Surgical management of embolized Amplatzer septal occluder into the left ventricle tangled with the mitral valve.

Device embolization is a rare major complication of atrial septal defect percutaneous closures which requires surgical management if noninvasive retrieval fails. We report a symptomatic delayed embolization of an Amplatzer septal occluder device into the left ventricle outflow tract tangled with the mitral valve, complicated with ventricular arrhythmias and cardiac tamponade during percutaneous retrieval attempt. Emergent surgical treatment was performed, requiring a combined approach through the right atrium and the aorta for surgical removal.

Trileaflet Mitral Valve Treated with the MitraClip® System.

A 79-year-old woman with a history of ischemic dilated cardiomyopathy, severely depressed left ventricular ejection fraction and significant mitral regurgitation (MR) was admitted to the authors´ institution for percutaneous mitral valve repair. Transesophageal echocardiography (TEE) revealed the presence of a posterior mitral cleft at the P2 level, causing a trileaflet mitral valve that contributed significantly to the regurgitant jet. The procedure was performed under general anesthesia and guided by real-time three-dimensional TEE. Three MitraClip® devices (Abbott Vascular, Santa Clara, CA, USA) were implanted, which reduced the MR to grade 1+.

Survival Advantage of MitraClip® Over Medical Treatment in Patients with Mitral Regurgitation: A Meta-Analysis.

BACKGROUND: The MitraClip® system is a percutaneous treatment for mitral regurgitation (MR) that has shown promising results in patients who are inoperable or at high risk for mitral surgery. Data on the efficacy of the system over optimal medical therapy, above all in patients with functional MR, are scarce. The study aim was to assess the effect of MitraClip on the survival of patients with moderate/severe or severe MR compared to medical therapy, using meta-analytical techniques. METHODS: Independently, reviewers searched electronically for relevant articles based on predefined criteria and end-points. Only articles with a comparison between MitraClip and conservative therapy were included. Standard meta-analysis techniques were used. The primary outcomes were 30-day and one-year mortalities. RESULTS: Five observational reports were included that enrolled a total of 1,271 patients: 720 patients underwent percutaneous mitral valve repair (PMVR) with the MitraClip device, and 551 were managed conservatively. A total of 49 all-cause mortality events was reported at 30 days: 3.05% (22/720) in the PMVR arm, and 4.90% (27/510) in the conservative group, with no significant differences in all-cause mortality (OR 0.64; 95% CI 0.36-1.14). A total of 269 all-cause mortality events at one year was reported: 15.14% (109/720) in the PMVR arm, and 29.04% (160/551) in the conservative group. A significant difference favoring PMVR with the MitraClip system over medical therapy alone was observed (OR 0.44; 95% CI 0.30-0.64, p <0.0001). Neither significance between study heterogeneity (p = 0.18) nor publication bias was detected (p = 0.3). CONCLUSIONS: PMVR with the MitraClip system may be associated with an improvement in one-year survival compared to stand-alone medical management.

Transapical mitral valve-in-valve ring implantation with the Edwards Sapien 3 prosthesis.

We present the case of a high-risk patient with symptomatic severe mitral regurgitation following a surgical annuloplasty ring. An inverted aortic Edwards Sapien 3 bioprosthesis (Edwards Lifesciences, Irvine, CA) was successfully implanted through a transapical approach inside the previously implanted annuloplasty ring.

A Simple Technique for Aortic Root Dissection and Massive Aortic Regurgitation Repair after Blunt Chest Trauma.

Aortic regurgitation due to valve injury after blunt chest trauma is a rare condition that may be caused by leaflet or commissural rupture, aortic dissection, or a combination of both. The case is presented of a 48-year-old male patient with an aortic dissection and aortic valve commissural detachment and massive aortic regurgitation after a 12-meter vertical free fall and secondary thoracic blunt trauma. The aortic root tear and dissection was repaired with a continuous polypropylene 5/0 suture and subcommissural annuloplasty that restored the aortic valve geometry and resulted in a normally functioning aortic valve.

Subclinical Hypothyroidism Might Increase the Risk of Postoperative Atrial Fibrillation after Aortic Valve Replacement.

