Cytokines Removal During Ex-Vivo Lung Perfusion: Initial Clinical Experience.

Ex Vivo Lung Perfusion (EVLP) can be potentially used to manipulate organs and to achieve a proper reconditioning process. During EVLP pro-inflammatory cytokines have been shown to accumulate in perfusate over time and their production is correlated with poor outcomes of the graft. Aim of the present study is to investigate the feasibility and safety of cytokine adsorption during EVLP. From July 2011 to March 2020, 54 EVLP procedures have been carried out, 21 grafts treated with an adsorption system and 33 without. Comparing the grafts perfused during EVLP with or without cytokine adsorption, the use of a filter significantly decreased the levels of IL10 and GCSFat the end of the procedure. Among the 38 transplanted patients, the adsorption group experienced a significant decreased IL6, IL10, MCP1 and GCSF concentrations and deltas compared to the no-adsorption group, with a lower in-hospital mortality (p = 0.03) and 1-year death rate (p = 0.01). This interventional study is the first human experience suggesting the safety and efficacy of a porous polymer beads adsorption device in reducing the level of inflammatory mediators during EVLP. Clinical impact of cytokines reduction during EVLP must be evaluated in further studies.

Minimally Invasive Surgery: Standard of Care for Mitral Valve Endocarditis.

Background. Minimally invasive surgery via right mini-thoracotomy has become the standard of care for the treatment of mitral valve disease worldwide, particularly at high-volume centers. In recent years, the spectrum of indications has progressively shifted and extended to fragile and higher-risk patients, also addressing more complex mitral valve disease and ultimately including patients with native or prosthetic infective endocarditis. The rationale for the adoption of the minimally invasive approach is to minimize surgical trauma, promote an earlier postoperative recovery, and reduce the incidence of surgical wound infection and other nosocomial infections. The aim of this retrospective observational study is to evaluate the effectiveness and the early and late outcome in patients undergoing minimally invasive surgery for mitral valve infective endocarditis. Methods. Prospectively collected data regarding minimally invasive surgery in patients with mitral valve infective endocarditis were entered into a dedicated database for the period between January 2007 and December 2022 and retrospectively analyzed. All comers during the study period underwent a preoperative evaluation based on their clinical history and anatomy for the allocation to the most appropriate surgical strategy. The selection of the mini-thoracotomy approach was primarily driven by a thorough transthoracic and especially transesophageal echocardiographic evaluation, coupled with total body and vascular imaging. Results. During the study period, 92 patients underwent right mini-thoracotomy to treat native (80/92, 87%) or prosthetic (12/92, 13%) mitral valve endocarditis at our institution, representing 5% of the patients undergoing minimally invasive mitral surgery. Twenty-six (28%) patients had undergone previous cardiac operations, whereas 18 (20%) presented preoperatively with complications related to endocarditis, most commonly systemic embolization. Sixty-nine and twenty-three patients, respectively, underwent early surgery (75%) or were operated on after the completion of the targeted antibiotic treatment (25%). A conservative procedure was feasible in 16/80 (20%) patients with native valve endocarditis. Conversion to standard sternotomy was necessary in a single case (1.1%). No cases of intraoperative iatrogenic aortic dissection were reported. Four patients died perioperatively, accounting for a thirty-day mortality of 4.4%. The causes of death were refractory heart or multiorgan failure and/or septic shock. A new onset stroke was observed postoperatively in one case (1.1%). Overall actuarial survival rate at 1 and 5 years after operation was 90.8% and 80.4%, whereas freedom from mitral valve reoperation at 1 and 5 years was 96.3% and 93.2%, respectively. Conclusions. This present study shows good early and long-term results in higher-risk patients undergoing minimally invasive surgery for mitral valve infective endocarditis. Total body, vascular, and echocardiographic screening represent the key points to select the optimal approach and allow for the extension of indications for minimally invasive surgery to sicker patients, including active endocarditis and sepsis.

Is there life on the airway tree? A pilot study of bronchial cell vitality and tissue morphology in the ex vivo lung perfusion (EVLP) era of lung transplantation.

