Circumflex Coronary Artery Fistula Draining into Coronary Sinus

ABSTRACT Coronary artery fistula draining into the coronary sinus is a rare vascular malformation, and its diagnosis and clinical manifestations usually occur late. We describe the case of a 72-year-old female patient with dyspnea on exertion (New York Heart Association Class III) associated with palpitations. The transthoracic echocardiogram showed significant tricuspid insufficiency. Cardiac catheterization showed aneurysm of the circumflex coronary artery and fistula of this artery draining into the coronary sinus. The patient underwent fistula ligation and tricuspid valve repair, with excellent surgical results.

Early- and Long-Term Outcomes of Mitral Valve Repair in a Low-Volume Centre in the Caribbean

Abstract Introduction: This study examines early- and long-term outcomes of mitral valve repairs in a low-volume cardiac surgery centre in the Caribbean. Methods: Ninety-six consecutive patients underwent mitral valve repair from April 2009 to December 2018. Patients were divided into two groups: functional mitral regurgitation requiring simple mitral annuloplasty (FMR, n=63) or structural degenerative mitral regurgitation requiring more complex repair (DMR, n=33). Data collected prospectively were retrospectively analysed from the unit-maintained cardiac surgery database. Results: Thirty-day mortality in the whole series was 2.1%, with 3% in the FMR group and 0% in the DMR group. Early post-operative echocardiography in the FMR group demonstrated 51 patients (83.6%) without mitral regurgitation, 8 patients (13.1%) with trivial to mild regurgitation, and 2 patients (3.3%) with moderate regurgitation. However, at a mean follow-up of 98.2±50.8, only 21 patients (42.8%) were in NYHA class I, with 7 (14.2%) in class II, 16 (32.6%) in class III, and 5 (10.2%) in class IV. There were 9 cardiac-related deaths at final follow-up, with freedom from re-operation and survival of 98% and 75.6%, respectively. In the DMR group, early post-operative echocardiography demonstrated 29 patients (87.9%) without mitral regurgitation, 3 patients (9.1%) with trivial regurgitation and 1 patient (3.0%) with mild regurgitation. At a mean follow-up of 114.1±25.4 months, there was a good functional post-operative status in this group with 93.3% in NYHA class I, and 6.7% in class II. No patient required reintervention, 96.3% of patients had mild or no mitral regurgitation and survival was 90.9%. Conclusion: Despite challenges of maintaining skills in a low-volume centre, mitral valve repair can be performed safely with good early- and long-term results.

Clinical analysis of 152 mitral valvuloplasty surgeries performed by a single surgical team in one year / 中华胸心血管外科杂志

Objective:To summarize the clinical data of mitral valve surgery completed in a single surgical team in one year, to discuss the etiologic characteristics, methods, results and early postoperative outcomes of mitral valvuloplasty surgeries, and to analyze the epidemiologic trends of mitral valve diseases admitted to the hospital.Methods:A total of 209 mitral valve surgeries completed by the same surgeon in the single surgical team at the Cardiovascular Surgery, First Medical Center, Chinese PLA General Hospital, from January 2021 to December 2021 were retrospectively analyzed. Mitral valve surgery accounted for 53.6% of all surgeries in this team during the same period. There were 100 cases(47.8%) in males and 109 cases(52.2%) in females, aged 11-85 years old, with a mean of(53.5±15.2) years old. There were 121 cases(57.9%) of NYHA class Ⅱ and 88 cases(42.1%) of class Ⅲ/Ⅳ.Results:Of the 152 mitral valvuloplasty surgeries, 117(77%) were performed with a totally Thoracoscopic approach. Annuloplasty rings were applied in 145 cases(95.4%), including semi-rigid closed Physio II annuloplasty rings in 118 cases(81.4%), Gore-Tex artificial chordae were applied in 89 cases(58.6%) for a total of 145, leaflet repair in 15 cases(9.9%), edge-to-edge repair in 2 cases(1.3%), commissure suture in 34 cases(22.4%), and chordae tendineae and papillary muscle splitting in 15 cases(9.9%). The repair rate of degenerative mitral valve disease was 100%, and the repair rate of rheumatic mitral valve disease was 48.1%. The echocardiogram was received about one week after surgery, and there was no or trace regurgitation in 91 cases(59.9%), mild in 58 cases(38.2%), and moderate in 3 cases(2.0%). There were 2 cases(1.3%) of all-cause death.Conclusion:Degenerative mitral valve disease have become the leading cause of mitral valve disease in our center, and the proportion of rheumatic mitral valve disease has decreased. Degenerative mitral valve disease has a very high repair rate, and rheumatic mitral valve disease has a relatively low repair rate due to its special pathologic and anatomic characteristics. Most mitral valvuloplasty procedure can be performed in a totally thoracoscopic approach. The application of a mitral valvuloplasty ring combined with Gore-Tex artificial chordae by an experienced surgeon can achieve reliable repair results.

