Mid-term outcomes of surgical aortic valve replacement using a mosaic porcine bioprosthesis with concomitant mitral valve repair.

This study retrospectively evaluated the mid-term outcomes of surgical aortic valve replacement (SAVR) using a stented porcine aortic valve bioprosthesis (Mosaic; Medtronic Inc., Minneapolis, MN, USA) with concomitant mitral valve (MV) repair. From 1999 to 2014, 157 patients (median [interquartile range] age, 75 [70-79] years; 47% women) underwent SAVR with concomitant MV repair (SAVR + MV repair), and 1045 patients (median [interquartile range] age, 76 [70-80] years; 54% women) underwent SAVR only at 10 centers in Japan as part of the long-term multicenter Japan Mosaic valve (J-MOVE) study. The 5-year overall survival rate was 81.5% ± 4.1% in the SAVR + MV repair group and 85.1% ± 1.4% in the SAVR only group, and the 8-year overall survival rates were 75.2% ± 5.7% and 78.1% ± 2.1%, respectively. Cox proportional hazards analysis showed no significant difference in the survival rates between the two groups (hazard ratio, 0.87; 95% confidence interval, 0.54-1.40; P = 0.576). Among women with mild or moderate mitral regurgitation who were not receiving dialysis, those who underwent SAVR + MV repair, were aged > 75 years, and had a preoperative left ventricular ejection fraction of 30-75% tended to have a lower mortality risk. In conclusion, this subgroup analysis of the J-MOVE cohort showed relevant mid-term outcomes after SAVR + MV repair.

Long-Term Outcomes of the Mosaic Mitral Porcine Bioprosthesis in Japan　- Results From the Japan Mosaic Valve Long-Term Multicenter Study.

BACKGROUND: This study retrospectively evaluated the long-term patient outcomes and durability of the Mosaic mitral porcine bioprosthesis in the Japan Mosaic valve long-term multicenter study.Methods and Results:The medical records of 390 patients who underwent mitral valve replacement with the Mosaic bioprosthesis at 10 centers in Japan (1999-2014) were reviewed. Patient data were collected using the Research Electronic Data Capture software. Patient survival was determined using the Kaplan-Meier method. Freedom from structural valve deterioration (SVD) and valve-related reoperation and death were determined using actuarial methods. The median (interquartile range [IQR]) age of the cohort was 73 (69-77) years. The median (IQR) follow-up period was 4.83 (1.84-8.26) years. The longest follow-up period was 15.8 years. The 30-day mortality rate was 5.4%. The 12-year actuarial survival rate was 54.1±4.5%, and the freedom from valve-related death was 85.3±3.4%. The freedom from reoperation at 12 years was 74.3±5.7%. The freedom from SVD at 12 years was 81.4±6.6% for patients aged ≥65 years and 71.6±11.1% for those aged <65 years. The median (IQR) mean pressure gradient was 4.1 (3.0-6.0) and 5.6 (4.0-6.7) mmHg at 1 and 10 years, respectively. The median (IQR) effective orifice area was 1.7 (1.4-2.0) and 1.4 (1.2-1.6) cm2at 1 and 10 years, respectively. CONCLUSIONS: The Mosaic porcine bioprosthesis offered satisfactory long-term outcomes for up to 12 years.

Long-Term Outcomes of the Mosaic Aortic Porcine Bioprosthesis in Japan　- Results From the Japan Mosaic Valve Long-Term Multicenter Study.

BACKGROUND: This study retrospectively evaluated the long-term patient outcomes and durability of the Mosaic aortic porcine bioprosthesis in the Japan Mosaic valve long-term multicenter study.Methods and Results:We reviewed the records of 1,202 patients who underwent aortic valve replacement with the Mosaic bioprosthesis at 10 centers in Japan (1999-2014). Patient data were collected using Research Electronic Data Capture. Patient survival was determined by Kaplan-Meier methodology. Freedom from structural valve deterioration (SVD) and valve-related reoperation and death were determined by actuarial methods. The median (interquartile range [IQR]) age of the cohort was 76 (70-80) years. The median (IQR) follow-up period was 3.52 (1.71-5.35) years. The longest follow-up was 15.8 years. The 30-day mortality rate was 2.3%. The 12-year actuarial survival rate was 59.9±7.5%, and the freedom from valve-related death was 81.1±7.9%. The freedom from reoperation was 86.4±2.6% at 12 years. The freedom from SVD at 12 years was 93.5±2.9% for patients aged ≥65 years and 98.2±1.8% for those aged <65 years. The median (IQR) systolic pressure gradient was 17 (12-23) and 19 (12-25) mmHg at 1 and 10 years, respectively. The median (IQR) effective orifice area was 1.2 (1.1-1.5) and 1.1 (1-1.5) cm2at 1 and 10 years, respectively. CONCLUSIONS: The Mosaic porcine bioprosthesis showed satisfactory long-term outcomes over 12 years.

