Surgical revision after percutaneous mitral valve repair by edge-to-edge device in high-risk patients.

BACKGROUND: Patients scheduled for surgery after unsuccessful MitraClip® intervention present increasingly with multiple comorbidities, and they are often referred to the heart team to suggest the most appropriate intervention. The publication of successful results of initial patient cohorts treated with the MitraClip device has resulted in recruitment of more seriously ill patients, who otherwise would have been denied catheter-based/surgical treatment. There has been increasingly reports on conventional surgery after failed mitral valve repair with the MitraClip device. However, data on such procedures remain scarce and mostly focused on individual case studies. The inevitable increase in use of MitraClip, however, will raise the number of patients in need of surgery post MitraClip, making it imperative for surgeons to understand challenges and outcome data related with surgery in this patient cohort. We present our long-term institutional experience with surgery after MitraClip intervention in highest risk patients. METHODS: Eighteen patients underwent surgery of the mitral valve at our Institution between January 2015 and June 2020. These patients developed recurrent mitral regurgitation grade more than 2° at various intervals after MitraClip. Mitral valve repair was performed where possible and gross examination Valve/MitraClip were intra-operatively documented. Implanted MitraClip devices were analyzed histopathologically to evaluate the healing process and rule out inflammation. Regular patient follow-up was performed. RESULTS: Mean patient age was 74 (±9 years) and MitraClip implantation was performed at various tertiary institutions. Sixteen out of eighteen (16/18) patients received mitral valve replacement, whereas the remaining two patients received mitral valve repair and extracorporal membrane oxygenation, respectively. Four patients died of sepsis and intractable multi organ failure in-hospital. The remaining patients were discharged alive out of hospital to different rehabilitation centers. Follow-up was complete in all patients. CONCLUSIONS: Surgery is demanding when patients require surgery for persistent or recurrent mitral regurgitation after MitraClip therapy and can be successfully implemented as a possible therapy option for selective cases as an interdisciplinary approach despite calculated high perioperative mortality risk. These patients should not be denied surgery outright.

Clinical outcomes of conventional surgery versus MitraClip® therapy for moderate to severe symptomatic mitral valve regurgitation in the elderly population: an institutional experience.

BACKGROUND: The aim of this study was to compare treatment of moderate to severe symptomatic mitral regurgitation (MR) with either conventional surgery or the mitral valve edge-to-edge device (MitraClip®) in very elderly patients. The newly introduced MitraClip device has demonstrated promising acute results in treating this patient cohort. Also noteworthy is the fact that patients who otherwise would have been denied surgery are increasingly referred for treatment with the MitraClip device. We sought to review our institutional experience, comparing outcomes in both surgical and MitraClip arms of treatment in the elderly population with symptomatic MR. METHODS: From October 2008 through October 2014, 136 consecutive patients aged ≥ 80 with moderate to severe symptomatic MR were scheduled for either conventional surgery or MitraClip intervention. 56 patients ≥ 80 were operated for symptomatic MR and 80 patients ≥ 80 were treated with the mitraClip device. Patients suitable for this study were identified from our hospital database. Patients ≥80 with moderate/severe symptomatic MR treated with either conventional surgery or the MitraClip device were eligible for our analysis. We compared the surgical patient cohort with the mitraClip patient cohort after eliminating patients that did not meet our inclusion criteria. Forty-two patients were identified from the conventional cohort who were then compared with 42 patients from the mitraClip cohort. Forty-two patients (50%) underwent mitral valve repair or replacement (40.5% functional MR, 59.5% organic/mixed MR) and 42 patients (50%) underwent MitraClip intervention (50% functional MR, 50% organic/mixed MR). Associated procedures in the conventional surgical group were myocardial revascularization 38%, pulmonary vein ablation 23.8%, left atrial appendage resection 52.4% and PFO occlusion 11.9%. RESULTS: Patients who underwent MitraClip treatment were though slightly older but the differences did not attain statistical significance (mean, 82.2 ± 1.65 vs 81.7 ± 1.35 years, p = 0,100), had lower LVEF (mean, 47.6 ± 14.2 vs 53.4 ± 14.3, p = 0.072), lower logistic EuroScore II (mean, 11.3 ± 5.63 vs 12.1 ± 10.6, p = 0.655) but higher STS risk score (mean, 11.8 ± 6.7 vs 8.1 ± 5.6, p = 0.008) respectively compared to surgical patients. Procedural success was 100% vs 96% in surgery and MitraClip groups respectively. Thirty -day mortality was 7.1% vs 4.8% (p = 1.000) in surgery and MitraClip group respectively. Residual postoperative MR ≥2 at discharge was present in none of the patients treated surgically, whereas this was the case in 10 (23.8%) patients treated with the MitraClip device. At 1 year a cumulative number of four (9.52%) patients died in the surgical group vs 9 (21.4%) patients who died in the MitraClip group. CONCLUSIONS: Elderly patients presenting with moderate to severe symptomatic MR may either be treated by conventional surgery or with the MitraClip device with acceptable acute outcomes. The decision for treatment with the MitraClip device should not depend on age alone rather on cumulative risk of conventional surgery. Concomitant cardiac pathologies, often times treated simultaneously during surgery for symptomatic MR may be omitted, if patients are scheduled outright to MitraClip treatment. The effect of concomitant cardiac pathologies left untreated at the time of interventional mitral valve repair on outcome after MitraClip therapy remain widely unknown.

