Findings from transoesophageal echocardiographic follow-up after mitral transcatheter edge-to-edge repair.

BACKGROUND: Transoesophageal echocardiography (TOE) provides accurate evaluation of mitral valve (MV) function following mitral transcatheter edge-to-edge repair (M-TEER) and may better detect complications in case of suboptimal result. AIMS: We aimed to evaluate midterm anatomical changes and structural complications after M-TEER using TOE and investigate their association with clinical outcomes at 2 years. METHODS: A follow-up TOE at 6 months was systematically recommended to all patients included in our institutional prospective M-TEER registry until December 2021. We assessed changes in the incidence of mitral regurgitation (MR), MV stenosis (≥5 mmHg), and partial or complete single leaflet device attachment (SLDA) between the index procedure and follow-up and evaluated MV area and annular dimensions in a subset of patients with available three-dimensional (3D) datasets. The clinical endpoint was a composite of mortality and heart failure (HF) rehospitalisation at 2 years. RESULTS: Among the 373 patients included in the registry between February 2012 and December 2021, 128 patients (34%) underwent elective TOE at 6 months. Using TOE, severe MR was observed in 13.3% (n=17) of the patients. The number of patients with an elevated MV gradient increased from 17 (13.3%) after the procedure to 23 (18%) at 6 months, and a new partial or complete SLDA was detected in 7.8% (n=10). Based on 3D TOE measurements, significant increases in MV area, annular area, annular perimeter, and intercommissural (but not anteroposterior) diameter were observed compared to intraprocedural images. A mean MV gradient ≥5 mmHg (hazard ratio [HR] 2.30, 95% confidence interval [CI]: 1.10-4.81; p=0.023) and the presence of severe MR at 6 months (HR 3.26, 95% CI: 1.18-8.99; p=0.023) were associated with the primary endpoint, which was met in 34 (26.6%) patients at 2 years. CONCLUSIONS: TOE follow-up allowed the detection of complications that would not be diagnosed using transthoracic echocardiography only and should therefore be used liberally in the patients presenting with a suboptimal result. A mean MV gradient ≥5 mmHg and severe MR, diagnosed at the 6-month TOE follow-up, were associated with adverse clinical outcomes.

Case Report: Post-operative mitral valve replacement complicating with a large cardiac mass and the role of TEE in Imaging.

Background: Postoperative complications are an integral part of valve surgery. Common complications include hematomas, bleeding, valve dehiscence, paravalvular leak, and acute PV thrombosis. With the available data from published articles, the rate of all valve-related complications is 0.7 to 3.5% per patient annually. [1] The pathology involved is multifactorial, often blood vessel injury leading to bleeding and hematoma. Although postoperative complications are evident, incidental diagnosis of a cardiac mass in an asymptomatic and hemodynamically stable patient postoperatively is crucial, requiring non-invasive imaging for immediate surgical action. Case presentation: A woman in her 50s presented with chief complaints of worsening dyspnoea with suddenonset and chest pain. Clinical findings showed apex shifted downward and outward, wide split S2, and a mid systolic murmur radiating to the mid axillary line. Twelve-lead ECG showed LA enlargement, that aligned with X-ray findings. 2D Echocardiography revealed MVP with severe MR and a dilated LV. The patient underwent successful mitral valve replacement as per ACC/AHA class I recommendation. However, postoperative TTE showed a remarkably large mass measuring 5.6 cm*4.6 cm in the RA. Reexploration was performed, followed by mass excision. Plenty of organized clots were seen compressing the RA. TEE showed no evidence of mass. Following stabilization,the patient was discharged considering optimal INR values and prosthetic valve function assessed by echocardiography. The patient's symptoms improved during the first follow-up. Conclusion: Although postoperative cardiac complications are common, appropriate diagnosis with TTE and TEE has benefited surgeons. TEE-guided reexploration aids surgeons in decision-making and strategic approaches. Failure to diagnose such complications in asymptomatic patients can ultimately complicate the procedure. Henceforth, sonographers must be skilled in the detection and identification of unusual complications to guide redo interventions. Such an approach minimizes mortality, redo procedures, and avoids CPB hence reducing long-term prognosis and outcomes with valve replacement.

