The impact of functional vs degenerative mitral regurgitation on clinical outcomes among patients undergoing transcatheter aortic valve implantation.

BACKGROUND: Among patients undergoing transcatheter aortic valve implantation (TAVI), concomitant mitral regurgitation (MR) has been associated with adverse prognosis. We aimed to assess long-term clinical outcomes according to MR etiology. METHODS: In a single-center registry of consecutive patients undergoing TAVI, we investigated the impact of functional (FMR) vs degenerative (DMR) MR on cardiovascular (CV) mortality throughout 2years of follow-up. RESULTS: Among 603 patients (mean age 82.4±5.7years, 55% female) undergoing TAVI, 149 patients had moderate or severe MR (24.7%). Functional MR and DMR were documented in 53 (36%) and 96 (64%) patients, respectively. At 2years, patients with FMR and DMR had higher rates of CV mortality (30.2% vs 32.4%) as compared with patients with no MR (14.6%; FMR vs no MR: hazard ratio [HR] 2.32, 95% CI 1.34-4.02, P=.003; DMR vs no MR: HR 2.56, 95% CI 1.66-3.96, P<.001). In adjusted analyses, DMR was associated with an increased risk of CV mortality throughout the 2-year follow-up (adjusted HR 2.21, 95% CI 1.4-3.49, P=.001) as compared with FMR (adjusted HR 1.13, 95% CI 0.59-2.18, P=.707). Relevant MR was postprocedurally significantly reduced in both the DMR and FMR groups, whereas improvement of a decreased left ventricular ejection fraction was predominantly seen in the FMR group as compared with baseline. CONCLUSION: Patients with severe, symptomatic aortic stenosis undergoing TAVI complicated by moderate or severe MR portend impaired prognosis. Particularly, patients with DMR are at increased risk for CV mortality during long-term follow-up.

Left ventricular pseudoaneurysm formation in a patient presenting with a subacute myocardial infarction.

Left ventricular pseudoaneurysm is a rare mechanical complication of acute myocardial infarction. In the present case, an 80-year-old man presenting with a subacute non-ST segment elevation myocardial infarction was found to have an occluded second obtuse marginal branch of the left circumflex coronary artery. Following the implantation of two drug-eluting stents, the patient developed no-reflow phenomenon. Coronary angiography 6 weeks later revealed persistence of the no-reflow phenomenon. During the left ventriculogram, a massive pseudoaneurysm was diagnosed and the patient successfully underwent emergency surgery. The persistence of no-reflow was likely due to the fact that the myocardial territory supplied by the infarct-related artery was completely necrosed resulting in persistent flow impairment through the vessel.

Paradoxical embolism via a sinus venosus atrial septal defect causing an inferior ST-segment elevation myocardial infarction in a 23-year-old woman.

Cerebrovascular accidents constitute the most frequent clinical manifestation of paradoxical embolism. However, it is becoming increasingly recognised that acute myocardial infarction is also an important and potentially life-threatening clinical manifestation of paradoxical embolism. Various intracardiac or pulmonary shunts can provide a convenient conduit for an embolus to traverse from the venous vasculature into the systemic circulation with potentially devastating consequences. We present the case of a 23-year-old woman presenting with chest pain and ST-segment elevation myocardial infarction who ultimately was found to have a sinus venosus atrial septal defect associated with both partial anomalous pulmonary venous drainage and a persistent left superior vena cava.

Sudden cardiac arrest during emergency caesarean delivery in a 31-year-old woman, due to accelerated structural valve degeneration of an aortic valve bioprosthesis.

The choice of prosthetic valve to implant in women of childbearing age requiring a valve replacement is challenging. Mechanical valves mandate the use of oral anticoagulation (OAC) for the prevention of thromboembolic complications, but the use of OAC during pregnancy can lead to maternal and fetal complications, in particular, warfarin embryopathy. Conversely, the use of bioprosthetic valves during pregnancy eliminates the need for OAC, but can instead be associated with accelerated structural valve degeneration. We present the case of a 31-year-old woman with a bioprosthetic valve in the aortic position, who developed undetected accelerated structural valve degeneration 5.5 years following implantation of a Mitroflow bioprosthetic aortic valve, and who suffered a catastrophic complication during emergency caesarean delivery as a result.

Coronary thromboembolic acute myocardial infarction due to paroxysmal atrial fibrillation occurring after non-cardiac surgery.

Acute myocardial infarction is a well know precipitant of atrial fibrillation, but it is also becoming increasingly recognised that atrial fibrillation is a direct and indirect cause of acute myocardial infarction. Current guidelines do not recommend anticoagulation therapy in patients undergoing cardiac surgery who have a brief episode of atrial fibrillation lasting less than 48 h. However, recommendations for the management of atrial fibrillation following non-cardiac surgery are less clear. We describe the case of a 70-year-old man undergoing non-cardiac surgery, who developed a short episode of perioperative atrial fibrillation and later presented with thromboembolic acute myocardial infarction due to a thrombotic occlusion of the right coronary artery.