Corrigendum: Anomalous papillary muscle insertion into the mitral valve leaflet in hypertrophic obstructive cardiomyopathy: a lip nevus sign in echocardiography.

[This corrects the article DOI: 10.3389/fcvm.2023.1292142.].

Anomalous papillary muscle insertion into the mitral valve leaflet in hypertrophic obstructive cardiomyopathy: a lip nevus sign in echocardiography.

Background: Anomalous papillary muscle (APM) insertion into the mitral valve leaflet is rare but clinically important in hypertrophic obstructive cardiomyopathy (HOCM). In this study, we report the detection rate of APM insertion into the mitral valve using preoperative imaging modalities and the surgical outcomes of the patients. Methods: By retrospectively reviewing the clinical records of patients with HOCM who underwent surgical treatment by a single operation group at our center from January 2020 to June 2023, patients with APM insertion into the mitral valve leaflet were identified. Baseline data, image characteristics, and surgical outcomes were analyzed. Results: The incidence of APM insertion into the mitral valve leaflet was 5.1% (8/157). The insertion site was located at A3 in six cases, which was more common than at A2 (n = 2). Preoperative echocardiography was used to identify two patients (25%) with APM insertion. We observed a particular echocardiographic feature for APM in HOCM patients, which was noted as a "lip nevus sign", with a higher detection rate (62.5%). All patients successfully underwent septal myectomy with concomitant APM excision or mitral valve replacement via the transaortic (n = 5) or transmitral (n = 3) approach. The mean age was 49.0 ± 17.4 years and seven patients (87.5%) were female. Interventricular septum thickness (17.0 mm vs. 13.3 mm, P = 0.012) and left ventricular outflow gradient (117.5 mmHg vs. 7.5 mmHg, P = 0.012) were significantly decreased after surgery. Residual outflow obstruction, systolic anterior motion, and ≥3+ mitral regurgitation were negative. During the follow-up of 26.2 ± 12.2 months, there were no reported operations, adverse events, mitral regurgitation aggravations, recurrences of outflow obstruction, or instances of SAM. Conclusions: Papillary muscles inserted into the mitral valve leaflet are a subtype of subvalvular malformation in HOCM that requires surgical correction. The lip nevus sign on echocardiography is a characteristic of APM insertion in HOCM and may improve the preoperative detection rate. Adequate myectomy with anomalous papillary muscle excision has achieved good results in reducing the outflow gradient and eliminating mitral regurgitation, with good outcomes at short-to-intermediate follow-up.

Management of the mitral valve in thoracoscopic trans-mitral myectomy for hypertrophic obstructive cardiomyopathy.

Objective: This study aimed to compare clinical outcomes of different mitral valve (MV) management methods in thoracoscopic transmitral myectomy (TTM) and guide surgeons' decision making for hypertrophic obstructive cardiomyopathy (HOCM). Methods: Seventy-three consecutive patients (41 females; mean age, 53.7 ± 13.6 years) with HOCM who underwent TTM between January 2019 and October 2022 were enrolled and divided into 3 groups according to MV surgical strategy. Clinical outcomes were analyzed and compared among the groups. Results: None of the patients experienced postoperative residual left ventricular outflow tract obstruction. Percentages of patients with mitral regurgitation (MR) grade ≥3+ (57.5% vs 1.4%) and systolic anterior motion (95.9% vs 2.7%) were significantly decreased postoperatively (P < .001 for both). The preoperative anterior mitral leaflet length was longer in patients in the anterior mitral leaflet direct reattachment group (median, 2.9 cm [interquartile range (IQR), 2.7-3.3 cm] vs 2.7 [IQR, 2.4-2.9 cm]; P = .018), but the postoperative coaptation length was shorter (mean, 8.3 ± 2.1 mm vs 11.1 ± 3.8 mm; P = .038). After a median echocardiography follow-up of 11.8 months, the left ventricular outflow tract gradient (LVOTG) and mitral regurgitation grades remained significantly improved in all 3 groups (P < .05 for all). Conclusions: Total TTM in selected patients is safe and effective, and all 3 MV management strategies can significantly reduce the LVOTG while improving MR. Mitral valvuloplasty is the preferred initial management strategy over valve replacement except in the scenario of irreparable intrinsic MV disease and valvuloplasty failure.

Safety and efficacy of two-port thoracoscopic aortic valve replacement.

