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Circulation Journal : Official Journal... Mar 2024Percutaneous mitral valvuloplasty (PMV) is a standard treatment for severe rheumatic mitral stenosis (RMS). However, the prognostic significance of the change in mitral...
BACKGROUND
Percutaneous mitral valvuloplasty (PMV) is a standard treatment for severe rheumatic mitral stenosis (RMS). However, the prognostic significance of the change in mitral valve area (∆MVA) during PMV is not fully understood.Methods and Results: This study analyzed data from the Multicenter mitrAl STEnosis with Rheumatic etiology (MASTER) registry, which included 3,140 patients with severe RMS. We focused on patients with severe RMS undergoing their first PMV. Changes in echocardiographic parameters, including MVA quantified before and after PMV, and composite outcomes, including mitral valve reintervention, heart failure admission, stroke, and all-cause death, were evaluated. An optimal result was defined as a postprocedural MVA ≥1.5 cmwithout mitral regurgitation greater than Grade II. Of the 308 patients included in the study, those with optimal results and ∆MVA >0.5 cm² had a better prognosis (log-rank P<0.001). Patients who achieved optimal results but with ∆MVA ≤0.5 cm² had a greater risk of composite outcomes than those with optimal outcomes and ∆MVA >0.5 cm² (nested Cox regression analysis, hazard ratio 2.27; 95% confidence interval 1.09-4.73; P=0.028).
CONCLUSIONS
Achieving an increase in ∆MVA of >0.5 cmwas found to be correlated with improved outcomes. This suggests that, in addition to achieving traditional optimal results, targeting an increase in ∆MVA of >0.5 cmcould be a beneficial objective in PMV treatment for RMS.
PubMed: 38479852
DOI: 10.1253/circj.CJ-23-0552 -
Open Heart Sep 2023A substantial proportion of patients with rheumatic heart disease (RHD) have tricuspid regurgitation (TR). This study aimed to identify the impact of functional TR on...
OBJECTIVE
A substantial proportion of patients with rheumatic heart disease (RHD) have tricuspid regurgitation (TR). This study aimed to identify the impact of functional TR on clinical outcomes and predictors of progression in a large population of patients with RHD.
METHODS
A total of 645 patients with RHD were enrolled, mean age of 47±12 years, 85% female. Functional TR was graded as absent, mild, moderate or severe. TR progression was defined either as worsening of TR degree from baseline to the last follow-up echocardiogram or severe TR at baseline that required surgery or died. Incidence of TR progression was estimated accounting for competing risks.
RESULTS
Functional TR was absent in 3.4%, mild in 83.7%, moderate in 8.5% and severe in 4.3%. Moderate and severe functional TR was associated with adverse outcome (HR 1.91 (95% CI 1.15 to 3.2) for moderate, and 2.30 (95% CI 1.28 to 4.13) for severe TR, after adjustment for other prognostic variables. Event-free survival rate at 3-year follow-up was 91%, 72% and 62% in patients with no or mild, moderate and severe TR, respectively. During mean follow-up of 4.1 years, TR progression occurred in 83 patients (13%) with an overall incidence of 3.7 events (95% CI 2.9 to 4.5) per 100 patient-years. In the Cox model, age (HR 1.71, 95% CI 1.34 to 2.17), New York Heart Association functional class III/IV (HR 2.57, 95% CI 1.54 to 4.30), right atrial area (HR 1.52, 95% CI 1.10 to 2.10) and right ventricular (RV) dysfunction (HR 2.02, 95% CI 1.07 to 3.84) were predictors of TR progression. By considering competing risk, the effect of RV dysfunction on TR progression risk was attenuated.
CONCLUSIONS
In patients with RHD, functional TR was frequent and associated with adverse outcomes. TR may progress over time, mainly related to right-sided cardiac chambers remodelling.