Real-time monitoring and step-by-step guidance for transcatheter tricuspid annuloplasty using transesophageal echocardiography / 中华超声影像学杂志

Tricuspid regurgitation (TR) interventions are under rapid development. The K-Clip? system is the first domestic transcatheter tricuspid annuloplasty system with unique clamping procedure to achieve annular reduction.Intraoperative echocardiographic monitoring procedures for transcatheter tricuspid annuloplasty have not been reported yet in China. Thus, this review aimed to propose the standard two-dimensional and three-dimensional transesophageal echocardiographic workplanes and procedures to guide and monitor the implantation of K-Clip system based on our experience in Zhongshan Hospital, Fudan University to provide a reference point for the intraoperative echocardiographic monitoring of future transcatheter tricuspid annuloplasty devices in China.

Dual-Valve Repair in Dextrocardia and Situs Inversus Totalis / 日本心臓血管外科学会雑誌

A 59-year-old man, diagnosed with severe mitral regurgitation, moderate tricuspid regurgitation, and chronic atrial fibrillation with situs inversus totalis, was referred to our hospital. A median sternotomy approach was performed. The surgeon operated from the left side of the operating table, and had an excellent exposure to the mitral and tricuspid valves during the operation. The mitral valve was repaired with the posterior cusp plication technique and ring annuloplasty. The tricuspid valve was repaired with ring annuloplasty. We use a conventional semi rigid ring turned over, because the tricuspid valve has an asymmetric configuration. FullMAZE, and left atrial appendage closure were performed, too. The postoperative course was uneventful.

Valvuloplasty Without Prosthetic Ring or Band in Patients with Degenerative Mitral Regurgitation: Long-Term Results and Predictive Factors for Outcomes

Abstract Introduction: Mitral valvuloplasty including ring/band support is widely performed despite potential drawbacks of rings. Unsupported valvuloplasty is performed in only a few centers. This study aimed to report long-term outcomes of patients undergoing unsupported valvuloplasty for degenerative mitral regurgitation (MR) and to identify predictive factors for outcomes. Methods: This is a retrospective cohort including patients undergoing mitral valve repair for degenerative MR from 2000 to 2018. The main techniques were Wooler annuloplasty and quadrangular resection. Kaplan-Meier curves and Cox regression models were used for statistical analysis. Results: One hundred fifty-eight patients were included (median age: 64.0 years). In-hospital mortality was 2.5%. Maximum follow-up was 19.6 years, with a median of 4.7 years (992 patient-years). Overall survival at 5, 10, and 15 years was 91.0% (95% confidence interval [CI]: 85.7-96.3), 87.6% (95% CI: 80.7-94.5), and 78.1% (95% CI: 65.9-90.3), respectively. The European System for Cardiac Operative Risk Evaluation (EuroSCORE) II was an independent predictor of late death (hazard ratio [HR] 1.42; P=0.016). Freedom from mitral reoperation at 5, 10, and 15 years was 88.1% (95% CI: 82.0-94.2), 82.4% (95% CI: 74.6-90.2), and 75.7% (95% CI: 64.1-87.3), respectively. Left atrial diameter > 56 mm was associated with late reintervention in univariate analysis (HR 1.06; P=0.049). Conclusion: Degenerative MR can be successfully treated with repair techniques without annular support, thus avoiding the technical and logistical drawbacks of ring/band implantation while maintaining good long-term results. EuroSCORE II was a risk factor for late death, and larger left atrium was associated with late reoperation.