Background To evaluate the influence of subclinical hypothyroidism (SCH) on the development of postoperative atrial fibrillation (AF) in patients undergoing aortic valve replacement surgery with extracorporeal circulation. Methods A prospective study in a tertiary hospital between July 2005 and December 2013 in which all patients undergoing aortic valve replacement with no other valve surgery were consecutively included. Patients who were in preoperative sinus rhythm were selected and they underwent thyroxine (T4) and thyroid-stimulating hormone determination in the month before surgery. Postoperative AF was defined as the development of AF during hospital admittance. Descriptive analysis and binary logistic regression were performed for the target variable. Results A total of 467 patients were studied, with 35 cases of SCH. The incidence of postoperative AF was 57% in the group with SCH versus 30.3% (p = 0.001) in the group without hypothyroidism, without significant differences in other postoperative complications. In the logistic regression analysis, the independent predictors of postoperative AF were SCH, age, and aortic clamping time. SCH multiplies the odds ratio of postoperative AF by 3.14 (95% confidence interval: 1.24-7.96). Conclusion SCH behaves like a risk factor for the development of postoperative AF in patients undergoing aortic valve replacement with extracorporeal circulation. Other studies are needed to determine whether preoperative T4 replacement therapy and/or more aggressive AF prophylaxis can prevent this complication in patients undergoing aortic valve replacement.

Insertion of an Edwards Sapien 3 prosthesis as a mitral valve in valve implantation via a transapical approach.

We report a case of transapical mitral valve-in-valve implantation for a deteriorated bioprosthesis using the Edwards Sapien 3 prosthesis via the transapical approach. This case demonstrates the safety and feasibility of using the Edwards Sapien 3 prosthesis in treating degenerated bioprosthetic mitral valves.

[Readability of surgical informed consent in Spain]. / Legibilidad del consentimiento informado quirúrgico en España.

INTRODUCTION: To assess the readability of informed consent documents (IC) of the different national surgical societies. METHODS: During January 2012 we collected 504 IC protocols of different specialties. To calculate readability parameters the following criteria were assessed: number of words, syllables and phrases, syllables/word and word/phrase averages, Word correlation index, Flesch-Szigriszt index, Huerta Fernández index, Inflesz scale degree and the Gunning-Fog index. RESULTS: The mean Flesch-Szigriszt index was 50.65 ± 6,72, so readability is considered normal. There are significant differences between specialties such as Urology (43.00 ± 4.17) and Angiology and Vascular Surgery (63.00 ± 3.26, P<.001). No IC would be appropriate for adult readability according to the Fernández-Huerta index (total mean 55.77 ± 6.57); the IC of Angiology and Vascular Surgery were the closest ones (67.85 ± 3.20). Considering the Inflesz scale degree (total mean of 2.84 ± 3,23), IC can be described as «somewhat difficult¼. There are significant differences between the IC of Angiology and Vascular Surgery (3.23 ± 0.47) that could be qualified as normal, or Cardiovascular Surgery (2.79 ± 0.43) as «nearly normal readability¼; and others such as Urology (1, 70 ± 0.46, P<.001) and Thoracic Surgery (1.90 ± 0.30, P<.001), with a readability between «very¼ and «somewhat¼ difficult. The Gunning-Fog indexes are far from the readability for a general audience (total mean of 26.29 ± 10,89). CONCLUSIONS: IC developed by scientific societies of different surgical specialties do not have an adequate readability for patients. We recommend the use of readability indexes during the writing of these consent forms.

Global Longitudinal Strain Predicts Outcomes in Patients with Reduced Left Ventricular Function Undergoing Transcatheter Edge-to-Edge Mitral Repair.

BACKGROUND: The timing and selection of optimal candidates for mitral transcatheter edge-to-edge valve repair remains to be fully determined, especially in cases with severely depressed left ventricular ejection fraction (LVEF). The objective of this study is to evaluate the prognostic value of myocardial strain (LVGLS) in this setting. METHODS: Retrospectively, 172 consecutive patients with LVEF ≤40% and severe MR treated with MitraClip were included. Four groups were generated according to the LVEF (<30% or ≥30%) and median LVGLS. The primary end-point was cardiovascular mortality. RESULTS: Procedural success was high (96.5%) and complications were rare. At one-year follow-up, 82.5% of patients maintained MR grade ≤2, 79.2% were at a NYHA class ≤II and a reduction of 80% in heart failure admissions was observed in all groups. Interestingly, among patients with a more depressed LVEF, LVGLS was found to be an independent predictor for cardiovascular mortality (HR: 3.3; 95% CI: 1.1-10, p = 0.023). CONCLUSIONS: Mitral valve repair with MitraClip is safe and it improves the mid-term functional class of patients regardless of LVEF. LVGLS can help in the selection of optimal candidates and timing for this procedure, as well as in the recognition of those patients with worse prognoses.

Placement of a rigid tricuspid annuloplasty ring over a flexible ring for the treatment of recurrent tricuspid regurgitation.