Conventional Surgery for Early and Late Symptomatic Mitral Valve Stenosis After MitraClip® Intervention: An Institutional Experience With Four Consecutive Patients.

BACKGROUND: Surgical mitral valve repair is the gold standard for treatment of mitral regurgitation. Recently, the transcatheter treatment of mitral regurgitation with the MitraClip® device (Abbot Vascular Structural Heart, Menlo Park, CA) has demonstrated promising results in treating patients not amenable for surgical correction of mitral valve regurgitation. Most patients reported in the literature requiring surgical bailout after MitraClip treatment presented with residual or recurrent mitral valve regurgitation. Mitral valve stenosis after MitraClip treatment has been rarely reported. METHODS: From February 2010 to December 2014, four patients out of 165 patients who underwent MitraClip therapy developed symptomatic mitral valve stenosis (2.4%) and needed surgical correction. Data of the four patients were reviewed retrospectively. Follow-up data were obtained from each patient's general practitioner/cardiologist by phone calls and facsimile and were complete in all patients. RESULTS: All four patients were treated with ≥ 2 MitraClip (MC) devices during their initial presentation. All four patients underwent MV replacement with a tissue valve. The postoperative course was uneventful and there was no 30-day mortality. At 6-month follow-up, all patients were alive and in NYHA class I-III. CONCLUSION: Placement of multiple clip devices may lead to slightly elevated transmitral gradients. This may not necessarily interpret into symptomatic mitral stenosis. However, in some cases this is possible. Caution should be exercised at this phase of the learning curve of the percutaneous MC treatment, especially in use of multiple MC devices.

Arthralgia and blood culture-negative endocarditis in middle Age Men suggest tropheryma whipplei infection: report of two cases and review of the literature.

BACKGROUND: Whipple's disease is a rare, often multisystemic chronic infectious disease caused by the rod-shaped bacterium Tropheryma whipplei. Very rarely the heart is involved in the process of the disease, leading to culture-negative infective endocarditis. Up to 20 % of all infective endocarditis are blood culture-negative and therefore a diagnostic challenge. We present two unusual cases of culture-negative infective endocarditis encountered in two different patients with prior history of arthralgia. A history of rheumatic arthritis or even a transient arthralgia should put Tropheryma whipplei on the top of differentials in patients of this age group presenting with culture-negative infective endocarditis, especially in cases of therapy resistance to antirheumatic agents. CASE PRESENTATION: The first patient was a 55 year-old Caucasian male with culture-negative Whipple-related adhesive pericarditis and endocarditis of the aortic valve. Importantly, the patient reported a 15-year history of therapy resistant sero-negative migratory polyarthritis. Aortic valve endocarditis developed during treatment with tocilizumab. The second patient was a 65-year-old male patient with no prior history of the classic Whipple's disease who presented with a culture-negative aortic valve endocarditis. His past medical history revealed episodes of transient arthralgia, which he was not treated for however, due to the self-limiting nature of the symptoms. Both patients underwent aortic valve replacement surgery. During surgery, pericardectomy was necessary in the first patient due to adhesive pericarditis. Post surgery both patients were started on long-term treatment with trimetoprim-sulfamethoxazol. At 1-year follow-up of both patients, echocardiographic and clinical assessment revealed no signs of persistent infection. Both men reported negative history of arthralgia during the one year period post surgery. CONCLUSION: Tropheryma whipplei culture negative-infective endocarditis is an emerging clinical entity, predominantly found in middle-aged and older men with a history of arthralgia. These data highlight the need for ruling out Whipple's disease in patients with a history of arthralgia prior to initiation of biological agents in treatment of rheumatoid arthritis. There is also a need to assess for Tropheryma whipplei in all patients with culture- negative infective endocarditis.