Clover technique for the treatment of complex tricuspid valveinsufficiency / 中华胸心血管外科杂志

Objective:This study assesses the results of the clover technique for the treatment of tricuspid regurgitation(TR) due to severe prolapse or tethering.Methods:From March 2016 to November 2018, 28 patients with severe TR due to prolapsing or tethered or adhesion leaflets underwent clover technique. Annuloplasty was associated in 27 patients(97%). The aetiology of TR was rheumatic in 19 cases(68%), subacute bacterial endocarditis in 4(14%), degenerative in 3(11%) and ischemia of right ventricular(the peacing leads compress the septum leaflet in 1 case) in 2(7%). The main mechanism of TR was prolapse/flail of one leaflet in 7 patients(23%), of two leaflets in 13 patients(46%) and of all three leaflets in 6 patients(21%). The remaining 2 patients(7%) presented with severe leaflets’tethering.Results:None deaths occurred during hospitalisation and one patient dischargedvoluntary 12 days after surgery. Follow-up of the 27 hospital survivors was 100% complete[mean length(1.2±0.8)years, range 0.25-1.70 years]. At the last echocardiogram, no or mild TR was detected in 25 patients(88.7%), moderate(2+ /4+ ) in two(9.6%) and severe(4+ /4+ ) in one patient(3.6%). Mean tricuspid valve area and gradient were(4.3±0.6 )cm 2 and(2.8±1.4)mmHg(1 mmHg=0.133 kPa). There was no obvious valve stenosis in all cases. In all patients, echocardiography was performed and no signs of tricuspid stenosis were detected. At the multivariable analysis, the degree of TR at hospital discharge was identified as the only predictor of TR 2+ at follow-up. Conclusion:Clover procedure is simple and safe in the surgical management of various causes of TR besides severe tethering and calcification, it is an effective supplementary measure for annuloplasty.

Short and mid-term outcomes of valve repair in patients with insufficient bicuspid aortic valves / 中国胸心血管外科临床杂志

@#Objective    To evaluate the short and mid-term outcomes of valve repair in patients with insufficient bicuspid aortic valves (BAV). Methods    The clinical data of 27 consecutive patients with insufficient BAV undergoing valve repair in Shanghai Chest Hospital from September 2016 to January 2020 were retrospectively reviewed. There were 24 males and 3 females with a mean age of 38.5±14.6 years (range: 20-68 years). BAV of all patients was type 1 in Seviers' classification. There were 23 patients with left-right fusion and 4 patients with right-noncoronary fusion. There was aortic regurgitation in the patients measured by the echocardiogram, including moderate regurgitation in 3 patients, moderate-severe in 18 patients, and severe in 6 patients. The diameter of aortic annular base was 27.9±3.4 mm, and the largest diameter of aortic sinus was 39.9±7.6 mm. Left ventricular end diastolic diameter was 62.7±6.5 mm, and the volume was 197.9±53.6 mL. Results    All 27 patients completed the follow-up, and the mean time was 24.2±12.5 months (range: 12-51 months). No patient died or required aortic valve-related reoperation during the follow-up. The cardiac function of the patients significantly improved postoperatively (P<0.05). By echocardiography, 11 patients had no aortic regurgitation, 13 had mild aortic regurgitation, and 3 had moderate aortic regurgitation, and no patient had severe aortic regurgitation. Postoperative left ventricular end diastolic diameter and volume decreased, compared to preoperative ones (P<0.05). Conclusion    In patients with insufficient BAV, valve repair is safe and effective, and has excellent short and mid-term outcomes.

Reemplazo valvular mitral en pacientes con anillo calcificado / Mitral Valve Replacement in Patients with Mitral Annulus Calcification

RESUMEN Introducción: El anillo mitral calcificado es un proceso degenerativo que, de encontrarse presente en pacientes con indicación de tratamiento quirúrgico de la válvula mitral, implica un problema técnico de difícil resolución, que genera un aumento de probabilidad de complicaciones graves como accidente cerebrovascular, fugas perivalvulares, sangrado y muerte. Objetivo: El propósito del estudio es describir nuestra experiencia con cirugía valvular mitral en el contexto de calcificación grave del anillo mitral. Material y métodos: entre julio de 2010 y julio de 2020, 28 pacientes fueron intervenidos por patología valvular mitral en presencia de anillo mitral gravemente calcificado. La mediana de edad de la población fue de 77 años y el 68% fue de sexo femenino. Se realizó reemplazo valvular mitral en todos los casos asociado con reemplazo valvular aórtico en el 36%, con plástica tricuspídea en el 11% y con cirugía de revascularización miocárdica en el 21% de los casos. Resultados: Dos pacientes fallecieron en el hospital. Las complicaciones posoperatorias más frecuentes fueron la fibrilación auricular y la insuficiencia renal aguda. No se observaron fugas perivalvulares ni complicaciones asociadas con la prótesis. Conclusiones: La cirugía valvular mitral en presencia de anillo mitral calcificado puede realizarse con resultados aceptables para el perfil de riesgo de la población con la patología y de acuerdo con lo informado en publicaciones internacionales.