Geometric Changes in Mitral Valve Apparatus during Long-term Cardiac Resynchronization Therapy as Assessed with Cardiac CT.

Purpose To assess long-term geometric changes of the mitral valve apparatus using cardiac CT in individuals who underwent cardiac resynchronization therapy (CRT). Materials and Methods Participants from a randomized controlled trial with cardiac CT examinations before CRT implantation and at 6 months follow-up (Clinicaltrials.gov identifier NCT01323686) were invited to undergo an additional long-term follow-up cardiac CT examination. The geometry of the mitral valve apparatus, including mitral valve annulus area, A2 leaflet angle, tenting height, and interpapillary muscle distances, were assessed. Geometric changes at the long-term follow-up examination were reported as mean differences (95% CI), and the Pearson correlation test was used to assess correlation between statistically significant geometric changes and left ventricular (LV) volumes and function. Results Thirty participants (mean age, 68 years ± 9 [SD]; 25 male participants) underwent cardiac CT imaging after a median long-term follow-up of 9.0 years (IQR, 8.4-9.4). There were reductions in end-systolic A2 leaflet angle (-4° [95% CI: -7, -2]), end-systolic tenting height (-1 mm [95% CI: -2, -1]), and end-systolic and end-diastolic interpapillary muscle distances (-4 mm [95% CI: -6, -2]) compared with pre-CRT implantation values. The mitral valve annulus area remained unchanged. LV end-diastolic and end-systolic volumes decreased (-68 mL [95% CI: -99, -37] and -67 mL [95% CI: -96, -39], respectively), and LV ejection fraction increased (13% [95% CI: 7, 19]) at the long-term follow-up examination. Changes in interpapillary muscle distances showed moderate to strong correlations with LV volumes (r = 0.42-0.72; P < .05), while A2 leaflet angle and tenting height were not correlated to LV volumes or function. Conclusion Among the various geometric changes in the mitral valve apparatus after long-term CRT, the reduction in interpapillary muscle distances correlated with LV volumes while the reduced A2 leaflet angle and tenting height did not correlate with LV volumes. Keywords: Mitral Valve Apparatus, Cardiac Resynchronization Therapy, Cardiac CT Supplemental material is available for this article. © RSNA, 2024.

Role of Prophylactic N-Acetylcysteine Supplementation on Postoperative Outcomes in Patients Undergoing Elective Double-Valve Replacement (Aortic and Mitral Valve).

AIMS AND OBJECTIVES: The incidence of postoperative liver dysfunction is high in patients undergoing double-valve replacement - mitral and aortic valve replacement (DVR). This study aims to evaluate N-acetylcysteine's free radical scavenging property (NAC) to prevent postoperative liver dysfunction in these patients, thus affecting overall clinical outcomes. METHODS: A single-center, prospective, randomized, double-blinded interventional study of 60 patients divided into two groups of 30 each. Group N received prophylactic intravenous NAC, and Group C received volume-matched 5% dextrose. Data comprised demographics, liver function tests (LFT), renal function tests (RFT), vasoactive-inotropic scores (VIS) score, and C-reactive protein (CRP) at various time intervals. Postoperative parameters such as ventilation duration, length of stay in ICU (LOS-ICU), length of hospital stay (LOHS), atrial fibrillation (AF), acute kidney injury (AKI) requiring hemodialysis, and mortality were noted. Statistical analysis was performed with the Student's t-test and Chi-square test (SPSS 22 software). RESULTS: All postoperative LFT parameters (total bilirubin, serum glutamic oxaloacetic transaminase (SGOT), serum glutamic pyruvate transaminase (SGPT), and alkaline phosphatase (ALP)) were significantly lower (P < 0.05) at 24, 48, and 72 hours in Group N compared to Group C. RFT and VIS scores were lower in Group N; however, were not statistically significant except for Serum Creatinine at 48 hours (P = 0.0478). Ventilation duration (P = 0.0465) and LOS-ICU (P = 0.0431) were significantly lower in Group N. Other outcomes like AF, LOHS, and mortality were lower in Group N but were not statistically significant. CONCLUSION: Our study showed that prophylactic administration of NAC in patients undergoing DVR is associated with a reduction in the incidence of postoperative liver dysfunction with a positive impact on postoperative outcomes.

