Quantification of mitral regurgitation by real time three-dimensional color Doppler flow echocardiography pre- and post-percutaneous mitral valve repair.

BACKGROUND: Echocardiographic quantification of mitral regurgitation (MR) can be challenging if the valve geometry is significantly altered. Our aim was to compare the quantification of MR by the recently developed real time three-dimensional (3D) volume color flow Doppler (RT-VCFD) method to the conventional two-dimensional (2D) echocardiographic methods during the MitraClip procedure. METHODS: Twenty-seven patients (mean age 76 ± 8 years, 56% male) were prospectively enrolled and severity of MR was assessed before and after the MitraClip procedure in the operating room by 3 different methods: (1) by integrative visual approach by transesophageal echocardiography, (2) by transthoracic 2D pulsed-wave Doppler-based calculation of aortic stroke volumes (SV) and mitral inflow allowing calculation of regurgitant volume, and (3) by transthoracic 3D RT-VCFD-based calculation of regurgitant volume. RESULTS: We found moderate agreement between the integrative visual approach and the 3D RT-VCFD method for assessment of MR severity before (κ = 0.4, P < 0.05) and after MitraClip (κ = 0.5, P < 0.05). Relevant MR (3+ and 4+) was detected by visual approach in 27/27 and by 3D-VCFD method in 24/27 patients before and in 1 patient by both methods after the MitraClip procedure. In contrast, MR quantification by 2D SV method did not agree with the integrative visual approach or with the 3D RT-VCFD method. CONCLUSIONS: Quantification of MR before and after percutaneous MV repair by 3D RT-VCFD is comparable to the integrative visual assessment and more reliable than the 2D SV method in this small study population. Further automation of 3D RT-VCFD is needed to improve the accuracy of peri-interventional MR quantification.

Midterm outcomes of minimally invasive mitral valve surgery in a heterogeneous valve pathology cohort: respect or resect?

Background: Minimally invasive mitral valve surgery (MIV) through a right lateral thoracotomy has become the standard of care at specialized centers and might soon will be the only acceptable surgical treatment option in the future era of interventional procedures. The aim of our study was to analyze the outcomes of our MIV-specialized, single-center, mixed valve pathology cohort with regard to morbidity, mortality and midterm outcomes comparing two different repair techniques (respect versus resect). Methods: Baseline and operative variables, postoperative outcomes and follow-up information about survival, valve competence and freedom from reoperation were retrospectively collected and analyzed. The repair cohort was divided into three groups (resection, neo-chordae and both) and compared for outcomes. Results: Between July 22nd 2013 and May 31st 2022 a total of 278 consecutive patients underwent MIV. Out of those, we identified 165 eligible patients for the three repair groups: 82 patients (29.5%) had "resection", 66 "neo-chordae" (23.7%) and 17 "both" (6.1%). All preoperative variables were comparable between the groups. The predominant valve pathology of the entire cohort was degenerative disease with 20.5% Barlow's, 20.5% bi-leaflet and 32.4% double segment pathology. Bypass time was 164±47, cross-clamp time 106±36 minutes. All valves planned for repair (85.6%) were successfully repaired except for 13 resulting in a repair rate of 94.5%. Only 1 patient (0.4%) had to be converted to clamshell and 2 (0.7%) needed rethoracotomy for bleeding. Mean intensive care unit (ICU) stay was 1.8 days and hospital stay 10.6±1.3 days. In-hospital mortality was 1.1% and the incidence of stroke (1.8%). All in-hospital outcomes were comparable between the groups. Follow up was complete in 86.2% (n=237) for a mean of 3.7±0.8, up to 9 years. Five-year survival was 92.6% (P=0.5) and freedom from re-intervention 96.5% (P=0.1). All but 10 patients had mitral regurgitation less than grade 2 (95.8%, P=0.2) and all but two had less than New York Heart Association (NYHA) II (99.2%, P=0.1). Conclusions: Despite a heterogeneous cohort with mixed valve pathologies, there is a high reconstruction rate, low short- and midterm morbidity, mortality and need for re-intervention with comparable outcomes of the resect and respect technique in a specialized MIV center.