BACKGROUND: Ex vivo lung perfusion (EVLP) is a relevant procedure to increase the lung donor pool but could potentially increase the airway tree ischemic injury risk. METHODS: This study aimed to evaluate the direct effect of EVLP on the airway tree by evaluating bronchial cell vitality and tissue signs of injury on a series of 117 bronchial rings collected from 40 conventional and 19 EVLP-treated lung grafts. Bronchial rings and related scraped bronchial epithelial cells were collected before the EVLP procedure and surgical anastomosis. RESULTS: The preimplantation interval was significantly increased in the EVLP graft group (p < 0.01). Conventional grafts presented cell viability percentages of 47.07 ± 23.41 and 49.65 ± 21.25 in the first and second grafts which did not differ significantly from the EVLP group (first graft 50.54 ± 25.83 and second graft 50.22 ± 20.90 cell viability percentage). No significant differences in terms of histopathological features (edema, inflammatory infiltrate, and mucosa ulceration) were observed comparing conventional and EVLP samples. A comparison of bronchial cell viability and histopathology of EVLP samples retrieved at different time intervals revealed no significant differences. Accordingly, major bronchial complications after lung transplant were not observed in both groups. CONCLUSIONS: Based on these data, we observed that EVLP did not significantly impact bronchial cell vitality and airway tissue preservation nor interfere with bronchial anastomosis healing, further supporting it as a safe and useful procedure.

Chronic postsurgical pain and quality of life after right minithoracotomy mitral valve operations.

OBJECTIVES: Chronic postsurgical pain (CPSP) is a relatively common complication after cardio-thoracic operations with well-known consequences in terms of return to normal activities and quality of life. Little is known about the prevalence and severity of CPSP after minimally invasive cardiac surgery. The aim of this study was to measure the rate of CPSP in patients undergoing right minithoracotomy mitral valve (MV) surgery and to compare the effectiveness of different approaches to pain control. METHODS: A prospective observational study was conducted between March 2019 and September 2020. All patients undergoing right minithoracotomy MV surgery treated with morphine, continuous serratus anterior plane block (SAPB), or continuous erector spinae plane block (ESPB) were included. The Brief Pain Inventory questionnaire was used to evaluate 6-month CPSP and quality of life. RESULTS: A total of 100 patients were enrolled: postoperative pain control was obtained with morphine in 26 cases, with SAPB in 37 cases, and with ESPB in 37 cases. Median intensive care unit and hospital length of stay were 1 day and 6 days, respectively. Pain severity index was lower than 10 in 81 patients, and no differences were recorded between groups (p = .59). No patients reported chronic use of medications for pain management or severe pain interference in daily activities at follow-up. DISCUSSION: Right minithoracotomy approach is not burdened by a high incidence of CPSP: pain severity index was lower than 10 in more than 90% of patients. Then, in our experience, chronic pain seems not to be related to the type of perioperative analgesia adopted.

Antegrade Perfusion for Mini-Thoracotomy Mitral Valve Surgery in Patients with Atherosclerotic Burden.

BACKGROUND: The relationship between retrograde arterial perfusion and stroke in patients with peripheral vascular disease has been widely documented. Antegrade arterial perfusion has been favoured as an alternative approach in less invasive mitral valve (MV) operations. We aimed to analyse our experience in patients with peripheral arterial disease undergoing MV surgery through a right mini-thoracotomy adopting antegrade arterial perfusion. METHOD: A single-institution retrospective study on prospectively collected data was performed on patients undergoing right mini-thoracotomy MV surgery with antegrade arterial perfusion. Since 2009, indication for the latter was dictated by the severity of atherosclerotic burden. Preoperative screening included computed tomography, angiography, or both for the evaluation of the aorta and ileo-femoral arteries. RESULTS: Consecutive patients (n=117) underwent MV surgery through a right mini-thoracotomy with antegrade arterial perfusion, established either by transthoracic central aortic cannulation in 65 (55.6%) cases or by axillary arterial cannulation in 52 (44.4%). Mean logistic EuroSCORE was 11%±2.3%. Twenty-five (25) (21.4%) patients had undergone one or more previous cardiac operations. Operative mortality was 4.3% (n=5). Nonfatal iatrogenic aortic dissection occurred in one case (0.8%). The incidence of stroke was zero. CONCLUSIONS: Axillary or central aortic cannulation is a promising alternative route to provide excellent arterial perfusion in right mini-thoracotomy MV surgery, with a very low incidence of stroke and other major perioperative complications in patients with severe aortic or peripheral arterial disease.

Right mini-thoracotomy approach for grown-up congenital heart disease.