'Color Doppler stripes' make it difficult to diagnose the severity of valvular heart diseases: a report of two cases.

BACKGROUND: Echocardiography remains the reference-standard imaging technique for assessing valvular heart disease (VHD), but artifacts like the 'color Doppler stripe' can complicate diagnosis. This artifact is not widely recognized and can mimic severe VHD, leading to potential misdiagnoses. We present two cases where color Doppler stripes mimicked severe VHD, highlighting the need for awareness and accurate interpretation in echocardiographic assessments. CASE PRESENTATIONS: Case 1: An 85-year-old patient was referred for mitral valve surgery due to suspected severe mitral regurgitation (MR). Upon evaluation, transthoracic echocardiography (TTE) showed mitral valve prolapse (P3) and a high-echoic, vibrating structure attached to the mitral valve, indicative of chordal rupture. Color Doppler echocardiography revealed strong systolic signals in the left atrium, mimicking severe MR. Transesophageal echocardiography (TEE) also detected the vibrating structure and color Doppler stripes in the left atrium, left ventricle, and outside the cardiac chambers. The PISA method on TEE indicated moderate MR and left ventriculography showed Sellers grade II MR. The artifact was identified as color Doppler stripes caused by the vibrating high-echoic structure from the ruptured chorda. Case 2: A 64-year-old patient with severe aortic stenosis, end-stage kidney disease requiring hemodialysis, and a history of coronary bypass grafting presented for routine follow-up. B-mode echocardiography showed a severely calcified tricuspid aortic valve with a vibrating calcified nodule and restricted opening, corresponding to severe aortic stenosis. During systole, color Doppler signals were observed around the aortic, pulmonary, and tricuspid valves, mimicking significant pulmonary stenosis and tricuspid regurgitation. However, pulmonary stenosis was ruled out as the pulmonary valve opening was normal. Mild tricuspid regurgitation was confirmed in the apical view. CONCLUSIONS: These cases highlight the diagnostic challenges posed by color Doppler stripes. Recognizing and understanding this artifact are crucial for the accurate diagnosis and management of VHD, ensuring appropriate treatment and patient outcomes.

Secondary Mitral Regurgitation: Updated Review with Focus on Percutaneous Interventional Management.

Secondary mitral regurgitation (SMR) is associated with increased mortality and heart failure hospitalizations. The management of heart failure patients with SMR is complex and requires a multidisciplinary Heart Team approach. Guideline-directed medical therapies remain fundamental, yet in a proportion of patients SMR persists. In the past decade, transcatheter edge-to-edge repair (TEER) has been shown to improve survival in patients with SMR who remain symptomatic despite medical therapy. Technical advancements across newer generations of devices, improved imaging, and greater operator expertise have collectively contributed to the increased safety and efficacy of this procedure over time. Various emerging transcatheter mitral valve repair and replacement devices are currently under investigation and may offer superior, complementary or synergistic treatment options in patients ineligible for TEER. This review provides a state-of-the-art overview regarding the diagnosis of SMR, and currently available transcatheter mitral valve interventions and describes a contemporary approach to the management of SMR.

Prediction of Cardiovascular Events and Structural and Functional Remodeling of the Heart in Patients With Severe Mitral Regurgitation of Various Genesis Underwent Transcatheter Mitral Valve Repair "Edge-To-Edge".