ABSTRACT Background: Mitral annulus calcification is a degenerative process which poses a challenging technical problem in patients undergoing surgical treatment of the mitral valve, increasing the probability of severe complications as stroke, perivalvular leaks, bleeding and death. Objective: The aim of this study was to describe our experience in mitral valve surgery with severe mitral annulus calcification. Methods: Between July 2010 and July 2020, 28 patients underwent surgery due to mitral valve disease with severe mitral annulus calcification. Median age was 77 years and 68% of patients were female. Mitral valve replacement was performed in all patients, associated with aortic valve replacement in 36%, tricuspid valve repair in 11% and coronary artery bypass graft surgery in 21% of cases. Results: Two patients died during hospitalization. The most frequent postoperative complications were atrial fibrillation and acute kidney failure. No perivalvular leaks or prosthesis-associated complications were observed. Conclusions: Mitral valve surgery in the presence of mitral annulus calcification can be performed with acceptable results for the risk profile of the population with the disease and according to international publications.

Early Outcomes of Modified De Vega Annuloplasty for Functional Tricuspid Regurgitation at a Brazilian Hospital

Abstract Background: Right valve diseases are not benign, the tricuspid regurgitation has a significant impact on morbidity and mortality of patients. Objectives: This study aimed to report the short-term results of tricuspid annuloplasty using the De Vega technique modified by Manuel Antunes. Methods: A descriptive-analytical study was performed to evaluate the results of the tricuspid valvuloplasty performed at the Instituto de Medicina Integral Professor Fernando Figueira between 2012 and 2017. Data were collected by reviewing charts and databases of the Department of Cardiology and Cardiovascular Surgery of the institution. Those with rheumatic diseases or infective endocarditis with tricuspid valve involvement, or reoperation of the tricuspid valve were excluded. Student's t-test and McNemar's were used for statistical analysis. A p-value < 0.05 was considered statistically significant. Results: A total of 87 patients were studied, most of them were women (56.3%). The most associated heart valve diseases were mitral regurgitation (27.6%) and aortic regurgitation (20.7%). There was a significant decrease in the degree of tricuspid regurgitation in the postoperative period, with 83.3% of patients with none or mild regurgitation and only 1.1% with severe regurgitation (p = 0.0077). Conclusions: In the current study, tricuspid valve annuloplasty using the modified De Vega technique was shown to be effective in the short term. Further studies are needed to evaluate the long-term results.

A Case of Successful Valve Repair in Traumatic Aortic Regurgitation Associated with the Dilated Aortic Annulus / 日本心臓血管外科学会雑誌

Here, we present a case of successful aortic valve repair of traumatic aortic regurgitation (AR). A man in his early twenties had a chest blunt trauma due to a bicycle accident 6 years earlier and suffered sternum fracture. He recovered without cardiovascular complications. Three months previously, a new diastolic murmur was detected on medical checkup. Transthoracic echocardiography (TTE) showed severe AR, and the left ventricular end-diastolic-/end-systolic dimension was 69/51 mm. Transesophageal echocardiography showed severe AR with perforation of the non-coronary cusp and dilatation of the aortic annulus (29.6 mm). Aortic valve repair was performed with an autologous pericardial patch and external suture annuloplasty. Postoperative TTE showed normal aortic valve function with trivial AR. He was discharged on postoperative day 11. Three months later, TTE showed trivial AR along with a reduced left ventricular dimension and improved left ventricular ejection fraction.

