Outcomes of Severe Mitral Stenosis With the Revised Severity Criteria: Mitral Valve Replacement vs Percutaneous Mitral Valvuloplasty.

BACKGROUND: This study aimed to compare the outcomes, according to percutaneous mitral valvuloplasty (PMV) vs mitral valve replacement (MVR), of severe mitral stenosis (MS) with the updated criteria (MVA ≤ 1.5 cm2). METHODS: From the Multicenter Mitral Stenosis With Rheumatic Etiology (MASTER) registry of 3140 patients, we included patients with severe MS who underwent PMV or MVR between January 2000 and December 2021 except for previous valvular surgery/intervention, at least moderate other valvular dysfunction, and thrombus at the left atrium/appendage. Moderately severe MS (MS-MS) and very severe MS (VS-MS) were defined as 1.0 cm2 < MVA ≤ 1.5 cm2 and MVA ≤ 1.0 cm2, respectively. Primary outcomes were a composite of cardiovascular (CV) death and heart failure (HF) hospitalization. Secondary outcomes were a composite of primary outcomes and redo intervention. RESULTS: Among 442 patients (mean 56.5 ±11.9 years, women 77.1%), the MVR group (n = 260) was older, had more comorbidities, higher echoscore, larger left chambers, and higher right ventricular systolic pressure than the PMV group (n = 182). During a mean follow-up of 6.9 ± 5.2 years with inverse probability-weighted matching, primary outcomes did not differ, but the MVR group experienced fewer secondary outcomes (P = 0.010). In subgroup analysis of patients with MS-MS and VS-MS, primary outcomes did not differ. However, the MVR group in patients with VS-MS showed better secondary outcomes (P = 0.012). CONCLUSIONS: PMV or MVR did not influence CV mortality or HF hospitalization in both MS-MS and VS-MS. However, because of increased early redo intervention in the PMV group in VS-MS, MVR would be the preferable option without clear evidence of suitable morphology for PMV.

Stroke risk prediction in patients with atrial fibrillation with and without rheumatic heart disease.

AIMS: Patients with atrial fibrillation (AF) and rheumatic heart disease (RHD), especially mitral stenosis, are assumed to be at high risk of stroke, irrespective of other factors. We aimed to re-evaluate stroke risk factors in a contemporary cohort of AF patients. METHODS AND RESULTS: We analysed data of 15 400 AF patients presenting to an emergency department and who were enrolled in the global RE-LY AF registry, representing 47 countries from all inhabited continents. Follow-up occurred at 1 year after enrolment. A total of 1788 (11.6%) patients had RHD. These patients were younger (51.4±15.7 vs. 67.8±13.6 years), more likely to be female (66.2% vs. 44.7%) and had a lower mean CHA2DS2-VASc score (2.1±1.7 vs. 3.7±2.2) as compared to patients without RHD (all P<0.001). Significant mitral stenosis (average mean transmitral gradient 11.5±6.5 mmHg) was the predominant valve lesion in those with RHD (59.6%). Patients with RHD had a higher baseline rate of anticoagulation use (60.4% vs. 45.2%, P<0.001). Unadjusted stroke rates at 1 year were 2.8% and 4.1% for patients with and without RHD, respectively. The performance of the CHA2DS2-VASc score was modest in both groups [stroke at 1 year, c-statistics 0.69, 95% confidence interval (CI) 0.60-0.78 and 0.63, 95% CI 0.61-0.66, respectively]. In the overall cohort, advanced age, female sex, prior stroke, tobacco use, and non-use of anticoagulation were predictors for stroke (all P<0.05). Mitral stenosis was not associated with stroke risk (adjusted odds ratio 1.07, 95% CI 0.67-1.72, P=0.764). CONCLUSION: The performance of the CHA2DS2-VASc score was modest in AF patients both with and without RHD. In this cohort, moderate-to-severe mitral stenosis was not an independent risk factor for stroke.