We describe a technique that implants a rigid tricuspid annuloplasty ring over a previously inserted flexible ring for the treatment of recurrent tricuspid regurgitation. This technique avoids the trauma associated with the excision of a flexible ring in patients with friable annular tissue.

Prognostic Impact of Nutritional Status After Transcatheter Edge-to-Edge Mitral Valve Repair: The MIVNUT Registry.

Background Malnutrition is associated with poor prognosis in several cardiovascular diseases. However, its prognostic impact in patients undergoing transcatheter edge-to-edge mitral valve repair (TEER) is not well known. This study sought to assess the prevalence, clinical associations, and prognostic consequences of malnutrition in patients undergoing TEER. Methods and Results A total of 892 patients undergoing TEER from the international MIVNUT (Mitral Valve Repair and Nutritional Status) registry were studied. Malnutrition status was assessed with the Controlling Nutritional Status score. The association of nutritional status with mortality was analyzed with multivariable Cox regression models, whereas the association with heart failure admission was assessed by Fine-Gray models, with death as a competing risk. According to the Controlling Nutritional Status score, 74.4% of patients with TEER had any degree of malnutrition at the time of TEER (75.1% in patients with body mass index <25 kg/m2, 72.1% in those with body mass index ≥25 kg/m2). However, only 20% had moderate-severe malnutrition. TEER was successful in most of patients (94.2%). During a median follow-up of 1.6 years (interquartile range, 0.6-3.0), 267 (29.9%) patients died and 256 patients (28.7%) were admitted for heart failure after TEER. Compared with normal nutritional status moderate-severe malnutrition resulted a strong predictor of mortality (adjusted hazard ratio [HR], 2.1 [95% CI, 1.1-2.4]; P<0.001) and heart failure admission (adjusted subdistribution HR, 1.6 [95% CI, 1.1-2.4]; P=0.015). Conclusions Malnutrition is common among patients submitted to TEER, and moderate-severe malnutrition is strongly associated with increased mortality and heart failure readmission. Assessment of nutritional status in these patients may help to improve risk stratification.

A Score to Assess Mortality After Percutaneous Mitral Valve Repair.

BACKGROUND: Risk stratification for transcatheter edge-to-edge mitral valve repair (TEER) is paramount in the decision-making process for treating severe mitral regurgitation (MR). OBJECTIVES: This study sought to create and validate a user-friendly score (MitraScore) to predict the risk of mortality in patients undergoing TEER. METHODS: The derivation cohort was based on a multicentric international registry that included 1,119 patients referred for TEER between 2012 and 2020. Score discrimination was assessed using Harrell's c-statistic, and the calibration was evaluated with the Gronnesby and Borgan goodness-of-fit test. An external validation was carried out in 725 patients from the GIOTTO registry. RESULTS: After multivariate analysis, we identified 8 independent predictors of mortality during the follow-up (2.1 ± 1.8 years): age ≥75 years, anemia, glomerular filtrate rate <60 mL/min/1.73 m2, left ventricular ejection fraction <40%, peripheral artery disease, chronic obstructive pulmonary disease, high diuretic dose, and no therapy with renin-angiotensin system inhibitors. The MitraScore was derived by assigning 1 point to each independent predictor. The c-statistic was 0.70. Per each point of the MitraScore, the relative risk of mortality increased by 55% (HR: 1.55; 95% CI: 1.44-1.67; P < 0.001). The discrimination and calibration for mortality prediction was better than those of EuroSCORE II (c-statistic 0.61) or Society of Thoracic Surgeons score (c-statistic 0.57). The MitraScore maintained adequate performance in the validation cohort (c-statistic 0.66). The score was also predictive for heart failure rehospitalization and was correlated with the probability of clinical improvement. CONCLUSIONS: The MitraScore is a simple prediction algorithm for the prediction of follow-up mortality in patients treated with TEER.

Cryoablation of atrial fibrillation in cardiac surgery: outcomes and myocardial injury biomarkers.