AIM: To search for predictors of adverse cardiovascular events after edge-to-edge transcatheter mitral valve repair (TMVR) in patients with severe mitral regurgitation (MR) of various origins with an assessment of structural and functional remodeling of the heart and left ventricular (LV) contractile function. MATERIAL AND METHODS: The study included 73 patients (median age 71 [63; 80] years, 60.3% men) at a high surgical risk with severe MR of primary and secondary genesis, who underwent TMVR. The second-generation (58.9%) and fourth-generation (41.1%) clips were implanted. In addition to standard echocardiographic (EchoCG) indices, the parameters of left heart chamber longitudinal strain and LV myocardial function were assessed at baseline, on days 4-5, and at 6 and 12 months after the intervention. Also, the N-terminal fragment of the pro-brain natriuretic peptide (NT-proBNP) was assessed at baseline and on days 4-5 after TMVR. RESULTS: A significant decrease in MR was achieved during 12 months of follow-up. In the group with primary mitral regurgitation (PMR), MR decreased from 4.0 [3.4; 4.0] to 2.0 [1.5; 2.5] at one year of follow-up (p<0.001). In the group with secondary mitral regurgitation (SMR), MR decreased from 3.5 [3.0; 3.9] to 2.0 [2.0; 2.5] at 12 months of follow-up (p<0.001). This effect was associated with volumetric unloading of the left heart chambers evident as a significant decrease in the volumetric indices of the left chambers and an increase in the cardiac index. In the early postoperative period, the LV function was impaired as shown by decreases in the ejection fraction (EF), global longitudinal strain (GLS), LV myocardial function parameters, and an associated increase in NT-proBNP. By 12 months of follow-up, statistically significant improvements in global constructive work (GCW) and global work index (GWI) relative to baseline values were noted in both groups without significant changes in EF and LV GLS. A strong correlation was found between LV EF and GCW (r=0.812, p<0.001) and GWI (r=0.749, p<0.001). The overall survival was 89%, not differing between groups (p=0.72); the absence of hospitalization for decompensated heart failure (HF) was 79.5%, also without significant differences between the groups (p=0.78). According to multivariate regression analysis, the baseline GCW value was the strongest predictor of rehospitalization for decompensated HF (relative risk (RR) 0.997; 95% confidence interval (CI) 0.995-1.000; p=0.021) and the composite endpoint (CEP) (hospitalization for decompensated HF + all-cause mortality) (RR 0.998; 95% CI 0.996-1.000; p=0.033) in the cohort with PMR. In the group with SMR, the initial degree of MR was related with rehospitalization and the CEP (OR 12.252; 95% CI 2.125-70.651; p=0.005 and OR 16.098; 95% CI 2.944-88.044; p=0.001, respectively). The most significant predictor of overall mortality in the study population was the preoperative value of LV stroke volume (OR 0.824; 95% CI 0.750-0.906; p<0.001). CONCLUSION: Edge-to-edge TMVR exerts a positive effect on the prognosis and structural and functional remodeling of the heart in patients with PMR and SMR. Myocardial function indices may be useful in assessing the LV contractile function in patients with severe MR of various origins. Identification of predictors for adverse cardiovascular events, including with new EchoCG technologies, may contribute to better patient stratification.

Impact of Non-Valvular Atrial Fibrillation on Mitral Valve Anatomic Features: A Study of Three-Dimensional Mitral Valve by Transesophageal Echocardiography and Automatic Analysis Software.