Modified Yacoub technique with aortic annuloplasty in patients with aortic root aneurysm / 中国胸心血管外科临床杂志

@#Objective    To evaluate the feasibility and safety of modified Yacoub technique with aortic annuloplasty in the patients with aortic root aneurysm and dilatation of aortic annular base. Methods    We performed a retrospective review of 6 patients with aortic root aneurysm undergoing modified Yacoub technique with aortic annuloplasty from November 2017 to January 2019. There were 5 males and 1 female, with a mean age of 54.1±12.3 years. The preoperative cardiac function of 3 patients was in New York Heart Association (NYHA) classⅡand the other 3 patients were in class Ⅲ. There were two patients with bicuspid aortic valve, and no Marfan syndrome. There was aortic regurgitation in the patients measured by the echocardiogram, 1 in mild aortic regurgitation, 1 in moderate aortic regurgitation, and 4 in severe aortic regurgitation. The diameter of aortic annular base was 27.8±1.9 mm, and the largest diameter of aortic root was 49.8±3.7 mm. Six patients underwent modified Yacoub technique with aortic annuloplasty, including 5 patients who underwent aortic cusp repair at the same time. Results    All 6 identified patients survived. There was no severe complication (bleeding, stroke, or acute renal failure). The cardiopulmonary bypass time was 204.6±13.5 min, aortic cross-clamping time 168.0±17.1 min, mechanical ventilation time 21.3±19.5 h, ICU stay time 67.8±62.2 h. The follow-up time ranged from 4 to 18 months with an average time of 12.8±4.7 months. Patients' cardiac function improved postoperatively with four patients in NYHA classⅠand two patients with classⅡ. Two patients had no aortic valve regurgitation, four patients had mild regurgitation. Left ventricular end diastolic volume decreased significantly (118.6±20.4 mL vs. 169.1±58.4 mL, P<0.05). Conclusion    The modified Yacoub technique with aortic annuloplasty is effective and safe for the patients with aortic root aneurysm and dilatation of aortic annular base, and the early- and mid-term outcomes are satisfactory.

Assessment of left ventricular diastolic function by vector flow mapping in patients with mitral valve plasty / 中华超声影像学杂志

Objective To assess left ventricular diastolic function by vector flow mapping ( VFM ) in patients with mitral valve plasty . Methods A total of 30 patients undergoing mitral valve plasty were enrolled . The dissipative energy loss ( EL) of basal ,middle ,apical and global left ventricular segments in rapid filing phase ,slow filling phase ,and atria contract period were measured by VFM ,and the EL above were compared in 1 week preoperatively ,1 week and 1 month postoperatively . Results Compared with 1 week preoperatively ,EL in all diastole in basal and middle left ventricular segments were significantly increased at 1 week after operation (all P <0 .05) ,EL in some diastole in apical and global left ventricular segments were significantly increased at 1 week after operation ( all P <0 .05) ,and EL in all diastole in all left ventricular segments were significantly increased at 1 month after operation (all P <0 .05) . Compared with 1 week postoperatively ,EL in all diastole in all left ventricular segments were significantly increased at 1 month after operation ( all P < 0 .05) . Conclusions VFM can quantitatively evaluate left ventricular diastolic function ,and helps to evaluate treatment response at preoperative and postoperative .

Risk factors of postoperative acute kidney injury and the impact on outcome in non-senile patients undergoing cardiac valvular surgery / 中华心血管病杂志