Awake extracorporeal membrane oxygenation (ECMO) as bridge to recovery after left main coronary artery occlusion: a promising concept of haemodynamic support in cardiogenic shock.

Cardiogenic shock following acute myocardial infarction is associated with high mortality rate. Different management concepts including fluid management, inotropic support, intra aortic balloon counterpulsation (IABP) and extracorporeal membrane oxygenation (ECMO) mainly in mechanically ventilated patients have been used as cornerstones of management. However, success rates have been disappointing. Few reports suggested that ECMO when performed under circumvention of mechanical ventilation, may offer some survival benefits. We herein present our experience with the use of veno-arterial ECMO as bridge to recovery in an awake and spontaneously breathing patient after left main coronary artery occlusion complicated by cardiogenic shock.

Percutaneous mitral valve repair with the MitraClip system: perioperative and 1-year follow-up results using standard or multiple clipping strategy.

OBJECTIVES: The purpose of this study was to compare outcomes using standard clipping (SC) (one to two clips) or multiple clipping (MC) (more than two clips). BACKGROUND: MitraClip implantation using MC has been proposed to treat severe mitral regurgitation (MR) in high-risk patients. METHODS AND RESULTS: A tailored strategy was used implanting as many clips as required to eliminate MR. A total of 85 consecutive patients [78 ± 6 years, 48 men (56.5%) ] with MR (grade 3+ or 4+) were included. EuroSCORE was 24 ± 12 (2.5-56.3) and STS-score 12 ± 7 (1.2-31.2). SC was used in 61 (71.8%) and MC in 24 (28.2%) patients. Patients in MC group had larger mitral valve (MV) annuli (P = 0.025), MV orifice areas (MVOA) (P = 0.01), and MR degree (P = 0.005). Successful clip placement was achieved in 82 patients (96.5%). At discharge, no patient had grade 4+ MR. MR 3+ presented in 4 patients (7.0%) in the SC group and in 1 (4.5%) in the MC group (P = 0.72). There were 3 (3.5%) in-hospital deaths. Follow up (211 ± 173 days, range 4-652) echocardiography confirmed similar MVOA (P = 0.83) and MV gradients (P = 0.54) in the both groups. At linear regression there was no independent correlation between clips number and postoperative MVOA/gradient. One-year survival was 71.1% without difference between groups (P = 0.74). CONCLUSION: Although the hemodynamic and anatomical basis of MR may differ, every procedure should aim at eliminating MR. In some patients this goal can be achieved using MC with minimized risk of MV stenosis if preoperative anatomy/mechanism of MV regurgitation are adequately assessed.

Bilateral tension pneumothoraces leading to cardiac arrest after coronary artery bypass surgery.

Bilateral pneumothoraces are a very rare event. In clinical settings, inadvertent incursion into the pleural space resulting from diagnostic or therapeutic medical interventions such as bilateral venipunctures or damage to the lung parenchyma due to high pressure ventilation may be causative. Bilateral pneumothoraces postcardiac surgery are rarely reported. We present the case of bilateral tension pneumothoraces leading up to cardiorespiratory arrest in a 57-year-old male, weighing 130 kg, who underwent without any complications a coronary artery bypass surgery. Thoracic chest tubes (retrosternal and intrapericardial) and a left pleural tube were removed 24 hours prior to the incident. Diffuse sternal pain sensation accompanied by slow progressive respiratory distress and confusion shortly before the incident were all developed over a period of 12 hours. A prompt cardiopulmonary resuscitation and bilateral chest tube insertion had prevented a fatality in the patient.

Culture-negative infective endocarditis of the aortic valve due to Aerococcus urinae: a rare aetiology.

Bacteria of the species Aerococcus urinae are Gram-positive, catalase-negative cocci that are arranged in pairs, tetrads, or clusters resembling enterococci or staphylococci. They are rare causative agents of infective endocarditis. Repetitive urinary tract infections based upon underlying genitourinary tract abnormalities could involve these bacteria. Due to their similarity to other Gram-positive cocci misinterpretation may occur along the line of microbiologic differentiation, which could potentially lead to a fatal outcome. We herein report on the clinical course of a 68 year-old male patient who in the setting of an embolic stroke was initially diagnosed with a culture-negative acute infective endocarditis of the aortic valve.