A rare cardiac tumor: Bronchogenic cyst of interatrial septum.

Intracardiac bronchogenic cysts are uncommon congenital tumors, which rarely become symptomatic. We describe a rare case of bronchogenic cyst in the atrioventricular node. A 36-year-old man with third-degree atrioventricular block was referred to our hospital. Transthoracic echocardiography revealed a cystic mass at the right atrial aspect of the low interatrial septum. He underwent surgical resection of the mass, and a permanent epicardium pacemaker was implanted. His postoperative course was uneventful. Microscopic examination showed a cyst surrounded by ciliated columnar epithelium and partially smooth muscle, and the histopathological diagnosis was bronchogenic cyst.

[Early Postoperative Hemodynamics of Mitral Valvuloplasty Using Colvin-Galloway Future Band].

The Colvin-Galloway( CG) Future annuloplasty band is a new semirigid partial band, which was introduced in 2012 in Japan. A total of 60 consecutive patients who underwent mitral valve repair with the CG Future Band were assessed by echocardiography in terms of residual mitral regurgitation and diastolic mitral function postoperatively. Intraoperative 3-dimensional echocardiography beautifully demonstrated the physiological change of the aortic curtain during the cardiac cycle. 30 mm was used in 18 patients, 32 mm in 17, 28 mm in 15, 34 mm in 5, 36 mm in 2, and 26 mm in 2. There were 2 patients with mild residual mitral regurgitation and 58 patients with less than mild. The mean gradient of diastolic mitral pressure gradient was 2.8±1.3 mmHg. Early results of mitral valve repair with a CG Future Band were acceptable in terms of residual mitral regurgitation and diastolic mitral function after repair.

Re-Repair of Tricuspid Valve after Tricuspid Suture Annuloplasty: An Analysis of the Causes for Reoperation and its Durability.

BACKGROUND: The outcomes of re-repair of the tricuspid valve to treat recurrent tricuspid regurgitation (TR) after tricuspid valve suture surgery were analyzed. METHODS: Thirty-six patients (mean age 65.3 ± 9.3 years) who underwent re-repair of the tricuspid valve to treat recurrent TR between January 1990 and November 2014 were reviewed retrospectively. All patients underwent suture annuloplasty for TR. Of these 36 patients, 15 (41.7%) underwent ring annuloplasty and 21 (58.3%) underwent re-suture annuloplasty. The mean follow up period was 5.8 ± 6.1 years. RESULTS: The overall hospital mortality rate was 13.9% (5/36). Pre-discharge TR grades were 1.2 ± 0.7 in the ring group and 1.4 ± 0.8 in the re-suture group (p = 0.7353). There were no significant differences in survival, freedom from late TR and freedom from valve-related events between the two groups. At the final follow up, TR >mild was present in four patients (36.4%) in the ring group, and in 12 patients (75%) in the re-suture group (p = 0.0447). Severe TR was present in five patients (31.3%) in the re-suture group, but none was present in the ring group (p = 0.2445). CONCLUSIONS: In the present study cohort, the durability of re-repair of the tricuspid valve using a flexible prosthesis appeared to be superior to the durability following re-suture annuloplasty.

Late outcome of tricuspid annuloplasty using a flexible band/ring for functional tricuspid regurgitation.