Objective@#To investigate the risk factors of postoperative acute kidney injury (AKI) in patients aged between 40 and 50 years old undergoing cardiac valvular surgery and the impact on outcome.@*Methods@#The clinical data of 286 patients aged between 40 and 50 years old undergoing cardiac valve surgery in Guangdong Provincial People′s Hospital from January 2012 to December 2016 were analyzed retrospectively. Preoperative coronary angiography was performed in all patients. All patients enrolled were divided into AKI group and non-AKI group according to the existence or not of postoperative AKI. Patients with AKI were further divided into AKI stage 1, stage 2, and stage 3 groups according to KDIGO guideline. Demographic characteristics, preoperative clinical data including serum creatinine, estimated glomerular filtration rate, hemoglobin, uric acid, urinary protein, presence or absence of chronic kidney disease, left ventricular ejection fraction, pulmonary artery pressure, New York Heart Association (NYHA) functional classification, preoperative co-morbidity (hypertension, diabetes, anemia, cerebrovascular disease, peripheral artery disease), preoperative medication(vasoactive drugs, diuretic, renin-angiotensin system inhibitor (RASI), surgical data (contrast dosage in coronary angiography, type of cardiac valve surgery) were recorded and analyzed in this retrospective study. The risk factors for postoperative AKI and its impact on clinical outcomes (mortality, hospitalization expenses and Intensive Care Unit stay duration) were evaluated. Logistic regression analysis was used to determine the risk factors for postoperative AKI and the adjusted variables with P<0.2 were selected for the multivariate logistic regression analysis to define the independent determinants for AKI.@*Results@#AKI was defined in 106 out of 286 enrolled patients, including 96 patients with AKI stage 1, 10 patients with AKI stage 2 and no patients with AKI stage 3. The proportion of coexisting cerebrovascular diseases was higher in AKI group than in non-AKI group (9(8.49%) and 5(2.78%), χ2=4.677, P=0.031), while there was no difference among other baseline data between the two groups. Multivariate logistic regression analysis showed that preoperative complications of cerebral vascular disease was an independent risk factor of postoperative AKI (OR=3.578, 95%CI 1.139-11.242, P=0.029). Five out of 106 AKI patients died during hospitalization while there was only 1 patient died among 180 patients without AKI. Patients with AKI after cardiac valve operation experienced higher mortality than patients without AKI (χ2=5.625, P=0.028). Further analysis showed that there was no difference in hospitalization mortality between patients with AKI stage 2 and stage (χ2=0.686, P=0.408) while the hospitalization mortality in patients with AKI stage 2 was higher than those without AKI (χ2=8.113, P=0.004). The hospitalization expenses in patients with AKI were 10.38(8.59,12.54) ×104 RMB, significantly higher than that in patients without AKI (9.72(8.03,11.93) ×104 RMB)(P=0.043). There was no difference in hospitalization expenses between patients with AKI stage 1 and without AKI (P=0.635). The hospitalization expenses in patients with AKI stage 2 was higher than those without AKI (P=0.023). Intensive Care Unit stay duration in patients with AKI was 3(1,4) days, significantly higher than those without AKI (P=0.044). There was no difference in Intensive Care Unit stay duration in patients with AKI stage 1 and without AKI (P=0.978), while Intensive Care Unit stay duration in patients with AKI stage 2 was significantly longer than those without AKI (P=0.006).@*Conclusions@#Preoperative complications of cerebral vascular disease is an independent risk factor of postoperative AKI. Non-senile patients with AKI after cardiac valvular surgery is associated with a higher proportion of mortality, hospitalization expenses and Intensive Care Unit stay duration as compared patients without postoperative AKI.

Mitral valve repair with an annuloplasty ring for mitral valve regurgitation in children and the short-term follow up / 中华胸心血管外科杂志

Objective Mitral valve regurgitation often leads to cardiac insufficiency or even heart failure .Methods We tried a mitral valve annuloplasty with a ring to improve the effect of mitral valvuloplasty , 5 males and 6 females; aged(8.0 ± 4.5)years;weight(26.1 ±13.9)kg.From February 2015 to December 2017, 11 children underwent mitral valve annuloplasty with an mitral valve ring in our hospital.Immediately after surgery, the degree of mitral valve regurgitation was significant im-proved from moderate-severe to mild-moderate(P<0.05).Results 1 case of early death, 1 case had a mitral valve replace-ment because of early hemolysis.The rest of the children were discharged smoothly.The follow-up of 3 months of mitral valve regurgitation was not aggravated comparing with that immediately after surgery(P>0.05).There was no worsening of cardiac function at follow-up(P>0.05), and no other adverse events.Therefore, artificial mitral annuloplasty with a ring is effective in treating mitral regurgitation in children .The annulus had potential growth characteristics and did not require lifelong oral an-ticoagulant.Conclusion For some patients with difficulty, this method of mitral valvuloplasty can enlarge the surgical indica-tion and improve the quality of life of children.The treatment effect is good.

Computational analysis of the electromechanical performance of mitral valve cerclage annuloplasty using a patient-specific ventricular model

We aimed to propose a novel computational approach to predict the electromechanical performance of pre- and post-mitral valve cerclage annuloplasty (MVCA). Furthermore, we tested a virtual estimation method to optimize the left ventricular basement tightening scheme using a pre-MVCA computer model. The present model combines the three-dimensional (3D) electromechanics of the ventricles with the vascular hemodynamics implemented in a lumped parameter model. 3D models of pre- and post-MVCA were reconstructed from the computed tomography (CT) images of two patients and simulated by solving the electromechanical-governing equations with the finite element method. Computed results indicate that reduction of the dilated heart chambers volume (reverse remodeling) appears to be dependent on ventricular stress distribution. Reduced ventricular stresses in the basement after MVCA treatment were observed in the patients who showed reverse remodeling of heart during follow up over 6 months. In the case who failed to show reverse remodeling after MVCA, more virtual tightening of the ventricular basement diameter than the actual model can induce stress unloading, aiding in heart recovery. The simulation result that virtual tightening of the ventricular basement resulted in a marked increase of myocardial stress unloading provides in silico evidence for a functional impact of MVCA treatment on cardiac mechanics and post-operative heart recovery. This technique contributes to establishing a pre-operative virtual rehearsal procedure before MVCA treatment by using patient-specific cardiac electromechanical modeling of pre-MVCA.