BACKGROUND/AIM: Mitral regurgitation (MR) is frequently observed in non-valvular atrial fibrillation (NVAF) patients and is a significant risk factor for its progression. This study aims to investigate the three-dimensional anatomical characteristics of the mitral valve (MV) in patients with different types of NVAF to elucidate the underlying mechanisms of MR. METHODS: A retrospective analysis was conducted on 82 paroxysmal atrial fibrillation patients (PAF group) and 66 persistent atrial fibrillation patients (PerAF group) who underwent real-time three-dimensional transesophageal echocardiography (RT 3D-TEE) before initial ablation. Additionally, 30 patients undergoing RT 3D-TEE for the assessment of patent foramen ovale were selected as the control group. Basic echocardiographic variables were measured, left atrioventricular volume and strain parameters were calculated using automated software (Dynamic-HeartModel and AutoStrain). MV anatomic features were analyzed using the 4D-MV Assessment software (TomTec Imaging Systems). RESULTS: The maximum left atrial volume (LAVmax) was highest in the PerAF group, followed by the PAF and control groups, with statistically significant differences (p < 0.01). Left atrial reservoir strain (LASr) showed an opposite trend, being the lowest in the PerAF group (p < 0.01). The proportion of moderate to severe MR was significantly higher in the PerAF group (27.3%) compared to the PAF group (11.0%) (p < 0.01). Compared to controls, the AF groups exhibited mitral annular (MA) dilation, flattening of the MA plane, and increased leaflet area (all p < 0.05). Correlation analysis between effective regurgitant orifice area (EROA) and left atrioventricular structure and function parameters, as well as various annular parameters, showed that EROA was significantly correlated with left ventricular end-diastolic volume (LVEDV), LAVmax, LASr, anterior and posterior diameter, annular area, ratio of annular height to commissural diameter (AH/CD ratio), posterior leaflet area, posterior leaflet length, and the C-shaped annulus length (all p < 0.05). CONCLUSIONS: Significant remodeling of the MV apparatus occurs in NVAF patients, with more pronounced changes in PerAF patients, contributing to a higher incidence of moderate to severe MR. RT 3D-TEE-based MV automated assessment offers significant advantages in accurately diagnosing MV remodeling and supporting the evaluation of MR in NVAF patients.

Pregnancy in a Rare and Acquired Mitral Stenosis Different from Rheumatic Mitral Involvement: Mitral Ring Mismatch.

There is an increasing incidence of diagnosing both congenital and acquired heart valve diseases in women during pregnancy. Factors such as elevated rates of pregnancy, older maternal age, and coexisting conditions like diabetes, hypertension, and obesity contribute significantly to the symptomatic manifestation and detection of valvular heart diseases in women planning for pregnancy. Pregnancy induces cardiovascular changes across the maternal physiology, posing a heightened risk of morbidity and mortality, especially in women afflicted with valvular heart diseases. In this article, we present a case of a 25-year-old patient who underwent mitral ring annuloplasty surgery at the age of 9. Her echocardiography revealed a mismatch of the mitral ring during a follow-up examination at the age of 20. Despite neglecting further follow-ups, the patient became pregnant and presented to us at the 6th week of pregnancy. She underwent evaluations at the 6th, 10th, and 22nd weeks of pregnancy, as well as before delivery. Following the resumption of follow-up appointments, intervention planning was initiated during the postpartum period. This case exemplifies successful management, resulting in a healthy delivery after navigating through the pregnancy.

Evaluation of Vitamin K Antagonists Management and Control in Patients with Mechanical Prosthetic Heart Valves during the COVID-19 Pandemic.

BACKGROUND: Patients with mechanical prosthetic heart valves must be treated with vitamin K antagonists (VKA) due to an increased risk of valve thrombosis and systemic embolism. OBJECTIVES: To assess the effects of the COVID-19 pandemic on VKA treatment control in patients with mechanical prosthetic heart valves. METHODS: We conducted a retrospective nationwide cohort study using the Clalit Health Services database. The cohort included patients who underwent either aortic or mitral valve replacement using a prosthetic mechanical valve. The primary outcomes included the overall time in therapeutic range (TTR) and the percent of patients with a TTR < 50% during the first year of the COVID-19 pandemic compared to preceding year. RESULTS: The cohort included 2381 patients. The percentage of patients who had at least two international normalized ratio (INR) tests during the first year of the COVID-19 pandemic was significantly lower compared to the year preceding the pandemic (81% and 87%, respectively, P < 0.001). In both years, the percentage of patients without any documented INR test was high (31.5% in the first COVID-19 pandemic year and 28.9% in the preceding year, P < 0.001). TTR was significantly lower during the 1st year of the COVID-19 pandemic compared to the preceding year (68.1% ± 26 and 69.4% ± 24, P = 0.03). A TTR > 50% was demonstrated in 78% and 81% during the pandemic and the preceding year, P = 0.009. CONCLUSIONS: We noted overall poor VKA control in patients with mechanical heart valves. During the COVID-19 pandemic, VKA control became even worse as reflected by significantly lower TTR and INR tests rates.

Frequency and Outcome of Postoperative Atrial Fibrillation Following Mitral Valve Replacement for Mitral Stenosis.