BACKGROUND: We assessed late outcome after tricuspid annuloplasty (TAP) using a flexible band or ring for functional tricuspid regurgitation (FTR). METHODS AND RESULTS: We reviewed 220 consecutive patients (mean age, 65.4±11.4 years) who underwent TAP for FTR during mitral valve surgery between January 2000 and December 2010. Indications for TAP included the following: (1) TR grade greater than mild; (2) history of right heart failure; (3) atrial fibrillation; and (4) systolic pulmonary artery pressure (SPAP) ≥50 mmHg. The mean follow-up period was 4.4±2.6 years. Overall hospital mortality was 5.5% (12/220). The 5- and 10-year survival rates were 90.2±2.1% and 82.4±5.6%, respectively. Freedom from recurrent TR at 8 years was 78.0±6.6%. Twenty patients had a greater than mild TR grade at final follow-up. Elevated SPAP was a predictor of recurrent TR (hazard ratio, 1.091; P=0.0003), which was associated with advanced age, atrial fibrillation, rheumatic etiology and preoperative TR grade. There was a significant difference in freedom from valve-related events between residual TR greater than mild and less than moderate (log-rank test, P=0.0464). Factors affecting residual TR were preoperative TR grade (OR, 7.368; P=0.0267) and mitral valve replacement (OR, 4.369; P=0.0402). CONCLUSIONS: Late outcome of TAP in the present series was acceptable. Late outcome can be improved by performing TAP before deterioration of TR.

In vivo assessment of novel stentless valve in the mitral position.

BACKGROUND: We conducted in vivo examinations of a newly designed stentless mitral valve (SMV), formed by suturing 2 leaflets with the "legs" serving as chorda tendinea, made from bovine pericardium, to a flexible ring. METHODS AND RESULTS: Seven pigs underwent implantation of the SMV constructed with a 23-mm (n=5) or 25-mm (n=2) Duran ring. Baseline echocardiography examinations were used to evaluate the annular anteroposterior diameter, and distance between the mitral annulus (MA) and papillary muscles (PMs) to determine SMV-leg length. After removing the native valve, the SMV-legs were fixed to the anterior and posterior PMs, followed by fixation of the ring to the native MA. Immediately after surgery, all animals presented none or trivial mitral regurgitation, with mean and peak trans-SMV pressure gradient values of 1.9±0.8 and 6.0±3.1 mmHg, respectively. The mean length of the SMV-leg was 19.4±3.9 mm, which correlated with the distance between anterior and posterior MA-PM (r=0.96 and 0.94, respectively, P<0.01 for both). The discrepancy between the anteroposterior diameter of the ring (outside diameter) and that of the native valve was 1.0±2.9 mm, which correlated with the trans-SMV pressure gradient (r=0.81, P=0.025). CONCLUSIONS: In our preliminary study, the SMV demonstrated excellent diastolic inflow dynamics and closing function in vivo. Preoperative precise assessment of MV configuration may serve as a basis for selection of appropriate ring size and SMV-leg length.

Trans-Septal Approach for Hypertrophic Obstructive Cardiomyopathy.

Transaortic septal myectomy, known as Morrow's procedure, is a standard treatment for hypertrophic obstructive cardiomyopathy (HOCM). The case is described of a 58-year-old male patient who suffered a repetition of syncope due to HOCM, in whom septal myectomy was performed. As resection of the hypertrophied septum using Morrow's procedure was considered insufficient by palpation to release mitral regurgitation (MR) and systolic anterior motion of the mitral valve, the surgical approach was changed such that the right ventricular outflow tract and ventricular septum was incised. The residual hypertrophied septum was successfully resected to the base of the anterior papillary muscle under direct vision. Postoperative echocardiography demonstrated a dramatic improvement in the MR and left ventricular outflow tract obstruction. The patient's postoperative course was good, with cibenzoline and calcium channel blocker therapy stopped and beta-blocker therapy reduced after surgery. If resection of the hypertrophied septum using Morrow's procedure is considered insufficient, a trans-septal approach represents an adequate option to treat HOCM.

Efficacy of Stentless Aortic Bioprosthesis Implantation for Aortic Stenosis with Small Aortic Annulus.

