Journal of Heart Valve Disease最新文献

Mixed connective tissue disease (MCTD) syndrome in children may lead to large aortic aneurysms, which in turn pose a difficult surgical problem. Valve-sparing root replacement is not always a viable option as the disease process invariably affects the aortic valve leaflets. Among pediatric patients, the Ross procedure is contraindicated on account of weakness of the pulmonary root, while Bentall surgery is the 'gold standard' treatment of aortic aneurysm, with reproducible and excellent long-term results. The case is presented of a three-year-old girl with a large thoracic aortic aneurysm in whom Bentall's surgery was performed, with a good result. The present patient, with MCTD syndrome, was too young to have undergone aortic root replacement with a composite mechanical valved graft.

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+.

Herein is presented the case of an 83-year-old male patient in cardiogenic shock with acute aortic regurgitation that occurred six years after aortic valve replacement (AVR) with a 23 mm Trifecta™ valve. Prosthesis endocarditis was initially suspected because of a floating structure attached to the aortic valve that was visible on echocardiography. Emergency redo-AVR surgery was performed, but no signs of endocarditis were found intraoperatively. Hence, cusp tearing of the implanted bioprosthesis was considered to be the reason for the severe aortic regurgitation.

A patient presented with a decompensated cardiomyopathy requiring invasive hemodynamic support with an Impella® heart pump. Extracorporeal life support (ECLS) became necessary during the further course and the patient was bridged to left ventricular assist device (LVAD) implantation. Postoperatively, the patient did not improve as expected due to new aortic regurgitation (AR) that was most likely caused by the previously placed Impella. A SAPIEN 3 transcatheter aortic valve was implanted as a bail-out strategy; an additional valve-in-valve rescue was required due to paravalvular regurgitation. This resulted in a restitution of valvular function and hemodynamic improvement. TAVI appears to be a valuable bail-out option for postoperative AR following LVAD implantation.

Pulmonary valve infections without the involvement of other valves account for only 1.5- 2% of all infective endocarditis cases. Isolated pulmonary valve endocarditis due to fungus is extremely rare. The case is presented of a 36-year-old male who was found to have isolated pulmonary valve endocarditis caused by a very rare organism, Candida parapsilosis, and that was solely managed with medical therapy. The patient was evaluated for three weeks of lowgrade fever, generalized rash and fatigue, and found to have C. parapsilosis in the blood. Transesophageal echocardiography (TEE) demonstrated a 4.5 cm vegetation on the pulmonary valve, without involvement of other valves. The patient was deemed not to be a surgical candidate and was subsequently started on intravenous liposomal amphotericin B and 5-flucytosine, with excellent clinical outcome. Based on these case details, it must be emphasized that in selective cases and if there are no known complications, fungal endocarditis can be managed successfully using anti-fungal agents.

Over the years, the surgery of ventricular postinfarction aneurysm has evolved from linear resection to endoaneurysmorrhaphy using a patch. Technically, several aims that include the restoration of ventricular shape and function, exclusion of dead space, minimization of the risk of thrombus formation and restoration of valve function are pursued. Herein is reported the case of a 58-year-old male with a giant inferobasal aneurysm involving the mitral valve apparatus who underwent successful endoaneurysmorrhaphy. Correct sizing of the patch proved to be the 'road to success' in this patient. The present case is the second reported instance of a giant ventricular aneurysm involving the mitral valve, with favorable outcome.

The case is described of a successful MitraClip procedure performed on an 88-year-old patient with severe mitral regurgitation (MR), five years after she had undergone mitral valve repair using the Alfieri surgical procedure. It is suggested that the MitraClip procedure is an option in patients with severe MR persisting after the Alfieri procedure. Video 1: Transesophageal echocardiography before the MitraClip procedure. Severe mitral regurgitation with preserved left ventricular systolic function. The main regurgitant jet originates from the medial commissure. Video 2: Transesophageal echocardiography: clip placement and jet reduction. A single clip placement on the medial portion of the mitral valve, resulting in elimination of the medial jet and reduction of the overall mitral regurgitant jet from grade 4+ to grade 2+.

Background: Echocardiographic predictors of redo-percutaneous balloon mitral valvuloplasty (redo-PBMV) have not been well studied, and indications are based mainly on Wilkins score. The study aim was to evaluate the immediate results of redo-PMBV and to introduce a simplified redo-score to predict the success of redo-PBMV.