Topics: Humans; Female; Adult; Middle Aged; Male; Rheumatic Heart Disease; Mitral Valve; Tricuspid Valve Insufficiency; Heart Valve Diseases; Atrial Appendage; Ventricular Dysfunction, Right
PubMed: 37657848
DOI: 10.1136/openhrt-2023-002295 -
Frontiers in Cardiovascular Medicine 2024Risk stratification of cardiovascular death and treatment strategies in patients with heart failure (HF), the optimal timing for valve replacement, and the selection of... (Review)
Review
Risk stratification of cardiovascular death and treatment strategies in patients with heart failure (HF), the optimal timing for valve replacement, and the selection of patients for implantable cardioverter defibrillators are based on an echocardiographic calculation of left ventricular ejection fraction (LVEF) in most guidelines. As a marker of systolic function, LVEF has important limitations being affected by loading conditions and cavity geometry, as well as image quality, thus impacting inter- and intra-observer measurement variability. LVEF is a product of shortening of the three components of myocardial fibres: longitudinal, circumferential, and oblique. It is therefore a marker of global ejection performance based on cavity volume changes, rather than directly reflecting myocardial contractile function, hence may be normal even when myofibril's systolic function is impaired. Sub-endocardial longitudinal fibers are the most sensitive layers to ischemia, so when dysfunctional, the circumferential fibers may compensate for it and maintain the overall LVEF. Likewise, in patients with HF, LVEF is used to stratify subgroups, an approach that has prognostic implications but without a direct relationship. HF is a dynamic disease that may worsen or improve over time according to the underlying pathology. Such dynamicity impacts LVEF and its use to guide treatment. The same applies to changes in LVEF following interventional procedures. In this review, we analyze the clinical, pathophysiological, and technical limitations of LVEF across a wide range of cardiovascular pathologies.
PubMed: 38385136
DOI: 10.3389/fcvm.2024.1340708 -
European Heart Journal. Case Reports Dec 2023Failing bioprosthesis is an emerging issue due to (i) a shift towards liberal bioprosthesis implantation instead of mechanical prosthesis and (ii) an ageing population....
BACKGROUND
Failing bioprosthesis is an emerging issue due to (i) a shift towards liberal bioprosthesis implantation instead of mechanical prosthesis and (ii) an ageing population. Management of high-risk patients with bioprosthesis degeneration remains challenging.
CASE SUMMARY
An 82-year-old patient with history of aortic and mitral valve replacement six years before presents with severe dyspnoea. Echocardiograpic assessment reveals (i) structural valve degeneration of the mitral prosthesis (severe stenosis and regurgitation) with concomitant major annular calcifications and (ii) structural valve degeneration of the aortic prosthesis with low-flow, low-gradient restenosis. Due to mitral annular calcifications, the risk of double valve re-replacement and the age of the patient conventional reoperation was deemed very high. The patient is evaluated for transapical double valve implantation. This option is rejected due to the high risk of left ventricular outflow obstruction. The patient is treated with an open transcatheter double valve-in-valve procedure at the following sequence: leaflet resection of the mitral bioprosthesis, mitral valve implantation and fixation under direct view, leaflet resection of the aortic bioprosthesis, and valve frame cracking and aortic valve implantation under direct view. Post-bypass echocardiography shows neither left ventricular outflow tract obstruction nor paravalvular leak or prosthesis dysfunction. The patient is extubated on the first post-operative day and transferred to normal care unit.
DISCUSSION
Open transcatheter double valve-in-valve replacement for degenerated bioprostheses on the arrested heart might be a valuable alternative to treat selected high-risk patients with bioprosthetic valve degeneration.
PubMed: 38130856
DOI: 10.1093/ehjcr/ytad617 -
Journal of Cardiology Cases Mar 2024We report a 73-year-old female who underwent mitral valve replacement for degenerative mitral stenosis (DMS) and aortic valve replacement for aortic valve stenosis. She...
UNLABELLED
We report a 73-year-old female who underwent mitral valve replacement for degenerative mitral stenosis (DMS) and aortic valve replacement for aortic valve stenosis. She was transferred to our hospital because of congestive heart failure. Transthoracic echocardiogram demonstrated severe mitral valve stenosis and aortic valve stenosis. Transesophageal echocardiogram (TEE) revealed severe mitral annular calcification (MAC) and calcification of the anterior mitral leaflet without commissure fusion. The diagnosis of DMS associated with MAC and aortic valve stenosis was made. Since she did not have other significant comorbidities except diabetes mellitus and hypertension, open-heart surgery for double valve replacement was scheduled by our heart team. Complete resection of the calcium bar and annulus reconstruction with an autologous pericardium allowed safe mitral valve replacement with a mechanical valve. Concomitant aortic valve replacement with a mechanical valve was carried out for aortic valve stenosis. Intraoperative TEE demonstrated good left ventricular function without perivalvular leakage in both mitral and aortic prosthetic valves. The postoperative course was uneventful, and the patient was discharged from the hospital. Surgical intervention may be one of the alternative treatments for elderly patients with degenerative mitral stenosis and MAC.