BACKGROUND: In patients with small aortic annulus, sufficient size of stented aortic bioprosthesis cannot be implanted without additional procedures. In such cases, we use stentless aortic bioprosthesis to obtain sufficient effective orifice area. In this study, we investigated long-term impact of stentless aortic bioprosthesis on clinical outcomes, compared with stented aortic bioprosthesis. MATERIALS AND METHODS: We retrospectively investigated 140 patients who underwent aortic valve replacement (AVR) with porcine bioprosthesis for severe aortic stenosis between 1999 and 2010. Patients who had moderate or more aortic regurgitation and who underwent concomitant mitral procedures were excluded. A total of 69 patients (49%) were implanted stentless bioprosthesis (Freestyle group; Medtronic Inc, Minneapolis, Minnesota, United States) and 71 patients (51%) were implanted stented bioprosthesis (Mosaic group; Medtronic Inc). Follow-up was complete in 97.9% patients. Median follow-up period was 4.2 years. RESULTS: Patients in Freestyle group had smaller body surface area, smaller aortic annulus diameter, smaller aortic valve area, larger mean pressure gradient, higher peak velocity across aortic valve, larger left ventricular mass index (LVMI), and lower left ventricular ejection fraction (LVEF). Mean size of implanted prosthesis was larger in Freestyle group. In-hospital mortality was 1.4% in Freestyle group and 2.8% in Mosaic group (p = 0.980). Five-year survival rate was not different between two groups (5-year survival rate was 87.5 ± 4.7% in Freestyle group and 84.1 ± 7.5% in Mosaic group; log rank, p = 0.619). Late New York Heart Association functional class was lower in Freestyle group. Late LVMI and LVEF became similar between two groups. CONCLUSION: Stentless aortic bioprosthesis is superior in left ventricular remodeling after AVR for aortic stenosis and is especially effective for small aortic annulus.

Long-term outcomes after mitral valve repair for degenerative mitral regurgitation with persistent atrial fibrillation.

BACKGROUND: Atrial fibrillation (AF) adversely affects surgical outcomes of mitral valve surgery. However, the long-term impact of Maze procedure has not been clear yet. PATIENTS AND METHODS: We retrospectively investigated 159 patients who underwent mitral valve repair for degenerative mitral regurgitation with persistent AF between 1991 and 2010. The mean age of patients was 63.1 ± 10.5 years. After we started performing Maze procedure in 2002, 65 patients underwent concomitant Maze procedure. The median follow-up time was 7.5 years. RESULTS: There was one operative death (0.63%). The overall survival rate was 91.0 ± 2.6% at 5 years and 79.1 ± 4.7% at 10 years. Survival was significantly better in patients who underwent Maze procedure than those who did not. The rate of freedom from AF in patients who underwent Maze procedure was 86.4 ± 4.5% at 1 year and 81.1 ± 5.6% at 5 years. The freedom rate from stroke was higher in patients who underwent Maze procedure than those who did not. Patients with postoperative AF had larger left ventricular systolic and diastolic diameters at follow-up and higher New York Heart Association functional class than patients without postoperative AF (1.4 ± 0.5 vs. 1.1 ± 0.3, p < 0.001). CONCLUSION: Maze procedure can have a positive effect on long-term survival, freedom from stroke, and cardiac function.

Long-term outcomes of mitral valve repair with the Duran flexible ring.

BACKGROUND: Mitral annuloplasty is a reliable mitral valve repair technique. There are two types of annuloplasy rings: the rigid ring and the flexible ring. This study sought to examine the long-term results of mitral valve repair using a Duran flexible ring. METHODS: We retrospectively reviewed 226 patients who underwent primary mitral valve repair using the Duran flexible ring for mitral regurgitation between September 1994 and March 2003. Patients' mean age was 56.7 years, and 39% were female. The mean follow-up was 10.6 years (0.04 ∼ 18.3), and echocardiographic follow-up was 83.3% complete. RESULTS: There were three early and 25 late deaths. Survival was 89.3 ± 2.2 for 10 years, and 83.5 ± 3.2% for 15 years. The 10- and 15-year freedom from reoperation on the mitral valve were 96.4 ± 1.4 and 95.3 ± 1.7%, respectively. The 10- and 15-year freedom from moderate or severe mitral regurgitation were 92.5 ± 2.2 and 73.7 ± 7.1%, respectively. Cox regression analysis revealed that age, male gender, and isolated anterior leaflet prolapse were predictive of recurrent moderate or severe mitral regurgitation. CONCLUSIONS: Mitral valve repair for mitral regurgitation using a flexible Duran ring is safe and durable for more than 10 years.