Propensity Matched Outcomes of Minimally Invasive Mitral Surgery: Does a Heart-Team Approach Eliminate Female Gender as an Independent Risk Factor?

BACKGROUND: There is increasing evidence that female gender is an independent risk factor for cardiac surgery. Minimally invasive mitral surgery (MIV) has proven to have excellent long-term results, but little is known about gender-dependent outcomes. The aim of our study was to analyze our heart team's decision-based MIV-specialized cohort. METHODS: In-hospital and follow-up data were retrospectively collected. The cohort was divided into gender groups and propensity-matched groups. RESULTS: Between 22 July 2013 and 31 December 2022, 302 consecutive patients underwent MIV. Before matching, the total cohort showed that women were older, had a higher EuroSCORE II, were more symptomatic, and had more complex valve pathology and tricuspid regurgitation resulting in more valve replacements and tricuspid repairs. Intensive and hospital stays were longer. In-hospital deaths (n = 3, all women) were comparable, with more atrial fibrillation in women. The median follow-up time was 3.44 (0.008-8.9) years. The ejection fraction, NYHA, and recurrent regurgitation were low and comparable and atrial fibrillation more frequent in women. The calculated 5-year survival and freedom from re-intervention were comparable (p = 0.9 and p = 0.2). Propensity matching compared 101 well-balanced pairs; women still had fewer resections and more atrial fibrillation. During the follow-up, women had a better ejection fraction. The calculated 5-year survival and freedom from re-intervention were comparable (p = 0.3 and p = 0.3). CONCLUSIONS: Despite women being older and sicker, with more complex valve pathology and subsequent replacement, early and mid-term mortality and the need for reoperation were low and comparable before and after propensity matching, which might be the result of the MIV setting combined with our patient-tailored decision-making. We believe that a multidisciplinary heart team approach is crucial to optimize patient outcomes in MIV, and it might also reduce the widely reported increased surgical risk in female patients. Further studies are needed to prove our findings.

Injectable living marrow stromal cell-based autologous tissue engineered heart valves: first experiences with a one-step intervention in primates.

AIMS: A living heart valve with regeneration capacity based on autologous cells and minimally invasive implantation technology would represent a substantial improvement upon contemporary heart valve prostheses. This study investigates the feasibility of injectable, marrow stromal cell-based, autologous, living tissue engineered heart valves (TEHV) generated and implanted in a one-step intervention in non-human primates. METHODS AND RESULTS: Trileaflet heart valves were fabricated from non-woven biodegradable synthetic composite scaffolds and integrated into self-expanding nitinol stents. During the same intervention autologous bone marrow-derived mononuclear cells were harvested, seeded onto the scaffold matrix, and implanted transapically as pulmonary valve replacements into non-human primates (n = 6). The transapical implantations were successful in all animals and the overall procedure time from cell harvest to TEHV implantation was 118 ± 17 min. In vivo functionality assessed by echocardiography revealed preserved valvular structures and adequate functionality up to 4 weeks post implantation. Substantial cellular remodelling and in-growth into the scaffold materials resulted in layered, endothelialized tissues as visualized by histology and immunohistochemistry. Biomechanical analysis showed non-linear stress-strain curves of the leaflets, indicating replacement of the initial biodegradable matrix by living tissue. CONCLUSION: Here, we provide a novel concept demonstrating that heart valve tissue engineering based on a minimally invasive technique for both cell harvest and valve delivery as a one-step intervention is feasible in non-human primates. This innovative approach may overcome the limitations of contemporary surgical and interventional bioprosthetic heart valve prostheses.

Cardiac CT angiography for the diagnosis of mitral valve prolapse: comparison with echocardiography1.

