Exuberant mitral annular calcification.

Mitral annular calcification (MAC) is a chronic, progressive process characterized by calcium deposition on the mitral valve annulus. There is no current grading system to relay the severity of MAC. The primary purpose of this study was to investigate the extreme end of the severity spectrum in order to describe "exuberant mitral annular calcification", and a retrospective chart review of all patients with exuberant mitral annulus calcification evaluated at Mayo Clinic Rochester between January 1996 and December 2014 was performed. This is the first study to define criteria of "exuberant mitral annular calcification", emphasizing the importance of identifying the extreme degree of mitral annular calcification.

Atrial Septostomy as a Bridge to Replace a Thrombosed Mechanical Aortic Valve Requiring Extracorporeal Membrane Oxygenation.

Atrial septostomy is an infrequently used percutaneous technique to decompress either side of the heart. Here, a case is reported of atrial septostomy performed as an emergency 'bridge' procedure in a hemodynamically unstable 62-year-old man with acute mechanical prosthetic aortic valve thrombosis requiring peripheral venoarterial (VA) extracorporeal membrane oxygenation (ECMO). ECMO was placed emergently as the patient suffered cardiac arrest during anesthesia induction for surgical replacement of the thrombosed prosthetic aortic valve. The increased afterload as a result of ECMO, in the setting of severe prosthetic valve dysfunction, led to a marked elevation of the left heart pressures, pulmonary edema and multiorgan dysfunction. A percutaneous atrial septostomy led to a rapid decompression of the left heart by shunting blood to the right atrium, allowing for a marked improvement in the patient's clinical condition. This facilitated the performance of re-do surgery to replace the dysfunctional thrombosed aortic prosthetic valve. Postoperatively, the pulmonary edema resolved completely and the patient achieved full recovery with no residual cardiac symptoms at three months. Video: Gated cardiac CT angiography demonstrating a large thrombus present between the St. Jude Medical mechanical aortic prosthetic leaflets, resulting in severe restriction of leaflet motion.

Coronary Interventions before Liver Transplantation Might Not Avert Postoperative Cardiovascular Events.

Percutaneous coronary intervention and coronary artery bypass grafting may be performed before orthotopic liver transplantation (OLT) to try to improve the condition of patients who have severe ischemic heart disease. However, data supporting improved outcomes are lacking. We reviewed the medical records of 2,010 patients who underwent OLT at our hospital from 2000 through 2010. The 51 patients who underwent coronary artery angiography within 6 months of transplantation were included in this study: 28 had mild coronary artery disease, 10 had moderate disease, and 13 had severe disease. We compared all-cause and cardiac-cause mortality rates. We found a significant difference in cardiac deaths between the groups (P <0.001), but none in all-cause death (P=0.624). Of the 10 patients who had moderate coronary artery disease, one underwent pre-transplant coronary artery bypass grafting. Of 13 patients with severe disease, 3 underwent percutaneous coronary intervention, and 6 underwent coronary artery bypass grafting. Overall, 50% of patients who underwent either intervention died of cardiac-related causes, whereas no patient died of a cardiac-related cause after undergoing neither intervention (P <0.0001). We conclude that, despite coronary intervention, mortality rates remain high in OLT patients who have severe coronary artery disease.

Use of a melody pulmonary valve in transcatheter valve-in-valve replacement for tricuspid valve bioprosthesis degeneration.

Bioprosthetic heart valves can degenerate and fail over time. Repeat surgery as a means of replacement increases morbidity and mortality rates, and some patients are not candidates for reoperation. A newer treatment, percutaneous transcatheter valve-in-valve implantation, might delay or substitute for invasive procedures. We present the case of a 51-year-old woman, a poor candidate for surgery who had prosthetic tricuspid valve degeneration and stenosis. We successfully performed valve-in-valve placement of a Melody(®) valve, using a procedure originally intended to treat pulmonary valve conduit obstruction or regurgitation. To our knowledge, this is among the first case reports to describe the use of the Melody pulmonary valve in transcatheter valve-in-valve replacement for prosthetic tricuspid stenosis that was otherwise not correctable. Additional data and longer follow-up periods are necessary to gain an understanding of ideal indications and selection of patients for the percutaneous transcatheter treatment of tricuspid valve stenosis.

Radiation dose in cardiac imaging: how should it affect clinical decisions?

OBJECTIVE: The purpose of this article is to discuss whether and how the risks of exposure to ionizing radiation should affect clinical decision making in patients with known or suspected cardiovascular disease. CONCLUSION: Although the prevalence of cardiovascular disease and frequency of diagnostic testing has risen dramatically, cardiovascular mortality has declined. Earlier and more accurate detection of cardiovascular disease may play an important role. Concerns regarding excessive radiation exposure from cardiovascular imaging have been raised. Efforts to reduce exposure have included selection of appropriate patients for cardiovascular testing, technologic advances, educational resources, and a directed patient-centered approach to testing.