Persistent tricuspid regurgitation after tricuspid annuloplasty during redo valve surgery affects late survival and valve-related events.

BACKGROUND: Long-term survival and incidence of late tricuspid regurgitation (TR) were studied in patients who underwent tricuspid annuloplasty (TAP) during redo valve surgery. METHODS AND RESULTS: We retrospectively analyzed 125 patients (mean age, 64.5±10.4 years) who underwent TAP using suture (n=54, group S) or ring (n=71, group R) implantation during redo surgery in a 20-year period. There was a significant difference in prevalence of preoperative atrial fibrillation (P=0.0199). More group S patients were in New York Heart Association functional class III or IV than group R patients (P=0.0066). Mean follow-up was 6.6±5.3 years. Mortality rate for group S was 9.3%, and for group R, 7.0% (P=0.6508). Survival at 5 and 10 years was 72.2±6.6% vs. 88.1±4.0%, and 66.4±7.3% vs. 61.0±7.2%, respectively (log-rank, P=0.7235). Less than moderate TR (hazard ratio [HR], 0.113; P=0.0198) before discharge was a predictor of late survival. There was no statistically significant difference in freedom from valve-related events (log-rank, P=0.5196). A predictor of freedom from valve-related events was less than moderate TR before discharge (HR 0.428; P=0.0100). It was also a positive predictor of freedom from late TR more than mild (HR 0.070; P<0.0001). CONCLUSIONS: Less than moderate TR before discharge after TAP during redo valve surgery was an independent risk factor for better long-term outcome.

Phase II clinical trial of CD34+ cell therapy to explore endpoint selection and timing in patients with critical limb ischemia.

BACKGROUND: A prior phase I/IIa clinical trial provided evidence for safety, feasibility and potential efficacy of i.m. injection of granulocyte colony-stimulating factor (G-CSF)-mobilized CD34+ cells in patients with critical limb ischemia (CLI). METHODS AND RESULTS: A phase II trial of CD34+ cell therapy was conducted in patients with CLI to explore endpoint selection and timing. No-option CLI patients (n=11) underwent i.m. transplantation of G-CSF-mobilized CD34+ cells isolated by magnetic sorting. Ischemic rest pain scales improved from week 2 vs. baseline (P<0.05). Skin perfusion pressure (P=0.0175), transcutaneous partial oxygen pressure (P=0.0446) and pain-free walking distance (P=0.0056) improved from week 2, total walking distance from week 8 (P=0.0182) and toe brachial pressure index from week 12 (P=0.0174) vs. baseline. These parameters peaked at week 36 or 52. Rutherford's category improved from week 24 vs. baseline (P=0.0065). CLI-free ratio serially increased and peaked (85.7%) at week 36. Serial change in Rutherford's category correlated with that in Rest Pain Scale (P=0.0374), but not with that in any physiological parameters. CONCLUSIONS: Ischemic rest pain scales and physiological parameters improved relatively early after cell therapy, then plateaued later accompanied by recovery from the CLI state. Rutherford's category and CLI-free ratio at week 36 or later may be suitable endpoints in cell therapy clinical trials for CLI. Functional parameters should be evaluated independently of such clinical endpoints for ischemia severity. ( CLINICAL TRIAL REGISTRATION: URL: https://dbcentre3.jmacct.med.or.jp/jmactr/Default.aspx. Unique identifier: JMA-IIA00022)

Redo valvular surgery in elderly patients aged > 75 years.