BACKGROUND: Right mini-thoracotomy cardiac surgery has been recognized as a safe and effective procedure, with remarkable early and long-terms outcomes. However, most of the literature is focused on mitral valve surgery and few studies report on the minimally invasive approach applied to congenital disease. Aim of this study was to review our experience on patients with grown-up congenital heart (GUCH) undergoing right mini-thoracotomy cardiac surgery. METHODS: Data of patients with GUCH undergoing right mini-thoracotomy cardiac surgery from 2006 to 2019 were retrospectively analyzed. Inclusion criteria were atrial septal defect, partial anomalous pulmonary venous return, partial atrioventricular septal defect, and mitral or tricuspid valve dysfunction in congenital heart diseases. RESULTS: During the study period 127 patients with GUCH underwent right mini-thoracotomy cardiac surgery. Mean age was 43.6 years and more than 60% were females; diagnosis was atrial septal defect in 57 cases (44.9%); 24 patients were redo (18.9%). No cases of stroke and major vascular complications were reported. Conversion to sternotomy was required in one case (0.8%). No residual shunts or valves dysfunction were recorded at the postoperative echocardiographic evaluation. Perioperative mortality was 1.6%. CONCLUSIONS: Right mini-thoracotomy cardiac surgery in selected patients with GUCH allows to avoid the big scar of the sternotomy approach and to accelerate the recovery in a young population. Moreover, in redo cases, it allows the surgeon to reach the heart and the aorta avoiding the well-known risks of a re-sternotomy procedure.

Violation of prophylactic vancomycin administration timing is a potential risk factor for rate of surgical site infections in cardiac surgery patients: a prospective cohort study.

BACKGROUND: Intensivists and cardiothoracic surgeons are commonly worried about surgical site infections (SSIs) due to increasing length of stay (LOS), costs and mortality. The antimicrobial prophylaxis is one of the most important tools in the prevention of SSIs. The objective of this study was to investigate the relationship between the timing of antimicrobial prophylaxis administration and the rate of SSIs. METHODS: A prospective cohort study was carried out over 1-year period in all consecutive adult patients undergoing elective cardiac surgery. The population was stratified in patients whose antimicrobial prophylaxis administration violated or not the vancomycin timing protocol (i.e., when the first skin incision was performed before the end of vancomycin infusion). To compare SSI rates, the cohort was further stratified in patients at low and high risk of developing SSIs. RESULTS: Over the study period, 1020 consecutive adult patients underwent cardiac surgery and according to study inclusion criteria, 741 patients were prospectively enrolled. A total of 60 SSIs were identified for an overall infection rate of 8.1%. Vancomycin prophylaxis timing protocol was violated in 305 (41%) out of 741 enrolled patients. SSIs were observed in 3% of patients without violation of the antimicrobial prophylaxis protocol (13/436) compared with 15.4% of patients with a violation of the timing protocol (47/305) (P < 0.0001). Patients at low risk with protocol violation had a higher occurrence of SSIs (P = 0.004) and mortality (P = 0.03) versus patients at low risk without protocol violation. Similarly, patients at high risk with protocol violation had a higher occurrence of SSIs (P < 0.001) and mortality (P < 0.001) versus patients at high risk without protocol violation. The logistic regression analysis showed that internal mammary artery use (P = 0.025), surgical time (P < 0.001), intensive care unit (ICU) LOS (P = 0.002), high risk of developing SSIs (P < 0.001) and protocol violation (P < 0.001) were risk factors for SSI occurrence as well as age (P = 0.003), logistic EuroSCORE (P < 0.001), ICU LOS (P < 0.001), mechanical ventilation time (P < 0.001) and protocol violation (P < 0.001) were risk factors for mortality. CONCLUSIONS: This study showed that violation of the timing of prophylactic vancomycin administration significantly increased the probability of SSIs and mortality from infectious cause in cardiac surgery patients.

Peripherally inserted central catheters in non-hospitalized cancer patients: 5-year results of a prospective study.