Treatment of Isolated Type Ic Lesion-Induced Aortic Regurgitation by External Suture Annuloplasty Alone / 日本心臓血管外科学会雑誌

A diagnosis of active aortic valve endocarditis was made in a 52-year-old man who presented with fever and edema. Blood cultures were positive for Streptococcus gallolyticus subsp. pasteurianus. The infection was treated successfully using antibiotics and dental care, but a mobile vegetation-like structure on the aortic valve and severe aortic regurgitation, mainly due to aortic annulus dilatation, remained and required surgery. During the surgical procedure, the aortic valve leaflets were seen to be almost normal, and the regurgitation was found to be mainly due to aortic annulus dilation. Regurgitation could be managed with external suture annuloplasty alone, although a second session was necessary to reduce the annular size by one size. The annular size has been stable for over 1 year after surgery without re-operation of the aortic valve. This procedure not only reduces the operation time but also decreases the surgical stress and avoids the need for prosthetic valve replacement.

Reparación de la insuficiencia tricuspídea: resultados a largo plazo en 114 pacientes / Repair of tricuspid valve insufficiency: long-term results in 114 patients

Resumen Antecedentes la reparación de la insuficiencia tricuspídea funcional está indicada en casos de insuficiencia cardíaca, generalmente, asociada a enfermedades de las válvulas cardíacas izquierdas y en algunos casos de enfermedad coronaria o cardiopatías congénitas. Objetivo : evaluar los resultados a largo plazo de la reparación tricuspídea en pacientes operados en la región centro sur de Chile. Pacientes y métodos : estudio retrospectivo de registros clínicos y operatorios en 114 pacientes con edad promedio 57.8 (DE 13) años (72 mujeres) sometidos a reparación tricuspídea asociada a otros procedimientos quirúrgicos entre 2009 y 2017. Resultados : la etiología de la insuficiencia tricuspídea fue debida a enfermedad reumática inactiva en 45% y a endocarditis infecciosa en 2.6%. 63% estaban en fibrilación auricular y 75% en capacidad funcional NYHC III. 15.8% tenían cirugía valvular cardíaca previa. El ecocardiograma mostró insuficiencia severa en 56% de los casos y había hipertensión pulmonar severa en 39.5%. La cirugía consistió en la implantación de un anillo semi-rígido en forma concomitante a reemplazo o reparación de lesión valvular mitral, reemplazo valvular aórtico, cierre de comunicación interauricular, cirugía coronaria o resección de tumor intra cardíaco. La mortalidad post operatoria global fue 16%, debido a falla multisistémica en 6%, insuficiencia cardíaca en 5% y hemorragia cerebral en 4.3%. El seguimiento promedio fue 78.8 (DS 7.2) meses. La supervivencia actuarial fue 74% a los 60 y 68% a los 96 meses. Conclusión : La cirugía de reparación de la insuficiencia tricuspídea moderada o severa, asociada a otras enfermedades cardíacas provee una buena recuperación sintomática, con excelente sobrevida alejada.

