Surgery for a mitral annulus abscess penetrating into the pericardial cavity

Although a mitral annulus abscess often develops with infective endocarditis, penetration into the pericardial cavity is a very rare and fatal complication. Herein, we report a case of surgery with thorough debridement and appropriate reconstruction for a mitral annulus abscess with penetration into the pericardial cavity.     

Implantation of collar-reinforced SuMit valve for patient with large calcified mass obstructing the mitral valve orifice

A 56-year-old female had a severely calcified mitral valve annulus and a huge subvalvular mass. To avoid critical damages of the coronary artery and left ventricle, the annular calcification and the part of the mass adherent to the left ventricle were not resected. Then we performed mitral valve replacement using SuMit^TM valve and collared reinforcement technique with xenopericardium without any major complications. The SuMit^TM valve is designed to be placed in a supraannular position, and is useful to prevent valves from getting stuck.     

Surgical outcomes of mitral valve replacement with concomitant mitral annular reconstruction

Background and aim of the study

We evaluated the early and long‐term outcomes of mitral annular reconstruction (MAR) with pericardium during mitral valve replacement (MVR), and analyzed the risk factors associated with post‐operative mortality.

Methods

Between May 1997 and April 2013, 78 consecutive patients underwent MVR with MAR. The indications for MAR were treatment for annular infection in native valve endocarditis (n = 23, 29.5%) or prosthetic valve endocarditis (n = 26, 33.3%), reinforcement of damaged annulus resulting from a previous operation (n = 17, 21.8%), complete excision of extensive calcification (n = 9, 11.5%), and left ventricular or left atrial rupture (n = 3, 3.8%). Patients were classified into infective endocarditis (n = 49) and non‐endocarditis groups (n = 29). The mean follow‐up period was 59.4 ± 47.3 months.

Results

There were two operative deaths and 11 cases of late mortality in the endocarditis group and five cases in the non‐endocarditis group. Late prosthetic valve endocarditis occurred in four patients. The overall survival rate at 1 and 10 years was 94.8% and 65.1%, respectively. There was no statistical difference in the overall survival, freedom from reoperation, and freedom from endocarditis rates between the groups (P = 0.565, P = 0.635, and P = 0.449, respectively). Univariable and multivariable analyses revealed that pre‐operative left ventricular dysfunction (ejection fraction <40%) was an independent predictor of overall mortality.

Conclusions

The early and long‐term results of MAR with pericardium during MVR are acceptable in both endocarditis and non‐endocarditis patients.     

Annular reconstruction for mitral valve replacement in a destroyed or calcified mitral annulus

Mitral valve replacement in the presence of severe annular calcification and an infectious lesion may be complicated by atrioventricular rupture, left circumflex coronary artery injury, and recurrence of infective endocarditis. Confronted with these circumstances, we have developed a technique of annular reconstruction for mitral valve replacement. The prosthetic valve is made by enlarging the circumference of the sewing ring with a Dacron collar. The collar can be sutured to the left atrial wall above the mitral annulus. This technique has been employed in five patients: three had extensive annular calcification, and two had acute valve endocarditis with destruction of mitral annulus. In all cases, the circumferential or partial annular reconstruction permitted secure implantation of the prosthetic valve. The one postoperative death was related to hemodialysis due to chronic renal failure. There were no other fatalities during the postoperative course, and the valves functioned normally. Our results suggest that this technique can be performed in high operative risk patients when mitral valve replacement is impossible using conventional techniques.     

Tricuspid annulus diameter does not predict the development of tricuspid regurgitation after mitral valve repair for mitral regurgitation due to degenerative diseases

Background

Heart valve surgery guidelines suggest that tricuspid valve annuloplasty may be beneficial in patients with a tricuspid annulus (TA) ≥40 mm even in the absence of functional tricuspid regurgitation (TR) at the time of surgery for left-sided valve lesions (class 2a). Given the broad spectrum of degenerative diseases that affect the atrioventricular valves, we hypothesize that this measurement might not be predictive of TR after mitral valve (MV) repair.