LEARNING OBJECTIVE
Degenerative mitral stenosis (DMS) associated with mitral annular calcification (MAC) is a severe heart valve disease in the elderly population in developed countries. The prognosis of patients with severe DMS is poor, and open-heart surgery for elderly patients with MAC is especially challenging from a surgical point of view. We report a surgical treatment for a patient with DMS and aortic valve stenosis considering the patient's comorbidities and extent of MAC.
PubMed: 38481641
DOI: 10.1016/j.jccase.2023.11.004 -
Structural Heart : the Journal of the... Mar 2024Transcatheter mitral valve-in-valve (MViV) replacement has emerged as an alternative to redo mitral valve (MV) surgery for the management of failed bioprosthetic MVs....
BACKGROUND
Transcatheter mitral valve-in-valve (MViV) replacement has emerged as an alternative to redo mitral valve (MV) surgery for the management of failed bioprosthetic MVs. The degree of cardiac remodeling assessed by echocardiography has been shown to have prognostic implications in degenerative mitral regurgitation patients undergoing MV surgery. The impact of transcatheter MViV in patients with degenerative bioprosthetic MV failure on cardiac remodeling and its associated prognosis remains undescribed.
OBJECTIVES
The aim of this study is to describe the early anatomic and functional changes of the left-sided chambers and right ventricle by echocardiography posttranscatheter MViV intervention and their impact on mortality outcomes. Additionally, we sought to analyze the outcome of heart failure in bioprosthetic MV failure patients undergoing transcatheter MViV replacement.
METHODS
We analyzed consecutive patients undergoing MViV intervention for symptomatic bioprosthetic MV failure. Echocardiograms before intervention and within 100 days postintervention were analyzed. A chart review was performed to obtain baseline characteristics, follow-up visits, 30-day heart failure and 1-year all-cause mortality outcomes.
RESULTS
A total of 62 patients (mean age 69 ± 13 years, 61% male) were included in the study. Most patients were undergoing MViV intervention for prosthetic mitral stenosis n = 48 (77.4%) and the rest for mitral regurgitation or mixed disease. Compared with baseline, significant reductions were observed in median left atrial volume (LAV; 103 [81-129] ml vs. 95.2 [74.5-117.5] ml, < 0.01) and mean (SD) left atrial conduit strain (9.1% ± 5.2% vs. 10.8% ± 4.8%, = 0.039) within 100 days postintervention. Early reduction in right ventricular free wall global longitudinal strain and fractional area change also occurred postintervention. No significant change in left ventricular chamber dimensions or ejection fraction was observed. During the 1-year follow up period, 5 (8%) patients died. While baseline LAV was not associated with 1-year all-cause mortality (OR 0.98 CI 0.95-1.01; = 0.27), a change in LAV in the follow up period was associated with all-cause mortality at 1 year (OR 1.06 CI 1.01-1.12; = 0.023). At 30 days postintervention, 65% of patients had an improvement in their New York Heart Association functional class.
CONCLUSION
In this retrospective study of patients undergoing transcatheter MViV intervention for failed bioprosthetic MVs, early reverse remodeling of the left atrium occurs within 100 days postintervention and reduction in LAV is associated with reduced all-cause mortality at 1 year. In addition, there is significant improvement in heart failure symptoms at 30 days following intervention but further investigation into the longitudinal remodeling changes and long-term outcomes is needed.
PubMed: 38481712
DOI: 10.1016/j.shj.2023.100264 -
Cureus Sep 2023A ball valve thrombus is a common entity in rheumatic mitral stenosis where a large clot forms in the left atrial appendage, the clot detaches from the left atrial...