Abstract Background : Surgery for functional tricuspid valve insufficiency is indicated in cases of congestive heart failure usually associated to left heart valve diseases or as a concomitant surgery for other causes such as congenital or coronary disease. Aim : To assess and report the long-term results of tricuspid valve repair in adult patients in a regional cardiac surgery center in south Chile. Patients and Methods : Retrospective review of clinical and operative records of 114 patients aged 57.8 +/- 13 years (72 women) subjected to tricuspid reparative surgery concomitant with other cardiac procedures between 2009 to 2017. Results : In 45% of cases etiology was due to inactive rheumatic disease and 2.6% was due to endocarditis. 63% presented with atrial fibrillation and 75% were in NYHC CFIII. 15.8% had a previous cardiac valve surgery. Preoperative echocardiography showed severe tricuspid insufficiency in 56% of cases and pulmonary hypertension was severe in 39.5%. In all cases tricuspid repair was performed through the insertion of a semi rigid ring as a concomitant procedure for mitral repair/replacement in most cases, aortic valve replacement, surgical closure of an ASD, CABG surgery and the resection of cardiac tumors. Overall postoperative mortality was 16% due to multi-organic dysfunction in 6%, cardiac failure in 5% and cerebral hemorrhage in 4.3%. Mean long term follow up was 78.8+/- 7.2 months. Actuarial survival was 74% at 60 and 68% at 96 months. Conclusion: Surgical tricuspid valve repair for moderate to severe tricuspid insufficiency isolated or associated to other cardiac diseases provides a good symptomatic recovery, with an excellent long term survival.

OPCABG for moderate cimr in elderly patients: a superior option?

Abstract Objective: To compare the early and late outcomes of off-pump coronary artery bypass grafting and coronary artery bypass graft + mitral valve repair in elderly patients with moderate chronic ischemic mitral regurgitation. Methods: One hundred and fifty elderly (age > 70 years) patients with moderate chronic ischemic mitral regurgitation who underwent off-pump coronary artery bypass grafting (n=95) or coronary artery bypass graft + mitral valve repair (n=55) between January 2007 and December 2014 were studied. They were subdivided according to presence or absence of high operative risk. Peri-operative variables and early operative outcomes were retrospectively studied. Survival, mitral regurgitation grade, and functional outcomes were prospectively analysed. Results: Both groups were comparable in terms of age (P=0.23), sex (P=0.74), left ventricle ejection fraction (P=0.6) and preoperative functional class (P=0.52). The mean number of grafts for off-pump coronary artery bypass grafting group was 3.14 and coronary artery bypass graft + mitral valve repair was 3.21. Off-pump coronary artery bypass grafting group had statistically significant better early operative outcomes i.e perioperative blood transfusions, intraaortic balloon pump usage, arrhythmias, renal dysfunction, liver dysfunction, sepsis, mean hours of ventilation, intensive care unit stay and operative mortality. On a prospective follow up of 5±2.33 years (1-9 years), coronary artery bypass graft + mitral valve repair in low operative risk subgroup had better improvements in mitral regurgitation grade than off-pump coronary artery bypass grafting. Both groups had similar improvements in functional class and cumulative survival was also comparable (63.2% vs. 54.5%). Conclusion: Off-pump coronary artery bypass grafting is a safer alternative to coronary artery bypass graft + mitral valve repair with better early operative outcomes and comparable late survival and functional outcomes in elderly patients with moderate chronic ischemic mitral regurgitation, especially those with higher operative risk.

Long-term results of mitral valve repair

Abstract Introduction: Current guidelines state that patients with severe mitral regurgitation should be treated in reference centers with a high reparability rate, low mortality rate, and durable results. Objective: To analyze our global experience with the treatment of organic mitral regurgitation from various etiologies operated in a single center. Methods: We evaluated all surgically treated patients with organic mitral regurgitation from 2004-2017. Patients were evaluated clinically and by echocardiography every year. We determined early and late survival rates, valve related events and freedom from recurrent mitral regurgitation and tricuspid regurgitation. Valve failure was defined as any mitral regurgitation ≥ moderate degree or the need for reoperation for any reason. Results: Out of 133 patients with organic mitral regurgitation, 125 (93.9%) were submitted to valve repair. Mean age was 57±15 years and 52 patients were males. The most common etiologies were degenerative disease (73 patients) and rheumatic disease (34 patients). Early mortality was 2.4% and late survival was 84.3% at 10 years, which are similar to the age- and gender-matched general population. Only two patients developed severe mitral regurgitation, and both were reoperated (95.6% at 10 years). Freedom from mitral valve failure was 84.5% at 10 years, with no difference between degenerative and rheumatic valves. Overall, late ≥ moderate tricuspid regurgitation was present in 34% of the patients, being more common in the rheumatic ones. The use of tricuspid annuloplasty abolished this complication. Conclusion: We have demonstrated that mitral regurgitation due to organic mitral valve disease from various etiologies can be surgically treated with a high repair rate, low early mortality and long-term survival that are comparable to the matched general population. Concomitant treatment of atrial fibrillation and tricuspid valve may be important adjuncts to optimize long-term results.