Reconstruction of a friable posterior mitral annulus after removing a calcified artificial ring using flipover technique of the anterior mitral leaflet

We report a new technique for reinforcement of a friable posterior mitral annulus using the anterior leaflet after removing a calcified artificial ring. A 72-year-old woman underwent mitral valve replacement for mitral stenosis and recurrence of regurgitation after mitral valve repair at 53 years of age. She had been on chronic hemodialysis for 20 years. The posterior mitral annulus became highly friable after débridement of the calcified artificial ring. The anterior mitral leaflet was detached from its annulus and transferred to the posterior annulus to cover the defect. The anterior leaflet was anchored to the posterior annulus by valve sutures, and mitral valve replacement was performed successfully. Postoperative ultrasonic cardiography revealed preservation of left ventricular function with no perivalvular leakage.     

Heparin-coated Cardiopulmonary Bypass Circuits Reduce Circulating Complement Factors and Interleukin-6 in Paediatric Heart Surgery

Children are sensitive to the inflammatory side effects of cardiopulmonary bypass (CPB). Our intention was to investigate if the biocompatibility benefits of heparin-coated CPB circuits apply to children. In 20 operations, 19 children were randomized to heparin-coated (group HC, n = 10) or standard (group C, n = 10) bypass circuits. Plasma levels of acute phase reactants, interleukins, granulocytic proteins and complement factors were measured. All were significantly elevated after CPB. Levels of complement factor C3a (851 (791-959) ng/ml [median with quartiles] in group C, 497 (476-573) ng/ml in group HC, p &lt; 0.001), Terminal Complement Complex (114 (71-130) AU/ml in group C, 35.5 (28.9-51.4) AU/ml in group HC, p &lt; 0.001), and interleukin-6 (570 (203-743) pg/ml in group C, 168 (111-206) pg/ml in group HC, p = 0.005), were significantly reduced in group HC. Heparin-coated CPB circuits improve the biocompatibility of CPB during heart surgery in the paediatric patient population, as reflected by significantly reduced levels of circulating complement factors and interleukin-6.     

Role of ageing, chronic renal failure and dialysis in the calcification of mitral annulus

Mitral annulus calcification, a common lesion of the elderly(over age 60 years), has been detected with increased frequencyand at younger ages in patients with uraemia. To date a pathogenicrole for dialysis and secondary hyperparathyroidism has beensuggested only on the basis of older dialytic age and increasedserum iPTH observed in the affected individuals. Because thisis a potentially dangerous lesion we deemed it useful to evaluatemore completely the respective roles of possible pathogeneticfactors in uraemic individuals. Evaluation included echocardiography, ECG, limb radiography,and serum assays. A total of 225 dialysis (HD) patients, 67chronic renal failure (CRF) patients on conservative treatmentand 67 normal subjects were studied. Mitral annulus calcificationwas detected in 87 of 225 (38.6%) HD patients, 11 of 67 (16.4%)CRF and six of 67 (8.9%) normals. In HD, patients with calcificationwere older and on longer-term renal replacement therapy comparedto those without calcification. They also had greater valuesof iPTH, BGP, AP, and Rx score of secondary hyperparathyroidism.Mitral annulus calcification was associated more frequently(x2= 14.8; P< 0.0001) with rhythm and cardiac conductiondefects, but not with ectopic calcifications. Multiple stepwiseregression analysis, with mitral annulus calcification scoreas dependent variable, selected dialysis duration, age, andiPTH (r_m= 0.368) as the most predictive parameters, with thefirst two carrying most of the information. The stratificationof patients according with these two parameters showed a progressiveincrease in the frequency of calcification both with HD durationand age. Moreover, compared to those without, patients withcalcification in the third, fourth, and fifth decades invariablyshowed significantly greater dialytic ages, while in the firstyear of HD they were significantly older. Finally, in all subjectsa progressive increase (x²= 34.4; P< 0.000001) of prevalenceof mitral annulus calcification in normals (0%), CRF (8.5%),and HD (36.7%) was observed only in those aged less than 60years, but not over age 60 (normals=30%; CRF = 35%; HD= 42.3%;x²= NS). Over age 60, ageing and dialysis do not have additiveeffects. In conclusion, our data show that dialysis duration plays amajor role in the development of mitral annulus calcificationmainly in younger patients (under age 60) with the possibilityof an increased mortality rate of affected patients. The pathogeneticmechanism seems to differ from that of other ectopic calcification,while secondary hyperparathyroidism seems to play an ancillaryrole.     

Comparison between angiographic right coronary artery motion and echocardiographic tricuspid annulus motion

Objective—To compare echocardiographic M‐mode measurements of tricuspid annulus motion (TAM) with angiographic M‐mode measurements of right coronary artery motion (RAM).