BACKGROUND: Pure aortic valve disease is common and has been treated with sternotomy aortic valve replacement for decades. Minimally invasive cardiac surgery has been widely used in atrioventricular valve lesions, but totally thoracoscopic aortic valve replacement has rarely been reported. METHOD: The profiles of 9 patients who were diagnosed with severe aortic valve diseases and treated with two-port thoracoscopic aortic valve replacement between February 2021 and February 2022 were retrospectively reviewed. The clinical data, including baseline characteristics, operative data, postoperative complications, and short-term outcomes, were reported. RESULTS: All nine patients successfully underwent two-port thoracoscopic aortic valve replacement, with a cardiopulmonary bypass time of 137.56 ± 27.99 min and an aortic cross-clamp time of 95.33 ± 17.96 min. Seven (77.78%) patients underwent mechanical valve replacement, and two (22.22%) patients underwent bioprosthetic valve replacement. Two (22.22%) patients underwent a concomitant aortic root enlargement procedure. There were no intraoperative or postoperative deaths. The incidence of procedural complications was 0%, while the results of ventilation time, intensive care unit stay length, blood transfusion, chest tube drainage, and kidney function were satisfactory. CONCLUSION: Two-port thoracoscopic aortic valve replacement is a safe and effective surgical treatment option for carefully selected patients with pure aortic valve diseases.

Thoracoscopic trans-mitral myectomy for hypertrophic obstructive cardiomyopathy: a retrospective single-centre study.

OBJECTIVES: Transaortic myectomy is a common procedure for patients with hypertrophic obstructive cardiomyopathy. Thoracoscopic trans-mitral myectomy has been described in a few small-sample studies and has been recommended as preferable. We herein report our clinical outcomes using the thoracoscopic trans-mitral approach with 76 patients. METHODS: This is a retrospective single-centre analysis of the safety and efficacy of thoracoscopic trans-mitral myectomy by comparing the clinical outcomes with that of transaortic myectomy. RESULTS: Between April 2019 and October 2021, 132 patients underwent either a transaortic (n = 56) or a thoracoscopic trans-mitral myectomy (n = 76). Compared with those in the transaortic group, patients in the trans-mitral group were more likely to be weaned off the ventilator within 24 h after surgery (80.3% vs 60.7%, P < 0.05) and to require a shorter duration of ventilation [29.01 (43.91) vs 51.12 (94.96) h, P = 0.08] and lower transfusion rate (26.3% vs 48.2%, P < 0.05). The in-hospital mortality rate of the transaortic and trans-mitral groups was 3.6% (n = 2) and 1.3% (n = 1), respectively. No significant inter-group differences were observed regarding in-hospital mortality, the incidence of low cardiac output syndrome or permanent pacemaker implantations. In the trans-mitral group, the thickness of the interventricular septum was significantly reduced postoperatively, with resultant relief of the left ventricular outflow tract obstruction [89.37 (27.5) vs 10.51 (0.65) mmHg, P < 0.01]. Transaortic myectomy also resulted in a significant reduction in left ventricular outflow tract gradient [90.41 (33.31) vs 11.35 (9.43) mmHg, P < 0.01]. And the incidence of residual systolic anterior motion of the trans-mitral group and the transaortic group was 2.67% and 1.9%, respectively. CONCLUSIONS: The thoracoscopic trans-mitral approach provides excellent exposure to the septum and anomalies of the mitral valve and papillary muscle. It relieves obstruction effectively, without increasing the incidence of major complications.

Primeval outcomes of thoracoscopic transmitral myectomy with anterior mitral leaflet extension for hypertrophic obstructive cardiomyopathy.