Methods: Two cohorts of symptomatic patients (derivation group, n = 218; validation group, n = 100) who had undergone redo-PBMV at a mean of 8.1 ± 2.9 years after a first successful PBMV were enrolled in the study. The mean Wilkins scores were 8.5 ± 1.7 in the derivation group and 8.4 ± 1.8 in the validation group. PBMV was performed using a multi-track technique. Independent echocardiographic predictors of outcome were assigned a points value: mitral valve area ≤1.0 cm2 (2 points), posterior mitral valve leaflet length (PMVL)/anterior mitral valve leaflet length (AMVL) ratio ≤1/2 (2 points), doming distance ≤12 mm (3 points), mitral annular calcification (mild = 1 point; moderate = 2 points; severe = 3 points), commissural status (no fusion = 0 points; uni-fusion = 2 points; bi-fusion = 3 points) and chordal length ≤10 mm (2 points).

Results: The minimum score was 5 and the maximum was 13. A receiver operating curve analysis showed the redo score to be highly significant in predicting redo-PBMV immediate results. The cut-off value of redo score to predict a favorable outcome was ≤8, with a sensitivity of 96% and specificity of 85% in the derivation cohort, and a sensitivity of 95% and specificity of 83% in the validation cohort. A Wilkins score ≤8 had a sensitivity of 71% and a specificity of 59% in the derivation cohort, while sensitivity was 70% and specificity 62% in the validation cohort.

Conclusions: The described scoring system was significantly more predictive than the Wilkins score, and was particularly valuable in predicting outcome in patients with a prior PBMV. It may serve as a satisfactory scoring system for correctly selecting patients with mitral restenosis for PBMV.

Paradoxical low-flow, low-gradient aortic stenosis (LFLG AS) is recognized as a subtype of aortic stenosis. A small left ventricular (LV) cavity with marked LV concentric remodeling leads to a reduced stroke volume in this condition. The case is reported of a paradoxical LFLG AS patient who was undergoing treatment for pulmonary hypertension (PH) and interstitial pneumonia associated with scleroderma. Echocardiography demonstrated enlargement of the right ventricle and a diminished LV cavity. Moreover, the aortic valve opening was restricted despite a preserved LV ejection fraction (61%). The patient's aortic valve area (obtained with the continuity equation) was 0.57 cm2 (indexed AVA was 0.39 cm2/m2), and the mean gradient was 16 mmHg. Multi-detector computed tomography findings confirmed that the aortic valve calcification was not severe. The main mechanism responsible for LFLG AS was considered to be a reduced LV cavity secondary to PH, rather than a sclerotic aortic valve. Thus, a decision was taken to treat the patient with additional medical management prior to performing any invasive procedures. It should be borne in mind that PH can lead to paradoxical LFLG AS, and that appropriate treatment should be contemplated depending on the underlying mechanisms. Video 1: Transthoracic echocardiography in the parasternal long-axis view showing right ventricular dilatation and a diminished left ventricular cavity. Video 2: Transthoracic echocardiography in the shortaxis view showing enlargement of the right ventricle and septal flattening due to pulmonary hypertension. Video 3: Transesophageal echocardiography clearly demonstrates an insufficient valve opening.

Background: Flow measurements using cardiac magnetic resonance imaging (CMRI) enable quantification of the stroke volume, regurgitant volume (RV) and regurgitant fraction (RF) in patients with aortic regurgitation (AR). These variables are used to assess the severity of the valve disease and for the timing of surgery. The aim of the study was to investigate the impact of an increased heart rate on measurement of the RV and RF in patients with AR.

Methods: Among 13 patients with known moderate or severe AR, regurgitant flow measurements, using phase-contrast cine magnetic resonance imaging, were obtained in the ascending aorta. Flow measurements were obtained at rest and at increased heart rates after intravenous administration of atropine.

Results: The mean heart rate was 61 beats per min at rest and 91 beats per min after atropine administration. The RV and RF were 52 ml and 35% at rest, respectively, and 34 ml (p <0.001) and 30% (p = 0.065) at increased heart rate, respectively.

Conclusions: An increased heart rate leads to a decreased RV. The RF is more stable and may therefore be preferable for severity grading in AR.