Mean age was 36 years and most (87%) were female. Median follow-up duration was 9.03 years (interquartile range, 0.33-23.38). Restenosis population, however, presented a significantly lower age at the procedure time as well as a higher Wilkins-Block score. At multivariate analysis, independent preprocedure predictors of restenosis were left atrium diameter (hazard risk [HR], 1.03; 95% confidence interval [CI], 1.02-1.05; P<.04), preprocedure maximum gradient (HR, 1.02; 95% CI, 1.00-1.03; P=.04), and higher Wilkins-Block score (>8) (HR, 1.38; 95% CI, 1.14-1.67; P<.01). CONCLUSIONS: At long-term follow-up, MV restenosis was observed in a quarter of the population undergoing PMBC. Preprocedure echocardiographic findings, including left atrial diameter, maximum MV gradient, and Wilkins-Block score were found to be the only independent predictors.

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.

Split right coronary artery and shepherd's crook course of direct origin of the conal artery: An unhitherto association in a case of rheumatic mitral stenosis.

In a 47-year-old lady, planned for redo percutaneous mitral commissurotomy for recurrent mitral valve stenosis, there was incidental detection of splitting of right coronary artery and direct origin and shepherd's crook course of the conal artery. Though these two anomalies have no hemodynamic significance, correct nomenclature and potential clinical implications have been described.

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

BACKGROUND: As Percutaneous mitral balloon valvotomy (PMBV) remains the keystone in treating mitral stenosis, we conducted this review to elucidate the cumulative frequency and predictors of complications following PMBV and their occurrence in various patient populations. AREAS COVERED: We searched digital databases for relevant studies covering complications of PMBV and retrieved articles using the Medical Subject Heading (MeSH) keywords. EXPERT OPINION: A total of 37 articles (8 RCTs, 7 nonrandomized clinical trials, 22 observational studies) were selected for qualitative analysis. A total of 11,803 patients undergoing PMBV among 37 studies were included, with a mean success rate of 84.54%. The most common complication was mitral regurgitation (8.2%) followed by an atrial septal defect (2.4%). Other relevant complications like stroke, pericardial tamponade, rupture of mitral leaflets, and conduction abnormalities were present in <1% of the patients.

Mitral valve stenosis in the current era: a changing landscape.

Mitral stenosis results from haemodynamic obstruction at the mitral valve level because of structural abnormalities of the valve apparatus, leading to increased resistance to the transmitral flow. Although rheumatic fever remains the predominant cause of mitral stenosis worldwide, other causes are increasingly relevant in the developed countries with degenerative mitral stenosis (DMS) because of mitral annulus calcification (MAC) becoming growingly prevalent in industrialized countries with higher life expectancy. Rheumatic mitral stenosis (RMS) and DMS display dramatic differences in pathophysiology, prognosis, and disease progression. Furthermore, to date, robust evidence regarding the management of DMS because of MAC is lacking. Nevertheless, new diagnostic techniques and catheter-based interventions are changing this landscape and paving the way to a significant reduction in DMS-related morbidity and mortality. Here we briefly review the current knowledge on the pathophysiology, diagnosis and treatment of DMS and RMS, underscoring the current diagnostic and therapeutic pathways, as well as persisting uncertainties and perspectives.

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.

Persistent right heart dilatation after percutaneous mitral balloon valvuloplasty: A weird coexistence of iatrogenic and congenital shunts.

We present an interesting case of concomitant congenital anomalies with an iatrogenic defect. The female patient underwent a percutaneous mitral balloon valvuloplasty due to rheumatic mitral stenosis. Unfortunately, an iatrogenic atrial septal defect (ASD) transpired during the procedure. Upon post-procedure examination, partial anomalous pulmonary venous (PAPVR) return was observed. The patient was symptomatic; on imaging, dilatation of the right heart chambers were detected. In addition, another crucial point was that the patient was planning a pregnancy, thus robotic surgery for iatrogenic ASD and PAPVR return was recommended. After a successful operation, the patient was asymptomatic and the size of right heart chambers were normalized.

Papillary muscle avulsion following balloon mitral valvotomy evaluated with three-dimensional echocardiography.