BACKGROUND: The transaortic Morrow procedure is the current gold standard for hypertrophic obstructive cardiomyopathy (HOCM) patients who are resistant to maximum drug therapy. It is controversial whether concomitant mitral valve intervention is necessary. Only a few centers apply for concomitant anterior mitral leaflet extension with a bovine or autologous pericardial patch to further decrease systolic anterior motion. Our aim is to assess the primeval outcomes of thoracoscopic transmitral myectomy with anterior mitral leaflet extension (TTM-AMLE) in symptomatic HOCM patients. METHODS: Between April 2019 and November 2020, 18 consecutive HOCM patients who underwent TTM-AMLE were enrolled in this study. Preoperative, postoperative, and follow-up outcomes were compared and statistically analyzed. RESULTS: The mean age was (50.17 ± 6.18) years and 10 (55.56%) were males. 18 (100%) patients had mitral regurgitation preoperatively, and they all successfully underwent TTM-AMLE with a median cardiopulmonary bypass and aortic cross-clamp time of 200.0 (150.8, 232.0), and 127.5 (116.0, 149.0) min, respectively. The median length of ICU stay was 2.7 (1.4, 5.2) days. The interventricular septum thickness was significantly reduced (from 18.03 ± 3.02 mm to 11.91 ± 1.66 mm, p < .001). There was no perioperative mortality, perforation of ventricular septum, or conversion to sternotomy observed. During a median follow-up of 18 months (IQR, 5-24 months), 1 (5.56%) patient had severe mitral regurgitation due to patch detachment and received reoperation. Moderate degree of mitral regurgitation and more than 50 mmHg in left ventricular outflow tract gradient were found in 2 (11.11%), and 1 (5.56%) patients, respectively. 1 (5.56%) patient who had second-degree atrioventricular block received permanent pacemaker implantation postoperatively. Overall, the maximum left ventricular outflow tract gradient (88.50 [59.50, 112.75] mmHg vs. 10.50 [7.00, 15.50] mmHg, p = .002), left ventricular outflow tract velocity (4.70 [3.86, 5.33] m/s vs. 1.60 [1.33, 1.95] m/s, p < .001) and the degree of mitral regurgitation (6.99 ± 4.47 cm2 vs. 2.22 ± 1.51 cm2 , p = .001) were significantly decreased, with a significant reduction in the proportion of systolic anterior motion (94.44% vs. 16.67%, p < .001). CONCLUSIONS: The TTM-AMLE is a safe and effective surgical approach for selected patients with HOCM. In our series, it provides excellent relief of left ventricular outflow tract obstruction, while significantly eliminating mitral regurgitation. The early outcomes of TTM-AMLE are satisfactory, but further studies and longer follow-ups are awaited.

Safety and efficacy of concomitant ablation for atrial fibrillation in rheumatic mitral valve surgery: A meta-analysis.

OBJECTIVES: This review aimed to evaluate the safety and efficacy of concomitant surgical ablation (SA) for patients with atrial fibrillation (AF) undergoing rheumatic mitral valve (MV) surgery. METHODS: A systematic search of relevant studies focusing on SA for patients with AF undergoing rheumatic MV surgery was performed. The primary outcomes included mortality, efficacy, and complications. RESULTS: Four randomized controlled trials (RCTs) and four observational studies covering 1931 patients met the inclusion criteria. In RCTs, no significant differences in reoperation for bleeding, low cardiac output syndrome, thromboembolic events, and early (risk ratio [RR], 2.07; 95% confidence intervals [CI], 0.37-11.40; p = .41) and midterm all-cause death (RR, 1.07; 95% CI, 0.40-2.88; p = .89) were noted between the SA group and the nonablation group. These results were similar to those obtained from observational studies. However, ablation was associated with a higher incidence of permanent pacemaker implantation (RR, 2.44; 95% CI, 1.15-5.18; p = .02) in observational studies but not in RCTs (RR, 2.03; 95% CI, 0.19-21.26; p = .56). Furthermore, additional SA was significantly more effective in sinus rhythm (SR) restoration than MV surgery alone at discharge and at the 12-month and 3-year follow-ups. CONCLUSIONS: Concomitant SA during rheumatic MV surgery does not increase perioperative adverse events. In addition, SA promotes considerable restoration of SR. Although some evidence exists that permanent pacemaker implantation is more common after ablation, not all studies support this notion.

Case report: Thoracoscopic ablation for a patient with atrial fibrillation and persistent left superior vena cava.

Persistent left superior vena cava (PLSVC) is a relatively rare congenital anomaly in the general population. It plays an important role in initiating and maintaining atrial fibrillation (AF) in some patients. Radiofrequency catheter ablation is the major treatment for patients with AF and PLSVC in most publications. Here, we reported a case of thoracoscopic ablation for a patient with atrial fibrillation and persistent left superior vena cava. After preprocedural simulation using virtual reality, we successfully completed box-lesion, ablation line from superior vena cava to inferior vena cava, left atrial appendage (LAA) excision, and PLSVC ablation. It provides a new perspective on surgical treatment for patients with AF and PLSVC.

Misconception contributed to COVID-19 vaccine hesitancy in patients with lung cancer or ground-glass opacity: a cross-sectional study of 324 Chinese patients.