OBJECTIVE: To determine the frequency and outcome of postoperative atrial fibrillation (POAF) in terms of in-hospital and 30-day mortality and morbidity after mitral valve replacement (MVR). STUDY DESIGN: Observational study. Place and Duration of the Study: Department of Cardiac Surgery, Northwest General Hospital and Research Centre, Peshawar, Pakistan, from September 2017 to March 2023. METHODOLOGY: A total of 186 patients between the ages of 20 and 70 years, who had severe mitral stenosis and normal sinus rhythm and underwent MVR surgery, were included in the study. The frequency of POAF within 7 days following surgery and outcomes in terms of in-hospital and 30-day mortality / morbidity were recorded. RESULTS: POAF occurred in 19.4% patients. Patients with POAF were predominantly male (p = 0.01), aged over 50 years (p = 0.002), diabetic (p = 0.02), hypertensive (p = 0.02), had impaired LV function (p <0.001), enlarged LA (p = 0.003), pulmonary hypertension (p = 0.009), previous PMBV (p <0.001), and previous infective endocarditis (p <0.001). In-hospital and 30-day mortality rates were 7% and 8.6%, respectively. POAF patients had prolonged ICU stays (p <0.001), hospital stays (p = 0.04), and higher mortality rates (p <0.001). Persistent AF (22%) contributed to 30-day morbidity in the form of embolic stroke, limb ischaemia, and congestive heart failure. CONCLUSION: POAF commonly occurs following the MVR surgery and significantly impacts perioperative and 30-day morbidity and mortality. KEY WORDS: Postoperative atrial fibrillation, Mitral stenosis, Mitral valve replacement.

Transmitral Pressure Gradients in Patients With Degenerative Mitral Regurgitation After Robotic Mitral Valve Repair With Leaflet Preservation Techniques.

INTRODUCTION: The hemodynamic effects of mitral valve repair (MVr) with respect to transmitral pressure gradients (TMPGs) have not been described well in patients undergoing leaflet preservation techniques. In a population of patients undergoing robotic MVr with leaflet preservation, we investigate the expected change of the postrepair intraoperative TMPG in the postoperative follow-up period. METHODS: We retrospectively studied 144 adult patients who underwent robotic MVr. Demographic, clinical, procedural, and echocardiographic data were collected and analyzed. RESULTS: We found a slight increase in the mean TMPG from the intraoperative postrepair to the immediate postoperative period (intraoperative 3.3 ± 1.4 mmHg vs. first postoperative transthoracic echocardiography [TTE] follow-up 3.6 ± 1.9 mmHg, p = 0.016) with a gradual decline in the long-term follow-up (mean TMPG at last follow-up TTE 2.4+2.1 mmHg). When dichotomizing the patient population using a cutoff of 3 mmHg for the intraoperative mean TMPG, patients with an intraoperative mean TMPG > 3 mmHg had higher mean TMPG gradients at first TTE (4.5 ± 2.4 vs. 3.1 ± 1.3 mmHg, p < 0.001) as well as at last TTE (3.0± 2.2 vs. 2.1 ± 2.0 mmHg, p = 0.01) when compared with patients with an intraoperative mean TMPG ≤ 3 mmHg. There was no difference in clinical outcomes. CONCLUSIONS: Although the hemodynamic effect of MVr seems to be small, patients with an intraoperative TMPG > 3 mmHg have a higher mean TMPG at follow-up. The hemodynamic effect does not seem to have an impact on clinical outcome.

The effect of pulmonary hypertension and right ventricular dysfunction on early mortality and morbidity in patients undergoing mitral valve replacement.