PURPOSE: Few prospective follow-up studies evaluating the use of peripherally inserted central catheters (PICCs) to deliver chemotherapy and/or home parenteral nutrition (HPN) have focused exclusively on oncology outpatients. The aim of this prospective study was to assess the reliability and the safety of PICCs over a 5-year use in non-hospitalized cancer patients requiring long-term intravenous therapies. METHODS: Since June 2008, all adult oncology outpatient candidates for PICC insertion were consecutively enrolled and the incidence of catheter-related complications was investigated. The follow-up continued until the PICC removal. RESULTS: Two hundred sixty-nine PICCs in 250 patients (98 % with solid malignancies) were studied, for a total of 55,293 catheter days (median dwell time 184 days, range 15-1,384). All patients received HPN and 71 % received chemotherapy during the study period. The incidence of catheter-related bloodstream infections (CRBSIs) was low (0.05 per 1,000 catheter days), PICC-related symptomatic thrombosis was rare (1.1 %; 0.05 per 1,000 catheter days), and mechanical complications were uncommon (13.1 %; 0.63 per 1,000 catheter days). The overall complication rate was 17.5 % (0.85 per 1,000 catheter days) and PICCs were removed because of complications only in 7 % of cases. The main findings of this study were that, if accurately managed, PICCs can be safely used in cancer patients receiving chemotherapy and/or HPN, recording a low incidence of CRBSI, thrombosis, and mechanical complications; a long catheter life span; and a low probability of catheter removal because of complications. CONCLUSIONS: Our study suggests that PICCs can be successfully utilized as safe and long-lasting venous access devices in non-hospitalized cancer patients.

Left main coronary artery ostial repair with autologous ring-shaped aortic patch for iatrogenic aortic dissection.

Iatrogenic left main coronary artery and aortic root dissection are rare complications during coronary catheterization. A case of catheter-induced left main coronary artery dissection with subsequent retrograde progression into the ascending aorta wall is reported. The patient was surgically managed with an ascending aorta replacement and left coronary ostial repair with an autologuos aortic wall ring-shaped patch in the paraostial position in order to seal the intimal tear.

Transapical implantation of an Edwards SAPIEN XT in a degenerated mitral bioprosthesis without fluoroscopic landmarks.

An 84-year-old male with degeneration of a radiolucent mitral bioprosthesis was successfully treated with transapical valve-in-valve implantation exclusively guided by transesophageal echocardiography. The techniques involved in performing this procedure are reviewed.

Clinical Impact of the Endo-aortic Clamp for Redo Mitral Valve Surgery.

Aim of this study was to compare redo MV surgery patients undergoing right mini-thoracotomy and EAC with redo MV patients undergoing surgery through other approaches. Redo MV patients from 7 European centers were analyzed. Primary endpoint was 30-day mortality; secondary endpoints were stroke, re-exploration, low cardiac output syndrome (LCOS), respiratory failure, and intensive care unit (ICU) and in-hospital length-of-stay. Forty-nine patients underwent right mini-thoracotomy and EAC (22.7%), and 167 (77.3%) underwent surgery through other approaches (112 sternotomy, 40 unclamped mini-thoracotomies, and 15 mini-thoracotomies with trans-thoracic clamp). Thirty-day mortality, stroke, re-exploration for bleeding, and weaning failure were comparable. The EAC group showed significant lower rate of LCOS (p = 0.03) and shorter ICU (p = 0.04) and in-hospital length of stay (p = 0.002). The EAC allows the surgeon to reach the aorta, to clamp it, and to deliver the cardioplegia with a "no-touch" technique, with significant improvement in outcomes.

Surgical Treatment for Isolated Tricuspid Valve Disease: A Less Invasive Approach for Better Outcomes.

Background. Severe tricuspid valve (TV) disease has a strong association with right ventricle dysfunction, heart failure and mortality. Nevertheless, surgical indications for isolated TV disease are still uncommon. The purpose of this study is to analyze outcomes of patients undergoing minimally invasive isolated TV surgery (ITVS). Methods. Data of patients undergoing right mini-thoracotomy ITVS were prospectively collected. A subgroup analysis was performed on late referral patients. Five-year survival was assessed using the Kaplan-Meier survival estimate. Results. Eighty-one consecutive patients were enrolled; late referral was recorded in 8 out of 81 (9.9%). No cases of major vascular complications nor of stroke were reported. A 30-day mortality was reported in one patient (1.2%). Five-year Kaplan-Meier survival analysis revealed a significant difference between late referral patients and the control group (p = 0.01); late referral and Euroscore II were found to be significantly associated with reduced mid-term survival (p = 0.005 and p = 0.01, respectively). Conclusions. To date, perioperative mortality in patients undergoing ITVS is still consistently high, even in high-volume, high-experienced centres, and this accounts for the low rate of referral. Results from our report show that, with proper multidisciplinary management, appropriate pre-operative screening, and allocation to the safest approach, ITVS may offer better results than expected.