PURPOSE: To evaluate the diagnostic performance of coronary computed tomographic (CT) angiography for the diagnosis of mitral valve prolapse (MVP). MATERIALS AND METHODS: The retrospective case-controlled multicenter study protocol was approved by the institutional review boards. The U.S. part of the study was HIPAA compliant. One hundred twelve patients who underwent electrocardiographically gated 64-section coronary CT angiography (n = 60) or dual-source coronary CT angiography (n = 52) and transthoracic echocardiography (TTE) were included. Fifty-three patients with MVP were matched for age and sex with 59 patients without MVP. CT images were analyzed on three-, two-, and four-chamber (CH) views by two independent observers. MVP was defined as a greater than 2-mm displacement of leaflets below the annulus plane and was subclassified as "billowing" (bowing) or "flail leaflet" (free leaflet margin displacement). Leaflet thickness was measured and defined as thickened if it was greater than 2 mm. RESULTS: The diagnostic performance of CT when three- and two-CH views were combined for the diagnosis of MVP was as follows: sensitivity, 96%; specificity, 93%; positive predictive value (PPV), 93%; and negative predictive value, 96%. On four-CH views, the excursion of billowing was higher than it was on three-CH views (P <.001), and the PPV of the four-CH view for diagnosis of MVP was 89%. The correlation between CT and TTE for excursion of billowing was high (r = 0.80-0.91). In a subset of 32 patients, the agreement between CT and TTE for differentiation of billowing (n = 13) and flail leaflet (n = 2) was 100%. Leaflet thickening was more prevalent in patients with MVP than it was in those without (71% vs 20%, P <.001), and correlation with TTE was good (r = 0.81 [anterior leaflet] and 0.77 [posterior leaflet]). CONCLUSION: The combined use of three- and two-CH views allows an accurate diagnosis of MVP at coronary CT angiography.

How good patient blood management leads to excellent outcomes in Jehovah's witness patients undergoing cardiac surgery.

OBJECTIVES: The refusal of blood products makes open-heart surgery in Jehovah's witnesses (JW) an ethical challenge. We demonstrate how patient blood management strategies lead to excellent surgical outcomes. METHODS: From 2003 to 2008, 16 JW underwent cardiac surgery at our institution. Only senior surgeons performed coronary revascularization (n=6), valve (n=6), combined (n=1) and aortic surgery (n=3) of which two patients presented with acute type-A dissection. Off-pump surgery remained the method of choice for patients requiring a bypass procedure (n=5). Preoperative hematocrit (Hk) and hemoglobin (Hb) were 42.8±4.7% and 14.5±2 g/dl. In three patients with an Hb<12 g/dl, preoperative hematological stimulating treatment was implemented. RESULTS: All patients survived, no major complications occurred and no blood transfusion was administered. The Cell Saver® system (transfused volume: 474±101 ml) and synthetic plasma substitutes [Ringer's Lactate: 873±367 ml and hydroxyethyl starch (HES) 6%: 700±388 ml] were used routinely as well as hemostaticas, such as bone wax, and fibrin glue. The decrease of Hk and Hb appeared to be the lowest after off-pump surgery when compared to all other procedures requiring cardiopulmonary bypass (CPB) (25±9% vs. 33±6%; P=0.01 and 22±9% vs. 31±6%; P=0.04). Similarly, the decrease of platelets was significantly lower (20±12% vs. 43±14%; P=0.01). In the follow-up period (52±34 months), one patient died due to a non-cardiac reason, whereas all others were alive, in good clinical condition and did not have major adverse cardiac events (MACE) or recurrent symptoms requiring re-intervention. CONCLUSION: Patient blood management leads to excellent short- and long-term outcomes in JW. Combined efforts in regard to preoperative hematological parameter optimization, effective volume management and meticulous surgical techniques make this possible but raise the cautionary note why this is only possible in JW patients.

Severe cardiomyopathy following treatment with the tumour necrosis factor-alpha inhibitor adalimumab for Crohn's disease.

Adalimumab belongs to the group of tumour necrosis factor-alpha inhibitors and has been approved for the treatment Crohn's Disease since 2007. Herein we report a severe adverse reaction to adalimumab in a 25-year-old female patient. One week after the initial-dose of adalimumab (160 mg), which was initiated due to an acute exacerbation of Crohn's disease, the patient developed a fulminant cardiomyopathy. In severe cardiogenic shock, the patient required an extracorporeal membrane-oxygenation system for 8 days until cardiac recovery.