INTRODUCTION: The indications for concominant tricuspid valve surgery in patients undergoing mitral valve surgery for rheumatic reasons are limited. The aim of our study was to investigate the effects of severe pulmonary hypertension and low TAPSE values on early-term mortality and morbidity in patients undergoing mitral valve replacement. METHODS: The data of all patients who underwent mitral valve replacement between January 2013 and August 2020 were examined retrospectively. Patients were divided into 2 groups according to pulmonary artery pressure (PAP ≥ 50 and PAP < 50). The group with PAP > 50 was then divided into 2 subgroups according to TAPSE (1.5 ≥ or < 1.5) values. The early-term mortality and morbidity rates of these groups were compared. RESULTS: Seventy-nine patients who underwent mitral valve replacement were included in the study. Fifty-four (68%) of them were female, and 25 (32%) were male. During the preoperative period, the TAPSE was 16.8 ± 3.0 mm, and the PAP was 52.1 ± 14.1 mmHg. There were 53 patients with PAP > 50 and 26 patients with PAP < 50. In the PAP > 50 group, the rates of tricuspid regurgitation (p < 0.001), blood transfusion (p < 0.001), intensive care unit stay (p < 0.001), need for CPAP (p = 0.043), reintubation (p = 0.048), acute renal failure (p = 0.028), and mortality (p = 0.026) were found to be significantly different. CONCLUSION: In conclusion, we believe that in patients with mitral valve pathology, early referral for surgical intervention, before the pulmonary pressures significantly increase and right ventricular function deteriorates, can enhance survival outcomes.

[Mid- and long-term outcomes of percutaneous balloon mitral valvuloplasty guided solely by echocardiography].

Objective: To evaluate the mid-and long-term clinical outcomes of percutaneous balloon mitral valvuloplasty (PBMV) guided solely by echocardiography. Methods: A total of 71 patients with moderate to severe mitral stenosis who underwent PBMV guided solely by echocardiography at Fuwai Hospital, Chinese Academy of Medical Sciences, from January 2016 to December 2022 were retrospectively included. The clinical data and follow-up information were collected and analyzed. Results: Finally, 71 patients (11 males and 60 females) aged (48.6±12.4) years, including 3 pregnant women were included. One patient required surgical intervention due to moderate to severe mitral regurgitation, resulting in a procedure success rate of 98.6% (70/71). The procedural duration was (84.1±40.2) minutes, with the balloon diameter of (26.5±1.1) mm and number of dilatations of 2.9±0.7. The mean mitral transvalvular pressure gradient decreased from (12.6±6.1) mmHg (1 mmHg=0.133 kPa) preoperatively to (5.4±2.4) mmHg postoperatively, while the mitral valve orifice area increased from (0.9±0.2) cm² to (1.7±0.3) cm² (both P<0.001). Before discharge, 16 patients developed new mild mitral regurgitation, five developed new moderate mitral regurgitation, and one patient had a small amount of pericardial effusion absorbed by herself. No severe complications such as death, pericardial tamponade, or thromboembolism occurred during the perioperative period. The average follow-up duration was 12-84 (49.7±21.4) months. At two years postoperatively, the mean mitral transvalvular pressure gradient was (6.2±2.5) mmHg, and the mitral valve orifice area was (1.6±0.3) cm². Eight patients underwent surgical mitral valve replacement at an median of [M(Q1, Q3)] 18 (5, 53) months postoperatively, and one patient died during the follow-up period due to non-cardiac reasons. Conclusion: The mid-and long-term outcomes of PBMV guided solely by echocardiography are favorable.

Monoamine Oxidase Contributes to Valvular Oxidative Stress: A Prospective Observational Pilot Study in Patients with Severe Mitral Regurgitation.

Monoamine oxidases (MAOs), mitochondrial enzymes that constantly produce hydrogen peroxide (H2O2) as a byproduct of their activity, have been recently acknowledged as contributors to oxidative stress in cardiometabolic pathologies. The present study aimed to assess whether MAOs are mediators of valvular oxidative stress and interact in vitro with angiotensin 2 (ANG2) to mimic the activation of the renin-angiotensin system. To this aim, valvular tissue samples were harvested from 30 patients diagnosed with severe primary mitral regurgitation and indication for surgical repair. Their reactive oxygen species (ROS) levels were assessed by means of a ferrous oxidation xylenol orange (FOX) assay, while MAO expression was assessed by immune fluorescence (protein) and qRT-PCR (mRNA). The experiments were performed using native valvular tissue acutely incubated or not with angiotensin 2 (ANG2), MAO inhibitors (MAOI) and the angiotensin receptor blocker, irbesartan (Irb). Correlations between oxidative stress and echocardiographic parameters were also analyzed. Ex vivo incubation with ANG2 increased MAO-A and -B expression and ROS generation. The level of valvular oxidative stress was negatively correlated with the left ventricular ejection fraction. MAOI and Irb reduced valvular H2O2. production. In conclusion, both MAO isoforms are expressed in pathological human mitral valves and contribute to local oxidative stress and ventricular functional impairment and can be modulated by the local renin-angiotensin system.

