Multidisciplinary decision-making in mitral valve disease: the mitral valve heart team.

BACKGROUND: Although decision-making using the heart-team approach is apparently intuitive and has a class I recommendation in most recent guidelines, supportive data is still lacking. The current study aims to demonstrate the individualised clinical pathway for mitral valve disease patients and to evaluate the outcome of all patients referred to the dedicated mitral valve heart team. METHODS: All patients who were evaluated for mitral valve pathology with or without concomitant cardiac disease between 1 January 2016 and 31 December 2016 were prospectively followed and included. Patients were evaluated, and a treatment strategy was determined by the dedicated mitral valve heart team. RESULTS: One hundred and fifty-eight patients were included; 67 patients were treated surgically (isolated and concomitant surgery), 20 by transcatheter interventions and 71 conservatively. Surgically treated patients had a higher 30-day mortality rate (4.4%), which decreased when specified to a dedicated surgeon (1.7%) and in primary, elective cases (0%). This was also observed for major adverse events within 30 days. Residual mitral regurgitation >grade 2 was more frequent in the catheter-based intervention group (23.5%) compared to the surgical group (4.8%). CONCLUSION: In conclusion, the implementation of a multidisciplinary heart team for mitral valve disease is a valuable approach for the selection of patients for different treatment modalities. Our research group will focus on a future comparative study using historical cohorts to prove the potential superiority of the dedicated multidisciplinary heart-team approach.

[Elderly women with abdominal pain due to an incarcerated 'femoral hernia']. / Oudere vrouwen met buikpijn door een beklemde 'dijbreuk'.

Symptoms and findings during physical examination of patients with a femoral hernia are notoriously aspecific. Signs in the inguinal region tend to be overlooked, particularly in obese patients. Three women aged 72, 83 and 68, presented with abdominal pain and ileus due to incarcerated femoral hernias. A correct diagnosis was not considered prior to emergency laparotomy. One progressively septic patient with disseminated breast cancer refused reintervention after successful correction of the femoral hernia, and succumbed. The other two recovered uneventfully. Any older female patient with recurrent abdominal complaints may harbour a femoral hernia. The inguinal region should be examined, if possible in the upright position. Ultrasound, CT or MRI scans should establish the diagnosis. Open or laparoscopic intervention is required in patients fit for surgery since incarceration of a femoral hernia is associated with considerable morbidity and even mortality.

[A patient with vague inguinal complaints due to a leiomyosarcoma of the inferior caval vein]. / Een patiënt met vage liesklachten door een leiomyosarcoom van de v. cava inferior.

A 64-year-old male presented with progressive right-sided inguinal pain radiating to the right flank and lower back. He had noticed an infrequent altered sensibility on frontal parts of his right upper leg. Physical examination demonstrated the presence of a process in the lower abdomen. Computer tomography showed a retroperitoneal tumor with a 10 cm diameter that probably originated from the inferior caval vein (ICV). During an explorative laparotomy a tumor that was compressing the right N. genitofemoralis was radically removed together with the right kidney and the ventral wall of the ICV. The histological diagnosis was a radically removed leiomyosarcoma. Based on the clinical picture, diagnostic imaging and pathologic examination the diagnosis leiomyosarcoma ofthe ICV was confirmed. A leiomyosarcoma of the ICV is a rare tumor with atypical symptomatology and a slow growth rate often leading to a late diagnosis. Surgery is the only effective treatment. The prognosis is moderate.