Intraoperative vancomycin pharmacokinetics in cardiac surgery with or without cardiopulmonary bypass.

BACKGROUND: Vancomycin is administered as antimicrobial prophylaxis to patients undergoing cardiac surgery, an intervention that usually requires cardiopulmonary bypass (CPB). Previous studies reported that CPB modifies vancomycin pharmacokinetic parameters. OBJECTIVE: To investigate intraoperative vancomycin pharmacokinetic changes in a large population of patients undergoing cardiac surgery with CPB (on-pump) and without CPB (off-pump). METHODS: In this prospective study, patients undergoing cardiac surgery received a single dose of vancomycin 1000 mg in a 60-minute intravenous infusion, with skin incision performed between 16 and 120 minutes after the end of the infusion. For the on-pump group, arterial samples were drawn before CPB (end of infusion, skin incision), during CPB (5, 30, and 60 minutes, and then every 60 minutes until CPB end), and after CPB (wound closure). For the off-pump group, arterial samples were drawn time-matched to the CPB period of the on-pump group. RESULTS: Two hundred thirty-six consecutive patients were enrolled: 215 in the on-pump group and 21 in the off-pump group. A total of 1682 serum vancomycin concentrations (median 7/patient) were measured. Vancomycin maximum concentration ([Cmax] on-pump, 45.6 mg/L; off-pump, 47.3 mg/L); area under the concentration-time curve, zero to 8 hours ([AUC0-8] on-pump, 104.6 mg*h/L; off-pump, 96.1 mg*h/L); volume of distribution ([Vd] on-pump, 31 L; off-pump, 28.2 L); and total body clearance ([Cl] on-pump, 6.23 L/h; off-pump, 7.05 L/h) were similar. Moreover, Cmax and AUC0-∞ (AUC, zero to infinity) showed values comparable to those found in previous studies performed on noncardiac surgery patients. CONCLUSIONS: In our study there were no significant differences in vancomycin Cmax, AUC0-8, Vd, and Cl between the on-pump and off-pump groups. CPB does not seem to significantly modify intraoperative vancomycin pharmacokinetics in patients undergoing cardiac surgery. The results of this study may contribute to increased knowledge of vancomycin pharmacokinetics.

Transjugular tricuspid valve-in-valve implantation.

A 60 year-old female underwent tricuspid valve replacement in 2002. Post-operative recovery was complicated by severe post-pericardiotomy-syndrome. Seven years later she underwent transcatheter valve-in-valve implantation through the right jugular vein because of early prosthesis deterioration. Moreover intra-operative transoesophageal echocardiography showed an important right-to-left shunt through the patent foramen ovale that immediately disappeared after the deployment of a 29-mm Sapien-XT. The patient had an immediate and dramatic improvement in day-by-day activities. This case shows that tricuspid valve deterioration can be safely and successfully treated through this approach.

Single-Dose St. Thomas Versus Custodiol® Cardioplegia for Right Mini-thoracotomy Mitral Valve Surgery.

OBJECTIVE: Custodiol® and St. Thomas cardioplegia are widely employed in mini-thoracotomy mitral valve (MV) operations. One-dose of the former provides 3 h of myocardial protection. Conversely, St. Thomas solution is usually reinfused every 30 min and safety of single delivery is unknown. We aimed to compare single-shot St. Thomas versus Custodiol® cardioplegia. METHODS: Primary endpoint of the prospective observational study was cardiac troponin T level at different post-operative time-points. Propensity-weighted treatment served to adjust for confounding factors. RESULTS: Thirty-nine patients receiving St. Thomas were compared with 25 patients receiving Custodiol® cardioplegia; cross-clamping always exceeded 45 min. No differences were found in postoperative markers of myocardial injury. Ventricular fibrillation at the resumption of electric activity was more frequent following Custodiol® cardioplegia (P = .01). CONCLUSION: Effective myocardial protection exceeding 1 h of ischemic arrest can be achieved with a single-dose St. Thomas cardioplegia in selected patients undergoing right mini-thoracotomy MV surgery.