The Role of Global Longitudinal Strain in Predicting Left Ventricular Reverse Remodeling After Mitral Valve Replacement Surgery in Patients With Primary Mitral Regurgitation.

OBJECTIVES: This study aimed to identify the utility of global longitudinal strain (GLS) as a reliable parameter that can accurately forecast left ventricle reverse remodeling (LVRR) in patients undergoing valve replacement surgery for severe chronic primary mitral regurgitation (MR), thereby aiding in assessing mortality and morbidity risk. METHODS: This retrospective observational study involved severe primary MR patients who underwent valve replacement surgery between 2018 and 2023. Pre- and postsurgery echocardiography data were collected, with GLS measurements utilized to assess left ventricular function. Various echocardiography parameters, including MR severity and LV dimensions, were analyzed. Bivariate and multivariate analyses were performed to explore relationships between GLS and LVRR. RESULTS: This study enrolled 103 patients (54.4% male; mean age 45.4 ± 13.6 years). Statistical analyses revealed GLS to be an independent predictor of LVRR, with a threshold of -16.25% showing 89% sensitivity and 50% specificity. Each 1% increase in GLS corresponded to a 1.14-fold (odds ratio [OR]: 1.14; 95% confidence interval [CI]: 1.01-1.31; p < 0.05) increased likelihood of LVRR. CONCLUSION: These findings highlight GLS's potential as a prognostic marker for postsurgical outcomes in severe MR patients.

Closed-chest robotic mitral repair using a semi-rigid ring inserted through a trocar.

There are several types of annuloplasty devices for mitral repair. We present a totally-thoracoscopic robotic mitral repair using a new semi-rigid ring with a nitinol core that makes it malleable so that it can be inserted through a trocar. This technique combines the advantages of semi-rigid rings and a totally-thoracoscopic approach, which may further expand this approach to other aetiologies.

Clinical impacts of concomitant left atrial appendage occlusion during mitral valve surgery in patients with mitral regurgitation.

Surgical occlusion of the left atrial appendage (LAA) during cardiac surgery in patients with atrial fibrillation (AF) is known to reduce thromboembolism. However, data on the clinical significance of LAA occlusion (LAAO) in patients with mitral regurgitation (MR) are lacking. A total of 237 AF patients with chronic severe MR who underwent mitral valve (MV) surgery were retrospectively analyzed. Patients were divided into two groups according to concomitant LAAO or LAA preservation. The primary outcome was a composite of all-cause death and thromboembolic events (ischemic stroke or systemic embolism). The LAA was surgically occluded in 98 (41%) patients and preserved in 139 (59%) patients. During the follow-up period (median, 37 months), 29 primary outcomes occurred. In the Kaplan-Meyer analysis, the LAA preservation group showed a greater cumulative incidence of the primary outcome (P = 0.002) and thromboembolic events (P = 0.003) than the LAAO group. In the univariate Cox regression analysis, coronary artery disease, CHA2DS2-VASc score, a cauliflower-shaped LAA, Maze, and no LAAO were significantly associated with the primary outcome. In the multivariate Cox regression analysis, concomitant LAAO was significantly linked to the primary outcome (hazard ratio [HR]: 0.30, 95% confidence interval [CI]: 0.10-0.91, P = 0.033) and thromboembolic events (HR: 0.19, 95% CI: 0.04-0.87, P = 0.032). These benefits from LAAO were consistent, even after propensity score-matched analysis. For patients undergoing surgery for chronic MR who also have AF, concomitant surgical LAAO is associated with favorable clinical outcome.