Is left atrial fibrosis an independent determinant of atrial fibrillation in mitral stenosis?

We prospectively studied whether left atrial (LA) fibrosis is a determinant of atrial fibrillation (AF) in mitral stenosis in patients who underwent balloon mitral valvotomy. There were 2 groups: Group A (n = 16), with AF and Group B (n = 27), without AF. Fibrosis was assessed by MRI. Patients underwent cardioversion before MRI. There were 27 females and 16 males, aged 29 ± 6 years. The LA areas in Groups A and B were 54.3 ± 4.4 mm2 and 39.4 ± 2.3 mm2 (p < 0.05) and the LA volume index was 46.2 ± 2.9 ml/m2 vs 33 ± 3 ml/m2 respectively (p < 0.0001). The presence of LA scarring was not statistically different in the two groups.

Detecting sub-clinical disease activity in patients with chronic rheumatic valvular heart disease.

OBJECTIVE: Valve disease progression in rheumatic heart disease(RHD) is generally attributed to recurrent attacks of acute rheumatic fever(ARF). However, persistence of chronic sub-clinical inflammation remains a plausible but unproven cause. Non-invasive means to identify sub-clinical inflammation may facilitate research efforts towards understanding its contribution to disease progression. METHODS: Patients with chronic RHD, without clinical evidence of ARF, undergoing elective valve surgery were enrolled. Sub-clinical inflammation was ascertained by histological evaluation of left atrial appendage and valve tissue excised during surgery. We assessed the diagnostic utility of Gallium-67 scintigraphy imaging, and inflammatory biomarkers, hsCRP, IL-2, IL-6, Tumor Necrosis Factor-Alpha(TNF-α), Interferon-gamma(IFN-γ), and Serum Amyloid A(SAA), in identifying patients with sub-clinical inflammation. RESULTS: Of the 93 RHD patients enrolled(mean age 34 ± 11 years, 45% females), 86 were included in final analysis. Sub-clinical inflammation was present in 27 patients(31.4%). Patients with dominant regurgitant lesions were more likely to have sub-clinical inflammation compared to those with stenotic lesions, though this association was not statistically significant(dominant regurgitant lesions vs isolated mitral stenosis: OR 3.5, 95%CI 0.68-17.96, p = 0.133). Inflammatory biomarkers were elevated in the majority of patients: hsCRP, IL-2, IL-6, TNF-α, and IFN-γ in 44%, 89%, 90%, 79%, and 81% patients, respectively. However, there was no significant association between biomarker elevation and histologically ascertained sub-clinical inflammation. Ga-67 imaging was unable to identify inflammation in the 15 patients in whom it was performed. CONCLUSION: Sub-clinical inflammation is common in RHD patients. Conventional inflammatory markers are elevated in the majority, but aren't discriminatory enough to identify the presence of histologic inflammation.

Clinical and echocardiographic trends in percutaneous balloon mitral valvuloplasty.

BACKGROUND: The prevalence of Rheumatic Mitral Stenosis (MS) has significantly changed over the last decades. We intend to examine patient demographics, Echocardiographic characteristics, procedural success rates, and complications throughout 30-years. METHODS: We conducted a single-center descriptive observational study. The study population consists of patients undergone percutaneous balloon mitral valvuloplasty (PBMV) at Emek Medical Center in Israel from January 1990 to May 2019. RESULTS: Four hundred seventeen patients underwent PBMV during the study period and were eligible for the study. Age did not change significantly over time (p = 0.09). The prevalence of Male and patients who were smoking and had multiple comorbidities such as hypertension, dyslipidemia, ischemic heart disease, and chronic kidney disease became increases over time (p = 0.02, p = 0.02, p = 0.001, p = 0.01, p = 0.02, and p = 0.001, respectively). Wilkins score and all its components increased over time, and the total score was higher in females (p = 0.01). Seventy-nine (18.9%) patients had complications. The rate of complications did not change over decades. Patients with Wilkins score > 8, post-procedural MR of ≥2, and post-procedural MVA < 1.5 had the highest risk for the need of Mitral valve replacement (MVR) surgery in 2 years following PBMV (3.64, 4.03, 2.44, respectively, CI 95%, p < .0001 for all). The median time in these patients was 630 days compared to 4-5 years in the entire population. Patients with Post-procedural MR of ≥2 and post-procedural MVA < 1.5 had ten times risk for developing heart failure (HR 9.07 and 10.06, respectively, CI 95%, P < .0001). CONCLUSION: Our research reveals trends over time in patients' characteristics and echocardiographic features. Our study population consists of more male patients with multiple comorbidities and more complex and calcified valvular structures in the last decade. Wilkins score > 8, post-procedural MR of ≥2, and post-procedural MVA < 1.5 cm2 were in-depended predictors for the time for surgery and heart failure hospitalization.