BACKGROUND AND AIM OF THE STUDY: Very few data exist regarding the clinical outcome of redo valvular surgery in patients aged > 75 years. METHODS: A retrospective analysis was conducted of 42 consecutive patients (mean age 78.3 years) who had undergone redo valvular surgery between January 1991 and December 2010, and who had been followed up for a mean of 2.5 years. Factors associated with early outcomes were analyzed using logistic regression analysis, while predictors of late death and valve-related events were identified using Cox regression analysis. RESULTS: The overall hospital mortality rate of redo procedures was 17%. Multivariate logistic regression analysis showed that prolonged ventilator support (OR 1.007; 95% CI: 1.000-1.014; p < 0.0464) was an independent risk factor for hospital mortality. Overall survival rates at one and three years were 78.3 +/- 6.8% and 67.1 +/- 8.6%, respectively. Multivariate Cox regression analysis of survival revealed that age (HR 1.399; 95% CI: 1.044-1.875; p < 0.0238) and prolonged ventilator support (HR 1.004; 95% CI: 1.001-1.006; p < 0.0051) were negative predictors of mid-term survival. Rates of freedom for valve-related events at one and three years were 77.4 +/- 7.5% and 60.2 +/- 9.6%, respectively. An absence of peripheral artery disease protected against valve-related events (HR 0.045; 95% CI: 0.004-0.44; p < 0.0080). CONCLUSION: Early and late outcomes for elderly patients who had undergone redo valvular surgery were relatively poor and satisfactory, respectively. Hence, an optimal referral for redo surgery is important to achieve better outcomes.

Does the number of redo mitral valve replacements for structural valve deterioration affect early and late outcomes?: experience from 114 reoperative cases.

BACKGROUND AND AIM OF THE STUDY: Whether the number of reoperative mitral valve replacements (MVRs) for structural valve deterioration (SVD) affects early or late survival is unclear. Hence, the aim of the present study was to investigate this issue. METHODS: A total of 114 consecutive patients (84 females, 30 males; mean age 63.4 +/- 11.9 years) who underwent 141 redo MVRs for SVD during a 20-year period was retrospectively analyzed. Of these patients, 87 (76.3%) had undergone first-time reoperations (87 redos; group A), while the remaining 27 (23.7%) had undergone two or more reoperations (54 redos; group B). The mean follow up period was 8.5 +/- 6.8 years, and the follow up rate was 96.2%. RESULTS: NYHA functional class III or IV was noted in 34 patients (39.1%) of group A, and in 17 patients (63.0%) of group B (p = 0.0292). The EuroSCORE and logistic EuroSCORE in group B were significantly higher than those in group A. The hospital mortality rate was 4.6% in group A and 11.1% in group B (p = 0.1430). Logistic regression analysis revealed risk factors for hospital mortality to be the number of reoperations (OR 4.399; p = 0.0467) and NYHA class III or IV (OR 9.090; p = 0.0483). There were no significant differences in five-, 10- or 15-year survival rates between groups A and B (log-rank test, p = 0.3369). A Cox regression analysis showed advanced age to be the only predictor of late mortality (HR = 1.098; p = 0.0013). CONCLUSION: Irrespective of whether a patient has undergone two or more reoperative MVRs, a better long-term survival can be expected before progression of the patient's NYHA functional class.

Mitral valve repair for severe organic mitral regurgitation in the elderly.

BACKGROUND AND AIM OF THE STUDY: Although mitral valve repair has become the standard surgical procedure for mitral regurgitation (MR), the procedure does not necessarily apply to elderly patients aged > 75 years because of high morbidity and mortality. METHODS: A total of 104 patients aged > 75 years who underwent mitral valve repair between January 1991 and December 2011 was reviewed retrospectively. The mean age was 78 years, and the mean follow up was 3.7 years. Possible risk factors for hospital death and morbidity were identified, and valve-related events during the follow up period were analyzed. RESULTS: The overall hospital mortality rate was 4.8% (5/104). Multivariate logistic regression analysis identified serum creatinine level > 2.0 mg/dl as the only independent predictor of hospital mortality. A total of 33 patients had postoperative complications. Infective endocarditis was the only independent predictor of hospital morbidity. Actual survival at five years was 85.6 +/- 4.1%. By Cox regression analysis, age (HR 1.195; p <0.012) proved to be a negative predictor of late survival, whereas the absence of chronic obstructive pulmonary disease (HR 0.129; p <0.014) was a positive predictor. Rates of freedom from thromboembolic events and bleeding at five years were 87.9 +/- 4.2% and 97.9 +/- 1.5%, respectively. Rates of freedom from moderate-to-severe MR and reoperation at five years were 80.3 +/- 6.5% and 97.5 +/- 2.5%, respectively. CONCLUSION: Late survival and freedom from valve-related events were favorable, in addition to hospital outcome, in patients aged > 75 years. Mitral valve repair is an acceptable surgical procedure in terms of hospital mortality/morbidity and freedom from valve-related events.

