Mitral annular disjunction in surgical mitral valve prolapse: prevalence, characteristics and outcomes.

BACKGROUND: There is a paucity of literature regarding outcomes of patients with mitral valve prolapse (MVP) and mitral annular disjunction (MAD) after mitral surgery, with many unanswered questions including the post-surgical persistence of MAD, effect of MAD on mitral valve reparability, and incidence of arrhythmia after mitral valve surgery. We aimed to examine the prevalence, imaging characteristics and clinical associations of mitral annular disjunction among patients undergoing mitral valve surgery for mitral valve prolapse, as well as outcomes after surgery including the persistence of MAD, arrhythmic events and excess mortality. RESULTS: A retrospective analysis of 111 consecutive patients who underwent mitral valve surgery for MVP was performed. A total of 32 patients (28.8%) had MAD. Patients with MAD were younger (64 vs 67 yrs, p = 0.04), with lower rates of hypertension (21.9% vs 50.6%, p = 0.01) and hyperlipidaemia (25% vs 50.6%; p = 0.01) and were more likely to be female (43.8% vs 21.4%, p = 0.04) with myxomatous leaflets > 5mm (90.6% vs 15.2%, p = < 0.01) and bileaflet prolapse (31.3% vs 10.1%, p = 0.02). Mitral valve repair was performed in 29/32 patients (90.6%) in the MAD positive group, and no patients had the persistence of MAD post-surgery. Post-operative ventricular arrhythmia was higher in the MAD positive group (28.13% vs 11.69%, p = 0.04) with no difference in mortality, 30-day hospital re-admission, or post-operative mitral regurgitation between patients with and without MAD over 3.91 years of follow up. CONCLUSION: In this study of consecutive patients with MVP undergoing surgery, MAD was a common finding (almost 1 in 3). MAD does not compromise mitral valve surgical reparability, and both repair and replacement are effective at correcting disjunction. Our data suggest that concurrent MAD in MVP patients undergoing surgery has no significant effect on post surgical outcomes. Further research as to whether this patient cohort requires post-surgical arrhythmia monitoring is warranted.

Primary Cardiac Lymphoma Presenting with Thrombocytopenia, Right Heart Failure, and Cardiogenic Shock.

Primary cardiac lymphoma (PCL) is a rare, potentially fatal subtype of non-Hodgkin's lymphoma. Thrombocytopenia has also infrequently been reported in association with other primary cardiac tumours and can add substantial morbidity to an already life-threatening diagnosis if present. We report a rare case of a 70-year-old man who presented with thrombocytopenia (91 × 109/L) and progressive right heart failure. Transthoracic echocardiogram revealed a large 8 × 4 cm right atrial mass with severe tricuspid obstruction, confirmed as PCL on subsequent endomyocardial biopsy and immunohistochemistry. He deteriorated into cardiogenic shock precipitated by atrial fibrillation, with worsening thrombocytopenia (18 × 109/L) in the setting of ischaemic hepatitis. The patient stabilised with initiation of high dose steroids prior to tissue diagnosis and platelet counts normalised following chemotherapy. This case demonstrates the importance of considering PCL as a diagnosis and preemptive initiation of high dose steroids to improve outcomes in PCL associated with cardiogenic shock. This case also elucidates a potential pathophysiological association between PCL and thrombocytopenia.

Valve-in-Ring Transcatheter Heart Valve for Severe Tricuspid Regurgitation.

We report the case of a man with recurrent decompensated right-sided heart failure secondary to severe tricuspid regurgitation after tricuspid annuloplasty. He was unfit for repeat surgical intervention and thus was considered for a valve-in-ring transcatheter heart valve. We detail the procedural complexities encountered and our approach to overcoming them. (Level of Difficulty: Advanced.).

Left atrial band: a rare congenital anomaly.

Left atrial fibromuscular band is a rare congenital cardiac anomaly. We present a patient with an incidental finding of left atrial band on an intra-operative transesophageal echocardiogram and characterize its appearance on two-dimensional and three-dimensional echocardiograms.

Recurrent ischaemic mitral regurgitation post mitral annuloplasty due to suture dehiscence evaluated using real time three dimensional transoesophageal echocardiography.

Ischaemic mitral regurgitation after myocardial infarction results from geometric changes in left ventricular shape and displacement of papillary muscles with resultant tethering and incomplete leaflet coaptation of mitral leaflets. Post mitral valve repair, both valve apparatus related factors such as persistent leaflet tethering and progressive left ventricular adverse remodelling and procedure related factors such as ring dehiscence are important causes of recurrent mitral regurgitation after initial undersized mitral ring annuloplasty. Three-dimensional echocardiography is a novel clinical tool that has the potential to provide additional anatomical and functional information regarding the mechanism of recurrent mitral regurgitation post mitral valve repair that is complementary to standard two dimensional transoesophageal echocardiography thus helping guide the most appropriate subsequent therapeutic intervention.