Uncomplicated prior right ventricular perforation due to a pacemaker lead - an incidental finding during coronary artery bypass surgery.

An elective coronary artery bypass grafting (CABG) surgery was performed on a 50-year-old male with an implanted two-chamber pacemaker in our clinic. Right ventricular adhesion to the inferior pericardium was detected following pericardiotomy. After the institution of cardiopulmonary bypass (CPB), careful preparation of the adhesion revealed prior perforation due to an indwelling ventricular pacemaker lead.

Infective endocarditis due to Bartonella quintana: a challenging diagnostic entity.

Bartonella quintana is a gram-negative microorganism, which may lead to infective endocarditis especially in compromised patients. The major concern about this pathogen is the diagnosis and detection. Furthermore, the treatment of the infection has been a challenge for physicians. In this report, we present a 71-year-old patient with Bartonella quintana aortic valve endocarditis from the view of diagnosis and treatment aspects.

Autologous bone marrow stem cell therapy for the ischemic myocardium during coronary artery bypass grafting.

Cardiovascular diseases remain the leading cause of morbidity and mortality worldwide. Especially the treatment of ischemic heart disease challenges physicians despite recent advances in medical and operative strategies. Due to the considerable developments in regenerative medicine cell-based treatment for ischemic heart disease has attracted great interest in the last decade. Numerous experimental and clinical approaches employing stem cell treatment from various sources and using different methods of cell delivery have shown improvement in cardiac function after acute or chronic ischemic jeopardy. In this report we will focus on our long-term experience on the safety of bone marrow derived CD133(+) stem cell transplantation with concomitant coronary artery bypass surgery and provide an overview of the current knowledge on utilizing cell-based treatment for ischemic heart disease.

Intramyocardial fate and effect of iron nanoparticles co-injected with MACS® purified stem cell products.

BACKGROUND: Magnetic activated cell sorting (MACS®) is routinely used to isolate stem cell subpopulations intended for the treatment of cardiovascular diseases. In strong contrast, studies examining the amount, effect and intramyocardial distribution of iron nanoparticles used for magnetic cell labelling are missing, although iron excess can cause functional disorders in the heart. METHODS AND RESULTS: CD133+ haematopoietic and CD271+ mesenchymal stem cells were purified from bone marrow using automatically and manually MACS® based systems. Flow cytometric measurements demonstrated a rapid loss of MACS® MicroBeads from cells under culture conditions, while storage under hypothermic conditions decelerated their detachment. Moreover, an average loading of ∼11 fg iron/cell caused by magnetic labelling was determined in magnetic particle spectroscopy. Importantly, hemodynamic measurements as well as histological examinations using a myocardial ischemia/reperfusion mouse model showed no influence of MACS® MicroBeads on cardiac regeneration, while the transplantation of stem cells caused a significant improvement. Furthermore, immunostainings demonstrated the clearance of co-injected iron nanoparticles from stem cells and the surrounding heart tissue within 48 h post transplantation. CONCLUSIONS: Our results indicate that iron amounts typically co-injected with MACS® purified stem cells do not harm cardiac functions and are cleared from heart tissue within a few hours. Therefore, we conclude that MACS® MicroBeads exhibit a good compatibility in the cardiac environment.

Streptococcus bovis infectious endocarditis and occult gastrointestinal neoplasia: experience with 25 consecutive patients treated surgically.

To assess the prevalence of gastrointestinal neoplasia in patients with Streptococcus bovis infectious endocarditis we performed a retrospective cohort analysis of all episodes of S. bovis infectious endocarditis treated at our institution between January 2000 through December 2014. Twenty-five patients were identified for this purpose. 12/25 patients received colonoscopy and 1/25 of the patients was assessed with CT colonography. Of the 13 who underwent colonic assessment, 11 were diagnosed with colonic neoplasms at different stages of development. In the absence of any strong contraindication, gastroenteroscopic evaluation in all patients diagnosed with S. bovis infectious endocarditis should be pursued.

Progressive Staphylococcus lugdunensis endocarditis despite antibiotic treatment.