Small Cavity of Left Ventricle Does Not Affect Short-term Outcome in Patients with Rheumatic Mitral Valve Stenosis Undergoing Mitral Valve Replacement.

BACKGROUND: Small cavity left ventricle (SCLV) may affect the clinical outcomes of patients undergoing mitral valve replacement (MVR). This study aims to investigate the incidence of SCLV in patients with rheumatic mitral valve stenosis undergoing MVR and analyze its effect on short-term patient outcomes. METHODS: We retrospectively examined all consecutive patients with isolated or concomitant MVR for rheumatic mitral valve stenosis in our center from 2013 to 2018. SCLV was defined as end-diastolic volume index ≤ 50 ml/m2. After inclusion and exclusion, a total of 1,437 patients were analyzed. The baseline information was collected and compared between SCLV and non-SCLV patients. Multivariate logistic regression analysis was conducted to determine the effect of SCLV on early mortality. RESULTS: A total of 1,437 patients were included in the study. SCLV was detected in 13.57% of the patients. Compared with the non-SCLV group, patients with SCLV were smaller-sized and primarily female. There were no significant differences between SCLV and non-SCLV patients regarding major postoperative complications, nor were there incidence of prosthesis-patient mismatch. Logistic regression analysis showed that SCLV was not a risk factor for short-term mortality (P = 0.998). CONCLUSIONS: Our results demonstrated that SCLV was not associated with poorer early outcomes after MVR surgery in patients with rheumatic mitral valve stenosis.

An Incomplete Form of Shone's Complex With Double Orifice Mitral Valve.

We present the case of an adult male patient with an incomplete form of Shone's complex associated with bicuspid aortic valve and a double orifice mitral valve. Intraoperative inspection of the mitral valve showed double orifice configuration with a small, rudimentary left-sided mitral valve and a large, dominant, right-sided parachute mitral valve with Barlow-type of degeneration. The patient underwent reconstruction of both valves through a minimally invasive incision. At one year echocardiographic control both valves function normally.

Modified Implant Technique of Perceval Sutureless Valve in Congenital Type 0 Bicuspid Valve Stenosis.

The Perceval sutureless valve has gained in popularity for treating degenerative aortic valve stenosis but not for congenital type 0 bicuspid aortic valve owing to anatomic challenges. We modified implant techniques following the four principles of ECHO-an acronym for elasticity, circularity, height, and orientation-to prevent paravalvular leakage and malposition.

Safety and feasibility of same-day discharge after elective percutaneous balloon mitral valvotomy: a prospective, single-center registry in India.