Patients highly vulnerable for COVID-19 infection have been proposed to take priority for vaccination. However, vaccine hesitancy is usually more prevalent in these patients. Investigation around modifiable contributors of vaccine hesitancy plays a pivotal role in the formulation of coping strategies. We aimed to evaluate the impact of vaccine misconception in patients with lung cancer or pulmonary ground-glass opacity (GGO). A web-based questionnaire was constructed based on a qualitative interview with 15 patients and reviewed by a multidisciplinary expert panel. Six Likert five-scale questions were used to generate a score of vaccine misconception (SoVM), which ranged from 0 to 24 points, with a higher score indicating a higher level of misconception. A total of 61.6% (324/526) patients responded to our questionnaire. A higher proportion of low willingness patients (n = 173), compared to high willingness patients (n = 151), disagreed that cancer patients should be prioritized for COVID-19 vaccination (82.1% vs. 50.3%, p < .001) and perceived themselves to have contraindications (45.7% vs. 15.9%, p < .001). The mean SoVM was significantly lower in the high willingness group than the low willingness group (9.9 vs. 13.0, p < .001). Among the unvaccinated patients, the SoVM increased as the willingness to be vaccinated decreased (p < .0001). In multivariable logistic regression, patients with higher SoVM (OR 0.783, 95% CI 0.722-0.848), being female (OR 0.531, 95% CI 0.307-0.918) or diagnosed with lung cancer (OR 0.481, 95% CI 0.284-0.814) were independently associated with a lower willingness to be vaccinated against COVID-19. Receiver operating characteristic curve suggested that a SoVM of 11 yielded the best discrimination for predicting the willingness to receive COVID-19 vaccine (AUC = 0.724). The study findings reveal that patient misconception significantly contributes to vaccine hesitancy and needs to be addressed by evidence-based education tailored to their specific concerns.

Long-term outcomes of a totally thoracoscopic approach for reoperative mitral valve replacement: a propensity score matched analysis.

BACKGROUND: This study aimed to summarize the perioperative and long-term outcomes of patients with previous mitral valve surgery (MVS) undergoing reoperative mitral valve replacement (MVR). METHODS: Data for all reoperative mitral valve replacements (re-MVRs) with or without concomitant tricuspid surgery were analyzed from Guangdong Provincial People's Hospital between January 2013 and December 2019. Propensity score matching resulted in 30 matched pairs with improved balance after matching in baseline covariates. Perioperative data and long-term clinical outcomes were analyzed. RESULTS: Results are based on the matched cohorts between the two groups. The in-hospital mortality was 3.3% (two deaths) in the entire cohort and was not significantly different between the median sternotomy (MS) group and the totally thoracoscopic (TT) group. Most patients in the TT group had their tracheal intubation removed within 24 hours of surgery. The TT group had a diminished requirement for blood transfusion and a reduced 4-day postoperative chest tube drainage amount. The incidence of early major complications, including all-cause death and reoperation due to bleeding, was lower in the TT group. No significant differences were observed in the 7-year survival probability between the two groups. CONCLUSIONS: The encouraging results regarding the perioperative and long-term outcomes of patients who underwent a TT re-MVR show that this approach is particularly beneficial for patients requiring reoperation.

Quadrangular resection versus chordal replacement for degenerative posterior mitral leaflet prolapse.

BACKGROUND: The aims of the present study was to compare midterm results of quadrangular leaflet resection versus chordal replacement for the repair of degenerative posterior mitral leaflet (PML) prolapse, and to explore the risk factors for recurrent severe mitral regurgitation (MR). METHODS: From January 2012 to December 2018, 1,423 consecutive patients underwent mitral valve (MV) repair. A total of 317 had degenerative PML prolapse and constituted the study population. Of these, 74 (23.3%) underwent quadrangular leaflet resection, and 243 (76.7%) underwent chordal replacement. Outcomes were compared by using unadjusted data and propensity score-matched analyses. RESULTS: Patients with multiple leaflet prolapse were more likely to undergo chordal replacement (18.4% vs. 41.9%, P<0.001), and performed as a minimally invasive approach (47.3% vs. 61.7%, P=0.027). Of the entire cohort, 1 death (0.3%) occurred due to intraoperative aortic dissection, and 1 patient who had undergone chordal replacement required reoperation before discharge for posterior leaflet tearing. There was no significant difference in the probability of freedom from recurrent severe MR at 82 months between the resection and neochordae groups in both the pre-matched (95.6% vs. 88.8%, P=0.105) and matched (95.2% vs. 88.5%, P=0.170) cohorts, which was consistent across all of the examined subgroups (P>0.05). Multivariate Cox regression indicated that dilated left ventricular end-systolic diameter (LVESD) was an independent risk factor for recurrent severe MR [<40 vs. >40 mm, hazards ratio (HR): 3.17, 95% confidence interval (CI): 1.20-8.39, P=0.020]; however, surgical technique was not (resection vs. neochordae, HR: 0.31, 95% CI: 0.07-1.37, P=0.122). CONCLUSIONS: Chordal replacement for the repair of degenerative posterior MV prolapse yields similar satisfactory outcomes when compared with quadrangular resection, and is promising in minimally invasive cardiac surgery for various lesions. However, it is also associated with more recurrent severe MR, albeit non-significant, for which patients with dilated LVESD are at high risk.