A 68-year old man with fever chills and a diastolic murmur was diagnosed with aortic-valve endocarditis caused by coagulase-negative Staphylococcus lugdunensis. The clinical condition initially improved with antibiotic therapy. On day seven, transoesophageal echocardiography revealed large abscesses extending from the aortic root to the left ventricular wall. Emergency cardiac surgery was performed successfully and a stentless bioprosthetic valve was inserted. S. lugdunensis endocarditis is known for its aggressive clinical course with valve destruction, abscess formation and embolic complications despite appropriate antibiotics. Antibiotic treatment alone is associated with a high mortality rate which can be reduced by early valve replacement.

Surgical revision after percutaneous mitral valve repair by edge-to-edge device: when the strategy fails in the highest risk surgical population.

OBJECTIVES: Percutaneous edge-to-edge devices for non-surgical repair of mitral valve regurgitation are under clinical evaluation in high-risk patients deemed not suitable for conventional surgery. To address guidelines for initial therapy decision, we here report on 13 cases of surgery after failed percutaneous edge-to-edge mitral valve repair or attempted repair, and discuss methodology and prognostic factors for operative outcome in this high-risk situation. METHODS: Thirteen patients referred to our cardiothoracic unit after failed percutaneous mitral valve repair or attempted repair using the edge-to-edge technique, were treated surgically for mitral valve failure between June 2010 and December 2012. Pathology of mitral valve before and after interventional mitral valve repair (especially prevalent mode of failure) was evaluated and classified for each individual patient by echocardiography and intraoperative direct visualization. Number of implanted edge-to-edge devices were identified. Preoperative risk scores were matched with intraoperative observations and histopathological findings of valve tissue. Postoperative morbidity and mortality were analysed with respect to mitral valve and patient-related data. RESULTS: Three of 10 patients were referred with severe mitral valve regurgitation/stenosis after initially successful percutaneous edge-to-edge therapy or attempted therapy. In 3 patients, ≥ 2 edge-to-edge devices were implanted leading to very tight edge-to-edge leaflet connection and fibrosis. All patients underwent successful surgical mitral valve replacement and concomitant complete cardiac surgery (CABG, aortic or tricuspid valve surgery, ASD closure and pulmonary vein isolation for atrial fibrillation). The likelihood of repair was reduced with respect to multiple edge-to-edge technology. One device could not be harvested surgically because of embolization. One patient died on the second postoperative day due to sepsis with multiple organ failure. The remaining 12 patients were discharged with excellent valve prosthesis function and followed up to 2 years post-surgery. The current long-term survival rate is 77%. CONCLUSION: Our series demonstrate that highest risk patients can survive mitral valve surgery after failed multiple edge-to-edge interventional mitral valve repair. As long-term results of the MitraClip therapy are pending, we recommend close meshed follow-up of patients treated with the MitraClip device, especially within the first year of the index procedure as delays in salvage management, interventional or surgical, when the index procedure fails may increase morbidity and mortality.

Percutaneous mitral repair with the MitraClip system in patients with mild-to-moderate and severe heart failure: a single-centre experience.

AIMS: Edge-to-edge repair of mitral regurgitation (MR) with the MitraClip(®) (MC) system is increasingly applied in advanced heart failure. Our objective was to compare outcomes in patients with mild-to-moderate and severe systolic heart failure. METHODS AND RESULTS: Between February 2010 and July 2012, 121 patients with MR of at least grade 3+ and a mean EuroSCORE II of 10.6% underwent MC implantation. Thirty-nine had a left ventricular ejection fraction (LVEF) of ≤30% (group A) and 82 of >30% (group B). Procedural success was comparable in both groups (100% vs. 95.2%) with multiple (>2) clip implantation in 34% and 25% of patients, respectively. At 12 months, absolute reduction in MR grade (2.3 vs. 2.2) and relative reduction in mitral valve orifice area (48% vs. 42%) were also comparable. New York Heart Association class had improved independent from baseline LVEF (P < 0.001). In-hospital mortality was low in both groups (2.6% vs. 2.4%), but there was a strong trend for higher 12-month mortality in group A (34% vs. 18%, P = 0.05) with no significant difference in the overall rate of major adverse cerebrovascular and cardiac events (36.8% vs. 28.9%, P = 0.38). On multivariate analysis, MR grade after repair was the strongest predictor of mortality (OR 2.121, 95% CI 1.095-4.109), whereas systolic impairment was no independent predictor. CONCLUSIONS: Percutaneous mitral valve repair led to comparable symptomatic improvement in patients with mild-to-moderately or severely reduced LV function. LV-EF < 30% was not an independent predictor of short-term mortality, which was mainly governed by residual MR after repair.