Real-time 3D transesophageal echocardiography for the evaluation of rheumatic mitral stenosis.

OBJECTIVES: The aims of this study were: 1) to assess the feasibility and reliability of performing mitral valve area (MVA) measurements in patients with rheumatic mitral valve stenosis (RhMS) using real-time 3-dimensional transesophageal echocardiography (3DTEE) planimetry (MVA(3D)); 2) to compare MVA(3D) with conventional techniques: 2-dimensional (2D) planimetry (MVA(2D)), pressure half-time (MVA(PHT)), and continuity equation (MVA(CON)); and 3) to evaluate the degree of mitral commissural fusion. BACKGROUND: 3DTEE is a novel technique that provides excellent image quality of the mitral valve. Real-time 3DTEE is a relatively recent enhancement of this technique. To date, there have been no feasibility studies investigating the utility of real-time 3DTEE in the assessment of RhMS. METHODS: Forty-three consecutive patients referred for echocardiographic evaluation of RhMS and suitability for percutaneous mitral valvuloplasty were assessed using 2D transthoracic echocardiography and real-time 3DTEE. MVA(3D), MVA(2D), MVA(PHT), MVA(CON), and the degree of commissural fusion were evaluated. RESULTS: MVA(3D) assessment was possible in 41 patients (95%). MVA(3D) measurements were significantly lower compared with MVA(2D) (mean difference: -0.16 ± 0.22; n=25, p<0.005) and MVA(PHT) (mean difference: -0.23 ± 0.28 cm(2); n=39, p<0.0001) but marginally greater than MVA(CON) (mean difference: 0.05 ± 0.22 cm(2); n=24, p=0.82). MVA(3D) demonstrated best agreement with MVA(CON) (intraclass correlation coefficient [ICC] 0.83), followed by MVA(2D) (ICC 0.79) and MVA(PHT) (ICC 0.58). Interobserver and intraobserver agreement was excellent for MVA(3D), with ICCs of 0.93 and 0.96, respectively. Excellent commissural evaluation was possible in all patients using 3DTEE. Compared with 3DTEE, underestimation of the degree of commissural fusion using 2D transthoracic echocardiography was observed in 19%, with weak agreement between methods (κ<0.4). CONCLUSIONS: MVA planimetry is feasible in the majority of patients with RhMS using 3DTEE, with excellent reproducibility, and compares favorably with established methods. Three-dimensional transesophageal echocardiography allows excellent assessment of commissural fusion.

An unusual precipitant of tako-tsubo cardiomyopathy.

A 76-year-old woman presents with acute pulmonary oedema and cardiogenic shock 10h after elective electrical cardioversion for atrial fibrillation. Her echocardiogram shows new wall motion abnormalities with akinesis of the apical and mid segments of the left ventricle and her resting ECG contains deep T wave inversion and QTc prolongation. Angiography reveals non-occlusive coronary artery disease. The echocardiogram on day 6 shows resolution of left ventricular wall motion abnormalities and a return to normal systolic function. The diagnosis of tako-tsubo cardiomyopathy was made. This is the first report of this condition precipitated by electrical cardioversion.

Cardiac pacemaker lead extraction using conventional techniques:a single centre experience.

BACKGROUND: New methods of lead extraction using laser sheath devices are under evaluation but these techniques are not available in the majority of centres and have cost implications. Furthermore, in the absence of comparative randomised trials, registry experience with new devices must be judged against contemporary data using conventional methods. We report a single centre series of pacemaker lead extraction using conventional methods. STUDY POPULATION: Attempted extraction of 165 leads during 95 procedures in 80 patients. Leads had been in place (dwell time) for a mean of 76 months (range 0.2-248.4 months). Indications for lead extraction: infection (41.1%), skin erosion (9.5%), advisory leads (12.6%), faulty leads (12.6%), other (24.2%). Extraction techniques: traction and/or locking stylets and dilator sheaths (89.7%), Byrd workstation (6.1%) and open thoracotomy (4.8%). RESULTS: Complete removal was achieved for 143 leads (86.7%), partial removal in 12 leads (7.3%) and 10 (6.1%) could not be removed. A shorter lead dwell time was associated with extraction success in both univariate (p=0.0004) and multivariate analyses (p<0.0001). There was a trend for a higher rate of success in atrial rather than ventricular leads (93.2% v 80.9%, p=0.052). Active fixation, patient gender, age and indication for lead extraction had no bearing on outcome. COMPLICATIONS: There were no deaths. Major complications occurred in 3 patients (3.2%): pericardial tamponade (1), pulmonary embolus (1) and stroke (1). Significant bleeding (requiring blood transfusion) occurred in 11 procedures (12%). CONCLUSIONS: Cardiac lead extraction using conventional methods has a high success rate of 86.7%. Success was significantly related to a shorter lead dwell time. Further prospective randomised trials are needed to compare traditional techniques with laser extraction both in terms of clinical outcome and cost-effectiveness.