Minimally invasive valve surgery: pushing boundaries over the eighty.

BACKGROUND: Mean age of patients with valves diseases is significantly increasing, and, in the near future, cardiac surgeons will have to deal with a considerable number of patients aged more than 80 years. The remarkable results gained by the minimally invasive approach have encouraged its application in more complex and fragile patients, such as older people. This study aimed to identify the rate of early mortality and major complications, and independent predictors for mid-term mortality in octogenarians undergoing minimally invasive valve surgery. METHODS: Octogenarian patients undergoing right mini-thoracotomy mitral and/or tricuspid valve surgery between 2006 and 2020 were included. Primary endpoint was to identify independent predictors for mid-term mortality, and secondary endpoints were operative morality, stroke, independent predictors for early composite outcome, and quality of life at follow-up. RESULTS: Analysis was performed on 130 patients. Stroke occurred in one patient (0.8%), while operative mortality was 6% (eight patients). One-year and five-year survival were 86% and 64%, respectively. Logistic regression identified age and creatinine level as independent predictors of mid-term mortality, survival analysis showed that age ≥ 84 years and creatinine level ≥ 1.22 mg/dL were the cut-off points for worst prognosis. Female gender and hypertension were found to be independent predictors of early composite outcome. CONCLUSIONS: Results of the present study show that age alone should not be considered a contraindication for minimally invasive valve surgery. Identifying patients who are most likely to have survival and functional benefits after surgery is decisive to achieve optimal health outcomes and prevent futile procedures.

New Echocardiographic Parameters Predicting Successful Trans-Ventricular Beating-Heart Mitral Valve Repair with Neochordae at 3 Years: Monocentric Retrospective Study.

The NeoChord procedure is an echo-guided trans-ventricular beating-heart mitral valve repair technique to treat degenerative mitral regurgitation (MR) due to prolapse and/or flail. The aim of this study is to analyze echocardiographic images to find pre-operative parameters to predict procedural success (≤moderate MR) at 3-year follow-up. Seventy-two consecutive patients with severe MR underwent the NeoChord procedure between 2015 and 2021. MV pre-operative morphological parameters were assessed using 3D transesophageal echocardiography with dedicated software (QLAB, Philips). Three patients died during their hospitalization. The remaining 69 patients were retrospectively analyzed. At follow-up, MR > moderate was found in 17 patients (24.6%). In the univariate analysis, end-systolic annulus area (12.5 ± 2.5 vs. 14.1 ± 2.6 cm2; p = 0.038), end-systolic annulus circumference (13.2 ± 1.2 vs. 14 ± 1.3 cm; p = 0.042), indexed left atrial volume (59 ± 17 vs. 76 ± 7 mL/m2; p = 0.041), and AF (25% vs. 53%; p = 0.042) were lower in the 52 patients with ≤ MR compared to those with > moderate MR. Annular dysfunction parameters were the best predictors of procedural success: 3D early-systolic annulus area (AUC 0.74; p = 0.004), 3D early-systolic annulus circumference (AUC 0.75; p = 0.003), and 3D annulus area fractional change (AUC 0.73; p = 0.035). Patient selection relying on 3D dynamic and static MA dimensions may improve the maintenance of procedural success at follow-up.

Echocardiographic Parameters to Predict Malignant Events in Arrhythmic Mitral Valve Prolapse Population.

Bileaflet Mitral Valve Prolapse (bMVP) has been linked to major arrhythmic events and sudden cardiac death (SCD). Consistent predictors in this field are still lacking. Echocardiography is the best tool for the analysis of the prolapse and its impact on the ventricular mechanics. The aim of this study was to find new echocardiographic predictors of malignant events within an arrhythmic MVP population. We evaluated 22 patients with arrhythmic bMVP with a transthoracic echocardiogram focused on mitral valve anatomy and ventricular contraction. Six of them had major arrhythmic events that required ICD implantation (ICD-MVP group), while sixteen presented with a high arrhythmic burden without major events (A-MVP group). The best predictors of malignant events were the Anterior Mitral Leaflet (AML) greater length and greater Mechanical Dispersion (MD) of basal and mid-ventricular segments, while other significant predictors were the larger mitral valve annulus (MVA) indexed area, lower MVA anteroposterior diameter/AML length ratio, higher inferolateral basal segment S3 velocity.