OBJECTIVE: Elevations of myocardial injury biomarkers after cardiac surgery without ablation of atrial fibrillation (AF) are related to perioperative myocardial ischemia and associated with an increased risk of mortality and cardiac events. However, there have not been any studies that examined the release of cardiac biomarkers after AF cryoablation procedures with concomitant cardiac surgery. The authors determined the levels of these biomarkers for 2 different procedures involving cryoablation and assessed their clinical implications. DESIGN: A prospective cohort study with cardiac surgical patients. SETTING: A tertiary care university hospital. PARTICIPANTS: One hundred fifty-two cardiac surgical patients. INTERVENTIONS: Patients underwent 1 of 2 different cryoablation approaches: the modified Cox-Maze (CM) III procedure (n = 63) or the isolated left atrial (LA) maze procedure (n = 89). Plasma levels of cardiac biomarkers were measured at 1, 6, 12, and 24 hours after surgery. Twenty-four-hour Holter monitoring was performed at 1 month and 1 year after surgery. MEASUREMENTS AND MAIN RESULTS: Both groups reached very high peak levels of CPK-MB (CM group, 368 ± 171.4 ng/mL and LA group, 203 ± 86.4 ng/mL) and troponin T (CM, 8 ± 4.5 ng/mL and LA, 3.4 ± 2.4 ng/mL). The CPK, CPK-MB, and troponin T levels were significantly higher in the modified CM group compared with the LA maze group. In the first 24 hours after surgery, the average CPK-MB and troponin T values were 78.2 ng/mL higher and 2.3 ng/mL higher, respectively, in the CM group compared with the LA group. In both groups, 79% of the patients remained free of AF at 12 months after surgery. CONCLUSIONS: Cryoablation in cardiac surgery causes the release of very high levels of myocardial injury biomarkers. The modified CM lesion causes a greater elevation of serum biomarker levels than the isolated LA maze procedure, but this increase does not seem to have an adverse effect on rhythm or overall outcome. Cryoablation is a safe and effective surgical treatment for AF.

Clinical Outcomes Following Urgent vs. Elective Percutaneous Mitral Valve Repair.

AIM: To examine procedural and clinical outcomes among patients undergoing percutaneous mitral valve repair (PMVR) within an admission for acute-decompensated heart failure (ADHF). METHODS AND RESULTS: Prospective registry of all consecutive patients with symptomatic mitral regurgitation (MR) grade 3+ or 4+ who underwent PMVR our centre and classified in 2 groups: elective group and urgent PMVR group (within the index admission for ADHF). Echocardiographic, procedural and clinical outcomes were compared between groups. 85 patients (median age 77.0 [67.8-83.4] years, 64.7% male) were treated within the recruitment period. Among them, 17 (20%) underwent urgent MitraClip®. Urgent PMVR were at a higher risk for conventional surgery (p = 0.002) and had worse estimated prognosis according to HF risk scores (p < 0.001). Overall technical success was 100%, without differences between groups. At 30 days, no differences were found in mortality, MR reduction and in NYHA functional improvement between groups. Cumulative estimated survival free from all-cause death was 92.9% (82.4% vs. 95.6%), 89.4% (82.4% vs. 91.1%), 76.3% (82.4 vs. 74.9%) at 6 months, 1-year and 2-years, respectively, with no significant differences between urgent or elective PMVR (p = 0.769). CONCLUSION: MitraClip® implantation can be considered as an urgent therapy during admission for ADHF.

Clinical and echocardiographic outcomes of transcatheter mitral valve repair in atrial functional mitral regurgitation.

BACKGROUND: Isolated atrial fibrillation can cause mitral regurgitation (MR) in patients with normal left ventricular systolic function and no organic disease of the mitral valve. Little information is available regarding outcomes of Mitraclip in patients with atrial functional mitral regurgitation (AFMR). We aimed to evaluate 12-month clinical and echocardiographic outcomes of transcatheter mitral valve repair (TMVR) with MitraClip in patients with AFMR compared to those with ventricular functional or degenerative/mixed MR. METHODS: Registry-based analysis of all consecutive patients who underwent TMVR and were included in the Spanish Registry of Mitraclip. Changes in MR and NYHA functional class, and a combined endpoint including all-cause mortality and hospitalizations due to heart failure were the main outcomes. RESULTS: Overall, 1074 (69.1% male, 73.3 ± 10.2 years-old) patients were analyzed in this report. 48 patients (4.5%) presented AFMR. AFMR was significantly reduced after TMVR, with a procedural success rate of 91.7%, and this reduction persisted at 12-month (p < 0.001). Patients with AFMR showed a significant functional improvement at 6- and 12-month follow-up in our series (baseline: NYHA III 70.8% IV 18.8% vs. 1-year: NYHA III 21.7% IV 0%; p < 0.001). The probability of survival free of readmission for heart failure and all-cause mortality within the first year after TMVR was 74.9%. Procedural and clinical outcomes, as well as recurrent rates of MR were similar acutely and at 1-year compared to other etiologies. CONCLUSION: TMVR in patients with AFMR showed no significant differences compared to ventricular functional or degenerative/mixed MR regarding MR reduction or clinical outcomes.