Design—Twenty‐four patients were included and examined by echocardiography before the angiographic examination. The amplitudes and the velocities of TAM and the atrial contribution to the total amplitude of TAM were measured. The obtained values were compared with angiographic M‐mode measurements of RAM at a proximal and a distal site of the second segment of the right coronary artery.

Results—There was no significant difference between several of the echocardiographic M‐mode measurements of TAM and the angiographic M‐mode measurements of RAM. However, the agreement was rather poor for some variables.

Conclusion—Different parameters obtained from echocardiographic TAM are not interchangeable with values from angiographic RAM. If measurements of RAM are to be used in the assessment of right ventricular (RV) function further studies are needed to examine the correlation and agreement between RAM and different methods of measuring RV function, i.e. radionuclide angiography or magnetic resonance imaging.     

Assessment of left ventricular function from M‐mode measurement of circumflex artery motion recorded by coronary angiography

Objective—To evaluate the usefulness of M‐mode measurement of circumflex artery motion (CAM) for assessment of left ventricular (LV) function.

Design—Seventy‐two patients referred for coronary angiography and LV angiography were included. Ejection fraction (EF) was calculated from LV angiography and systolic and diastolic parameters of CAM were measured by M‐mode from coronary angiography. Twenty‐three patients, examined by echocardiography of mitral annulus motion (MAM) within 24?h before the angiographic examination, formed a subgroup for comparison between angiographic M‐mode of CAM and echocardiographic M‐mode of MAM.

Results—In addition to previous reported CAM amplitude and longitudinal fractional shortening (FS _L ) the maximal systolic velocity of CAM can be reliably recorded by M‐mode. The diastolic indices, atrial contribution to the total amplitude and maximal early and late diastolic velocities, are also well monitored by M‐mode of CAM in comparison with echocardiographic MAM.

Conclusion—LV systolic and diastolic function can be assessed by M‐mode of CAM.     

Redo mitral valve repair with complete ring implantation over an open band

We present a case of redo mitral valve surgery after failed repair that consisted of implantation of a complete ring over an open band implanted several years prior. The patient presented with severe central mitral regurgitation. During surgical intervention, the open band was identified consolidated with the native annulus. We elected not to remove the posterior annulus given the presence of calcification. Instead, a new complete ring was secured with single sutures posteriorly over the band and anterior to the native annulus. This approach was safe, fast, and achieved a significant reduction in annulus circumference with no residual mitral regurgitation.     

Transcatheter mitral valve therapies: State of the art

Mitral regurgitation (MR) is one of the most prevalent valvular pathologies in the developed world. There continues to be a growing population of aging patients with MR who may be too high risk for surgical management. The rapid adoption and remarkable success of transcatheter aortic valve replacement (TAVR) generated enthusiasm for transcatheter mitral valve therapies; however, the complex anatomy and pathophysiology of the mitral valve confers several unique challenges for a fully percutaneous approach. Nevertheless, several devices are under development and in various phases of preclinical or clinical testing, both for transcatheter mitral valve replacement and repair. MitraClip (Abbott Vascular), which has received FDA approval, is the most established percutaneous repair strategy and has been performed in over 80,000 patients as of 2019. The following article serves as a review of the available and upcoming devices for the various etiologies of mitral valvular disease, as well as the unique challenges and potential complications of transcatheter mitral valve intervention.     

Optimal size of prostheses for functioning of the aortic prosthetic valve in aortic and mitral valve replacement with annular enlargement through Manouguian's technique

There is not yet agreement about the optimal size of the prostheses in aortic and mitral valve replacement with Manouguian's technique. In this technique, the aortic prosthetic valve can be pushed upon the mitral prosthesis which may cause dysfunction of the aortic prosthetic valve. The aim of this study was to clarify the size of the prostheses needed to avoid dysfunction of the aortic prosthetic valve. Three patients underwent aortic and mitral valve replacement through this procedure. Two of them had active aortic and mitral valve endocarditis. Aortomitral continuity involved with abscesses could be approached and completely excised using this technique. All patients survived the operation, but 1 of them suffered aortic mechanical valve dysfunction for the reason stated. Anatomical analysis of the geometrical relation of the 2 prosthetic valves suggests that the mitral annulus should be enlarged less than 25 mm to avoid dysfunction of the aortic prosthetic valve.