BACKGROUND: Percutaneous mitral balloon valvotomy (PBMV) is an alternative to surgery for patients with severe mitral valve (MV) stenosis. However, the safety and feasibility of same-day discharge (SDD) in patients undergoing elective PBMV for severe MV stenosis is yet to be investigated. This study aimed to assess safety and feasibility of SDD in patients undergoing elective PBMV because of severe MV stenosis in a tertiary-care hospital in India. METHODS: From January 2018 to November 2018, patients with a diagnosis of severe MV stenosis were treated with PBMV at our institution. Among these patients, those suitable for SDD were prospectively included in this registry. Vascular access was achieved in forearm arteries and femoral veins. Clinical, echocardiographic and hemodynamic features were collected before and after PBMV. The primary outcome was 30-day mortality. The secondary outcome was incidence of in-hospital complications. Other outcomes of interest were arterial spasm and forearm haematoma. RESULTS: A total of 98 patients scheduled for SDD after elective PBMV were included in the registry. Mean MV area increased from 0.8 ± 0.1 to 1.6 ± 0.2 cm2 (p < .001). Severe MV regurgitation after PBMV occurred in 3 patients, and 1 patient developed pericardial tamponade. Severe arterial spasm occurred in 2 patients. None of the included patients developed a clinically relevant haematoma of forearm. A total of 94 (96%) were discharged on the same day. No patient died up to 30-day follow-up. CONCLUSION: PBMV from the venous access site can reduce the hospital stay of patients to less than a day with less local site complications.

Severe functional mitral stenosis due to a left atrial myxoma masquerading as asthma.

While cardiac myxomas are the most common primary cardiac tumours, their overall incidence remains rare. Most cases (90%) are sporadic and occur in the third-sixth decades of life with a female predominance and have a specific predilection for the left atrium (75%). While often asymptomatic, clinical presentations depend on the tumour size, architecture and location. Echocardiography remains the mainstay for diagnostic evaluation. Tumour resection is the only definitive treatment. Histopathology using H&E and immunohistochemical stains, such as calretinin and CD34, confirms the diagnosis. We present a case of a patient with reported history of asthma who presented with recurrent acute on chronic shortness of breath refractory to inhaler therapy, multiple outpatient visits and hospitalisations for 'asthma exacerbations'. After further evaluation, she was diagnosed with a left atrial myxoma attached to the inferior aspect of the intra-atrial septum complicated by severe functional mitral stenosis.

Percutaneous Balloon Mitral Valvuloplasty During Antenatal Care and Apgar Score: The ANC-Valve Study.

OBJECTIVES: The present study aimed to evaluate maternal and fetal outcomes in patients who underwent percutaneous balloon mitral valvuloplasty (PBMV) during antenatal care. METHODS: Analysis of 117 pregnant women who underwent PBMV for rheumatic mitral stenosis. Demographic, clinical, echocardiographic, hemodynamic, and Doppler examinations were performed. The pregnant women were stratified according to New York Heart Association classification. Apgar scores were recorded at 1, 5, and 10 minutes to assess the neonatal outcomes. RESULTS: In our study cohort, 74.36% underwent PBMV during their second trimester, at gestational age of 22.49 ± 5.82. Term birth, mode of delivery, birth weight, and Apgar score at 5 minutes were significantly associated with pregnancy and neonatal outcomes. Mitral valve area, mitral valve gradient, and pulmonary artery systolic pressure were significantly improved (P<.001) after PBMV. Pulmonary edema, medical termination of pregnancy, hypothyroidism, hepatitis B infection, pneumonia, and postprocedural delivery, as well as postprocedure severe mitral regurgitation requiring surgery in 2 patients, were the few complications observed. Mean fluoroscopy time was 4 minutes, 50 seconds, with 100% success rate. No maternal mortality was observed. CONCLUSION: PBMV is a safe and effective intervention for mitral stenosis in pregnant women, with favorable maternal and short-term neonatal outcomes. PBMV offers excellent results in terms of symptomatic relief, hemodynamic improvement, and 100% success rate. Hence, it could be regarded as a preferred choice of intervention in managing symptomatic moderate to severe rheumatic mitral stenosis in pregnant women.

Mitral Stenosis After MitraClip: How to Avoid and How to Treat.