BACKGROUND: Percutaneous balloon mitral valvotomy is a common therapeutic approach for rheumatic mitral stenosis. Avulsion of the papillary muscle is a rare but serious complication of balloon mitral valvotomy. The papillary muscles are derived from the trabecular layer of the developing ventricular walls. When subjected to a force, avulsion of papillary muscle from the trabecular layer may occur. CASE PRESENTATION: In this case report, we describe a patient with rheumatic mitral stenosis, who experienced avulsion of the mitral papillary muscle from the left ventricular wall after undergoing balloon mitral valvotomy. Papillary muscle alvusion resulted in severe mitral regurgitation, which was finally treated by mitral valve replacement. CONCLUSION: We successfully diagnosed avulsion of the papillary muscle following balloon mitral valvotomy. Three-dimensional transthoracic echocardiography provides more information on mitral apparatus structure than two-dimensional transthoracic echocardiography.

Histopathological evaluation of chronic rheumatic mitral valve stenosis: the association with clinical presentation, pathogenesis, and management at a National Cardiac Institute, Tanzania.

AIMS: The histopathology of mitral valve (MV) tissues have been reported in necropsy and retrospective studies. We prospectively studied the histopathological changes in rheumatic mitral stenosis using advanced techniques and corroborated these with clinical presentation, pathogenesis, and management. METHODS: From January 2020 to February 2021, surgically excised rheumatic stenotic MV from 54 Tanzanian patients were studied. These were examined using hematoxylin-eosin, von Kossa staining, and immunohistochemistry. RESULTS: The median (range) age of patients was 39 (14-57) years with 34 (63%) females. Secondary prophylaxis was given to 7 (13%) patients and 2 (3.7%) had evidence of rheumatic fever (RF). With hematoxylin-eosin, 37 (68.5%) specimens showed fibrinoid degeneration (FD), 44 (81.5%) leucocytic infiltrates, 6 (11.1%) Aschoff nodules, 30 (55.6%) calcification, and 39 (72.2%) fibrosis. Thirty-five (64.8%) specimens were positive to von Kossa. The proportion of specimens positive for CD3, CD20, CD68, and CD8 were 46 (85.2%), 35 (64.8%), 39 (72.2%), and 8 (14.8%) respectively. Valvular calcium was high among older patients, males and with a higher trans-MV gradient. The degree of inflammatory cellular infiltration was associated with valvular calcification, FD with ARF, leucocytic infiltrates with disease duration of <10 years, and fibrosis with the absence of atrial fibrillation. C-reactive protein and anti-streptolysin titres were high in CD20 and CD8 staining cells. CONCLUSION: This study confirms that high MV calcium are found in patients who are old, male, and with severe mitral stenosis. The association between clinical parameters with histopathological-immunohistochemical studies observed in our study provides new insight to disease presentation. We found a low rate of secondary prophylaxis and two patients with ARF. Our findings are comparable with those from other countries suggesting similar pathogenesis and thus intervention modalities. This is the first study on mitral valve histopathology to be reported from Africa.

Flow adjusted transmitral pressure gradient as a modified indicator of functional mitral stenosis after repair for degenerative mitral regurgitation.

BACKGROUND AND AIM: After repair of degenerative mitral regurgitation (DMR), the focus is on functional mitral stenosis (FMS) when there is a decline of mitral hemodynamics. Yet, the clinical impacts and a standardized definition are still undecided. Since common mitral hemodynamic parameters are influenced by transmitral flow, the aim of this study is to seek the impact of flow adjusted transmitral pressure gradient (TMPG) by left ventricular stroke volume (LVSV) on the midterm outcomes. METHODS: Three hundred one patients who had undergone isolated mitral valve repair for degenerative lesions with annuloplasty prosthesis between October 2012 and June 2019 were included. Postoperative adverse events occurred in 20 patients (6.6%). Flow adjusted TMPG was defined as TMPG/LVSV. RESULTS: Common mitral hemodynamic parameters were not associated with adverse events. By multivariable analysis, patients' age, left ventricular ejection fraction (LVEF) and mean TMPG/LVSV were isolated as independent predictors (adjusted hazard ratio: 1.05, 0.95, and 1.16; p = .037, .005, and .035). Flow adjusted TMPG was significantly higher in the full ring group compared to the partial band group (0.051 mmHg/ml, [0.038-0.068] vs. 0.041 mmHg/ml, [0.031-0.056]; p < .001) and had a significantly negative correlation with the size of the annuloplasty prosthesis (r = -0.37, p < .001). CONCLUSIONS: Conventional mitral hemodynamic parameters were not associated with adverse cardiac events after repair for DMR. Adjustment by flow has a potential to advance pressure gradient to a more sensitive indicator of FMS associated with clinical outcomes.