A ball valve thrombus is a common entity in rheumatic mitral stenosis where a large clot forms in the left atrial appendage, the clot detaches from the left atrial appendage, swirls in the left atrium in a clockwise manner, obstructs the mitral inflow producing cyclic acute pulmonary edema, and likely causes left ventricular outflow tract obstruction producing transient syncope or embolism to the brain producing dense hemiplegia. Besides rheumatic mitral stenosis, ball valve thrombus has been described in post-mitral valve replacement patients and restrictive cardiomyopathy. Left atrial myxoma sometimes rocks across the mitral valve producing the effect of a ball valve thrombus. Right atrial ball valve thrombus has been described after prolonged parenteral nutrition through a central line in intensive care units and in carcinoma patients with cardiac metastasis. We report an extremely rare case of a ball valve thrombus in an obese individual where dyslipidemia was the sole triggering factor for the formation of a ball valve thrombus in the left atrium.
PubMed: 37799249
DOI: 10.7759/cureus.44625 -
ESC Heart Failure Feb 2024Valvular heart disease (VHD) is one of the leading causes of heart failure. Clinically significant VHD can induce different patterns of cardiac remodelling, and risk... (Meta-Analysis)
Meta-Analysis
AIMS
Valvular heart disease (VHD) is one of the leading causes of heart failure. Clinically significant VHD can induce different patterns of cardiac remodelling, and risk stratification is challenging in patients with various degrees of cardiac dysfunction. The study aimed to investigate the prognostic implications of Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) score in patients with VHD.
METHODS AND RESULTS
This study used data from the China Valvular Heart Disease (China-VHD) registry, which was a multicentre, prospective, observational cohort study for patients with significant (at least moderate) VHD. In total, 10 446 patients with moderate or greater VHD from the China-VHD study were included in the present analysis. The primary outcome of interest was all-cause mortality within 2 years. Among 10 446 patients with VHD, the mean age was 61.98 ± 13.47 years, and 5819 (55.7%) were male. During 2 years of follow-up, 895 (8.6%) patients died. The MAGGIC score was monotonically and independently associated with mortality in both total cohort [adjusted hazard ratio: 1.095, 95% confidence interval (CI): 1.084-1.107, P < 0.001] and most types of VHD (aortic regurgitation, mitral stenosis, mitral regurgitation, tricuspid regurgitation, mixed aortic stenosis and aortic regurgitation, and multiple VHD). The score was also an independent prognostic factor in patients with or without symptoms or preserved left ventricular ejection fraction (LVEF) and exhibited both satisfactory discrimination and calibration properties in predicting mortality. The prognostic value of MAGGIC score was robust in most quartiles of N-terminal pro-brain natriuretic peptide level, with no significant interaction observed (P = 0.498). Compared with the EuroSCORE II, the MAGGIC score achieved significantly better predictive performance in overall population [C index: 0.769 vs. 0.727; net reclassification improvement index (95% CI): 0.354 (0.313-0.396), P < 0.001; integrated discrimination improvement index (95% CI): 0.069 (0.052-0.085), P < 0.001] and in subgroups of patients divided by therapeutic strategy, LVEF, symptomatic status, stage of VHD, and aetiology of VHD.
CONCLUSIONS
The MAGGIC score is a reliable prognostic factor across the range of cardiac dysfunction in VHD and may assist in risk stratification and guide clinical decision-making.
Topics: Humans; Male; Middle Aged; Aged; Female; Risk Assessment; Stroke Volume; Prospective Studies; Ventricular Function, Left; Heart Valve Diseases; Chronic Disease; Heart Failure; Observational Studies as Topic; Multicenter Studies as Topic
PubMed: 38012105
DOI: 10.1002/ehf2.14586 -
The Turkish Journal of Pediatrics 2024Campotodactyly-artrhropathy-coxa vara-pericarditis (CACP) syndrome is a very rare autosomal recessive genetic disorder. It is characterized by flexion contracture of the...
BACKGROUND
Campotodactyly-artrhropathy-coxa vara-pericarditis (CACP) syndrome is a very rare autosomal recessive genetic disorder. It is characterized by flexion contracture of the fifth finger (camptodactyly); noninflammatory arthropathy; decreased angle between the shaft and the head of the femur (coxa vara) and pericarditis. Its association with mitral stenosis has not yet been reported. Hereby we report this unique association with CACP syndrome.