PURPOSE OF REVIEW: The goal of the paper is to highlight the importance of procedural planning and patient selection when using the MitraClip device in treating severe mitral regurgitation (MR). RECENT FINDINGS: Following the recent results of the COAPT trial and FDA approval for functional MR patients, the indications for mitral clip are continuing to expand. Because of this, mitral stenosis from mitral clip can become a problem if the appropriate patients are not selected. Proper valve imaging, utilizing 3D transesophageal echocardiography to identify the pathology, is important to prevent iatrogenic mitral stenosis. In the unfortunate event of severe mitral stenosis as a result of the MitraClip device, surgery is the only treatment.

Surgical Melody® valve implantation to replace the mitral valve in children.

In this video tutorial we present our technique for hybrid surgical Melody® valve implantation in the left atrio-ventricular valve (henceforth referred to as mitral valve) position in children. The key steps, including valve preparation, implantation, and balloon dilatation, are depicted. We discuss the short-term outcome, we red-flag potential complications, and we hypothesize medium-term outcomes, including late balloon dilatation.

Intra-atrial Neomitral Ring Creation in the Presence of Severe Mitral Annulus Calcification.

Severe mitral annulus calcifications significantly hinder surgical repair and replacement of the dysfunctional mitral valve. Herein, we present a novel surgical technique where we created an intra-atrial neomitral ring using a vascular Dacron graft in which a prosthetic valve was implanted. This approach is a simple alternative technique that can be used when anatomic prosthetic valve implantation is not feasible. Major assets of this approach are evasion of extensive debridement, implantation of an adequately sized prosthesis, and prosthetic material availability.

Exclusion versus preservation of the left atrial appendage in rheumatic mitral valve surgery.

OBJECTIVES: This study aimed to evaluate the impact of left atrial appendage exclusion on clinical outcomes in patients with atrial fibrillation (AF) undergoing rheumatic mitral surgery. METHODS: We retrospectively reviewed 1226 consecutive patients with AF (54.5±11.6 years; 68.2% females) who underwent rheumatic mitral valve (MV) surgery from 1997 to 2016. The left atrial appendage was preserved in 836 (68.2%) and excluded in 390 (31.8%) patients. Surgical AF ablation was performed in 506 (60.5%) and 304 (77.9%) patients with preserved and excluded left atrial appendage, respectively. For baseline adjustment, propensity matching was used. RESULTS: During a median follow-up of 63.4 months (IQRs, 20-111 months), there were no significant intergroup differences in the risks of mortality (2.77% vs 3.03%/patient-years) and thromboembolic events (0.91% vs 1.02%/patient-years). In the 258 pairs of propensity-score matched patients, death (2.77% vs 3.03%/patient-years) and thromboembolism (1.36% vs 0.82%/patient-years) outcomes were comparable for both groups. In a subgroup undergoing ablation (n=810), there were no significant differences in the adjusted risks of death (HR, 0.67; 95% CI, 0.34 to 1.32) and thromboembolism (HR, 0.47; 95% CI, 0.18 to 1.26). In a subgroup not undergoing ablation (n=416), however, left atrial appendage preservation tended to have higher adjusted risks for death (HR, 2.24; 95% CI, 0.98 to 5.13) and thromboembolism (HR, 4.41; 95% CI, 0.97 to 20.1). CONCLUSIONS: Left atrial appendage preservation did not seem to have greater risks of adverse clinical events in patients with AF undergoing rheumatic MV surgery particularly when ablation procedure is combined.

Minimally Invasive Hybrid Approach to High Risk Mitral Disease With Severe Mitral Annular Calcification.

Severe circumferential mitral annular calcification (MAC) remains a significant challenge, complicating surgical treatment of mitral valve disease. Transcatheter treatment options are attractive; however, they remain fraught with risks of annular fixation, paravalvular leak, atrioventricular-groove disruption, and left-ventricular outflow tract obstruction. We describe a novel minimally invasive hybrid technique of transcatheter mitral valve replacement in a patient with severe circumferential MAC.