Surgical treatment of giant intramural left ventricular fibroma in an adult patient with refractory ventricular tachycardia.

Cardiac fibromas are rare benign tumors predominantly diagnosed in children and teenagers. We report a 57-year-old male patient with class II dyspnea and angina. During electrocardiographic assessment, recurrent ventricular tachycardia was present and magnetic resonance imaging revealed a giant (12.5 × 5 × 4 cm) intramural left ventricular tumor compatible with cardiac fibroma. After surgical biopsy and histological confirmation, open-heart surgical resection was successfully performed. After nine months of follow up, the patient remains asymptomatic without evidence of ventricular tachycardia.

Beneficial effect of left atrial appendage closure during cardiac surgery: a meta-analysis of 280 585 patients.

In non-rheumatic atrial fibrillation (AF), left atrial appendage (LAA) is thought to be the source of embolism in 90% of the strokes. Thus, as recent clinical trials have shown the non-inferiority of percutaneous LAA closure (LAAc) in comparison to medical treatment, and despite a IIb recommendation in the latest guidelines for concomitant surgical LAAc, we sought to investigate the beneficial effect of LAAc in the surgical population. A meta-analysis model was performed comparing studies including any cardiac surgery with or without concomitant surgical LAAc reporting stoke/embolic events and/or mortality, from inception to January 2019. Twenty-two studies (280 585 patients) were included in the model. Stroke/embolic events both in the perioperative period [relative risk (RR) 0.66, 95% confidence interval (CI) 0.53-0.82; P = 0.0001] and during follow-up of >2 years (RR 0.67, 95% CI 0.51-0.89; P < 0.005) were significantly reduced in patients who underwent surgical LAAc (RR 0.71, 95% CI 0.58-0.87; P = 0.001). Regarding the rate of preoperative AF, LAAc showed protective effect against stroke/embolic events in studies with >70% preoperative AF (RR 0.64, 95% CI 0.53-0.77; P < 0.00001) but no benefit in the studies with <30% of preoperative AF (RR 0.77, 95% CI 0.46-1.28; P = 0.31). Postoperative mortality was also significantly lower in surgical patients with LAAc at the mid- and long-term follow-up. (RR 0.72, 95% CI 0.67-0.78; P < 0.00001; I2 = 0%). Based on these findings, concomitant surgical LAAc is associated with lower rates of embolic events and stroke in the postoperative period in patients with preoperative AF and also improves postoperative mortality in the mid- and long-term follow-up.

Percutaneous treatment with Mitraclip for functional mitral regurgitation: medium-term follow up according to left ventricular function.

BACKGROUND: Functional mitral regurgitation (FMR) is a bad prognosis condition despite optimal medical treatment. Nowadays there is an open debate about the surgical versus percutaneous treatment. The main objective of this study is to evaluate the mid-term follow up clinical outcomes of patients with FMR treated with MitraClip® system, according to their left ventricular ejection fraction (LVEF). METHODS: Data was obtained from two experienced centers in transcatheter mitral valve repair (TMVR). All consecutive cases of severe FMR undergoing TMVR in both centers with the same inclusion criteria were included prospectively in this study and followed-up. Periodical follow-ups with clinical and echocardiographic evaluation were scheduled from the baseline procedure, at 3 months and then yearly. RESULTS: From October 2015 to October 2019, a total of 119 patients with FMR at 2 centers in Spain underwent TMVR with the MitraClip® procedure and were included in this study. The mean age was 73.8±8.9 years old and 32 patients (26.9%) were female. A 39.5% of cases [47] had a LVEF ≤30% (group 1) and 60.5% (72 cases) had a LVEF >30% (group 2). There was a similar distribution in cardiovascular risk factors, age and other diseases. All MitraClip® implantations were elective and procedural success was achieved in 110 patients (92.4%) with a similar distribution between the groups. There were no differences in procedural time and the number of implanted clips. The median follow-up was 22.6 months (IQR, 11.43-34.98 months). The primary combined endpoint occurred in the 41.6% of the global cohort, 57.5% in group 1 and 30.99% in group 2 (P=0.036). LVEF was associated to the main event in the multivariate analysis (HR 2.09, 95% CI: 1.12-3.89; P=0.02). CONCLUSIONS: The MitraClip edge-to-edge technique is a safe and effective procedure for the treatment of FMR. In this study, patients with LVEF >30% treated with Mitraclip presented better clinical cardiovascular outcomes than those with a LVEF ≤30%. Regardless clinical outcomes, at the end of the follow-up, there was a sustained reduction in MR grades and an important improvement in NYHA functional class.