CASE
An eleven-year-old girl presented with non-productive cough, dyspnea, and orthopnea. She was diagnosed CACP syndrome at the age of seven and a biallelic frameshift mutation in the PRG4 gene was determined. The physical examination revealed pectus excavatum, camptodactyly, genu valgum, tachypnea and orthopnea. The functional capacity was NYHA III-IV. She had 2/6 soft pansystolic murmur at 4th left intercostal space and a rumbling diastolic murmur at apex. Echocardiography revealed an enlarged left atrium, severe stenotic mitral valve with a mean diastolic transmitral gradient of 22.5 mmHg, mild mitral regurgitation and mild apical pericardial effusion. The patient had mitral comissurotomy and partial pericardiectomy operation. Her post-operative transmitral gradient decreased to 6.9 mmHg and the pulmonary pressure was 30 mmHg. Her functional capacity increased to NYHA I-II.
CONCLUSIONS
The main defect is the proteoglycan 4 protein which acts like a lubricant in articular and visceral surfaces. Therefore, the leading clinical feature is arthropathy. Cardiac involvement other than clinically mild pericarditis is not usually expected. Three types of proteoglycans (decorin, biglycan, and versican) are present in the mitral valve. This could be the reason of mitral valve involvement in rare cases as like ours. It is important that these patients undergo echocardiographic examination regularly.
Topics: Female; Humans; Child; Coxa Vara; Mitral Valve Stenosis; Joint Diseases; Pericarditis; Dyspnea; Arthropathy, Neurogenic; Hand Deformities, Congenital; Synovitis
PubMed: 38523390
DOI: 10.24953/turkjped.2023.647 -
Turk Kardiyoloji Dernegi Arsivi : Turk... Jan 2024Moderate to severe mitral regurgitation (MR) and tricuspid regurgitation (TR) are present in approximately 20-60% of patients undergoing transcatheter aortic valve...
OBJECTIVE
Moderate to severe mitral regurgitation (MR) and tricuspid regurgitation (TR) are present in approximately 20-60% of patients undergoing transcatheter aortic valve implantation (TAVI). This study aims to evaluate the impact of TAVI on MR and TR, pulmonary hypertension, and reverse cardiac remodeling in these patients. Methods: Out of 240 patients who underwent TAVI, 79 who met the inclusion and exclusion criteria were analyzed.
RESULTS
In our study, 46.8% (n = 37) of the patients were male. Nineteen (24.1%) patients died within two years. Before TAVI, 34 (43%) patients had moderate-to-severe MR, which decreased to 18 (22.7%) after the procedure (P < 0.05). Similarly, the number of patients with moderate-to-severe TR decreased from 26 (32.9%) before TAVI to 12 (15%) after the procedure (P < 0.05). Of the patients, 50.6% (n = 40) did not require hospitalization after the procedure, while 25 were hospitalized once, 12 twice, and 2 three times. The mean systolic pulmonary artery pressure (sPAP) values of the patients decreased from 44.30 ± 14.42 mmHg before the procedure to 39.09 ± 11.77 mmHg after the procedure (Z=-3.506, P < 0.001). No correlation was found between changes in MR and TR grades after TAVI and mortality or hospitalization during follow-up. Furthermore, there was no statistically significant difference in tricuspid annular plane systolic excursion (TAPSE), free wall annular S' velocity, left atrial volume (LAV), or LAV index (LAVI) before and after TAVI. Conclusion: There was a significant decrease in moderate-to-severe MR and TR after TAVI; however, this did not impact hospitalization or mortality rates. Additionally, no significant differences were observed in right ventricular systolic function or in LAV and LAVI before and after TAVI.
Topics: Humans; Male; Female; Transcatheter Aortic Valve Replacement; Tricuspid Valve Insufficiency; Mitral Valve Insufficiency; Treatment Outcome; Heart Valve Prosthesis Implantation; Aortic Valve Stenosis; Aortic Valve
PubMed: 38221830
DOI: 10.5543/tkda.2023.08130