Mitral annular morphology in mitral valve disease with three-dimensional transesophageal echocardiography.

BACKGROUND AND AIM OF THE STUDY: Three-dimensional (3D) transesophageal echocardiography (TEE) is useful for the quantification of mitral valve structures. The study aim was to investigate, in quantitative manner, any differences in mitral valve anatomy among patients with mitral valve prolapse (MVP) or functional mitral regurgitation (FMR), compared to normal control subjects. METHODS: 3D-TEE was performed in 20 MVP patients, 10 FMR patients and in 15 control subjects. Analyses of the full-volume 3D mitral valve data sets were performed offline, using Q-Lab software. RESULTS: Distinctive patterns were identified in annular geometric changes in normal subjects compared to patients with MVP or FMR. Patients with FMR showed significant annular anterior to posterior dilatation (34.6 +/- 8.3 mm versus 28.4 +/- 2.9 mm, p < 0.04: FMR versus control), whereas in patients with MVP dilatation in the anterolateral to posteromedial diameter was more prominent (41.0 +/- 5.9 mm versus 36.6 +/- 2.4 mm, p < 0.03; MVP versus control). CONCLUSION: 3D-TEE represents a useful method for the evaluation of mitral valve geometry.

Reoperation for pseudoaneurysm of the thoracic aorta after cardiovascular surgery.

PURPOSE: Pseudoaneurysms of the thoracic aorta after cardiovascular surgery are rare, but life-threatening complications. We herein describe the clinical outcomes of pseudoaneurysms of the thoracic aorta arising after cardiovascular surgery. METHODS: We retrospectively reviewed 14 patients (mean age 64 years) who underwent reoperation for a pseudoaneurysm of the thoracic aorta between January 1997 and December 2010. RESULTS: Pseudoaneurysms of the thoracic aorta were detected incidentally during routine follow-up in 11 asymptomatic patients, whereas symptoms or signs indicating an aortic pseudoaneurysm were present in three patients. The mean intervals between repeat and previous cardiovascular surgeries and the follow-up were 167 and 62 months, respectively. The aortic pseudoaneurysms were located in the proximal and distal suture lines in six patients, and at aortotomy sites in four. These locations accounted for about 70 % of all aortic pseudoaneurysms. None of the patients died in the hospital. Postoperative complications, such as a need for permanent pacemaker implantation or groin-related issues, occurred in five patients. However, no major postoperative complications, aorta-related events or a need for reoperation developed during the follow-up period. CONCLUSIONS: Regular follow-up, including imaging modalities and physical examinations, is mandatory to detect aortic pseudoaneurysms after cardiovascular surgery.

Surgical treatment for degenerative mitral stenosis associated with aortic valve stenosis: A case report.

We report a 73-year-old female who underwent mitral valve replacement for degenerative mitral stenosis (DMS) and aortic valve replacement for aortic valve stenosis. She was transferred to our hospital because of congestive heart failure. Transthoracic echocardiogram demonstrated severe mitral valve stenosis and aortic valve stenosis. Transesophageal echocardiogram (TEE) revealed severe mitral annular calcification (MAC) and calcification of the anterior mitral leaflet without commissure fusion. The diagnosis of DMS associated with MAC and aortic valve stenosis was made. Since she did not have other significant comorbidities except diabetes mellitus and hypertension, open-heart surgery for double valve replacement was scheduled by our heart team. Complete resection of the calcium bar and annulus reconstruction with an autologous pericardium allowed safe mitral valve replacement with a mechanical valve. Concomitant aortic valve replacement with a mechanical valve was carried out for aortic valve stenosis. Intraoperative TEE demonstrated good left ventricular function without perivalvular leakage in both mitral and aortic prosthetic valves. The postoperative course was uneventful, and the patient was discharged from the hospital. Surgical intervention may be one of the alternative treatments for elderly patients with degenerative mitral stenosis and MAC. Learning objective: Degenerative mitral stenosis (DMS) associated with mitral annular calcification (MAC) is a severe heart valve disease in the elderly population in developed countries. The prognosis of patients with severe DMS is poor, and open-heart surgery for elderly patients with MAC is especially challenging from a surgical point of view. We report a surgical treatment for a patient with DMS and aortic valve stenosis considering the patient's comorbidities and extent of MAC.