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Given its complex pathological anatomy, recurrent left atrioventricular valve regurgitation after partial atrioventricular septal defect repair remains a challenge for surgical correction. Here, we introduce a modified bridging technique by shortening the anteroposterior leaflet distance in selected patients with inadequate coaptation to compensate for the short leaflet height, specifically that of the anterior leaflet.

In silico modeling has been proposed as a tool to simulate left ventricular (LV) outflow tract (LVOT) obstruction in patients undergoing transcatheter mitral valve replacement (TMVR). This study validated a simplified approach to simulate LV outflow hemodynamics in the setting of TMVR with anterior leaflet laceration, a clinical technique used to mitigate the risk of LVOT obstruction. Personalized, 3-dimensional computational fluid dynamics models were developed from computed tomography images of six patients who underwent TMVR with anterior leaflet laceration. LV outflow hemodynamics were simulated using the patient-specific anatomy and the peak systolic flow rate as boundary conditions. The peak outflow velocity, a clinically relevant hemodynamic metric, was extracted from each simulation (vsim-peak) and compared with the clinical measurement from Doppler echocardiography (vclin-peak) for validation. In silico models were successfully developed and implemented for all patients. The pre-processing time was 2 h per model and the simulation could be completed within 3 h. In three patients, the lacerated anterior leaflet exposed open cells of the transcatheter valve to flow. Good agreement was obtained between vsim-peak and vclin-peak (r = 0.97, p

Background: Tricuspid annuloplasty is the most common surgical approach to correct tricuspid regurgitation (TR). In some patients, however, anterior leaflet patch augmentation may be necessary to optimize tricuspid competence. We reviewed our center cohort over the midterm and long term. Methods: From January 2013 to August 2018, 424 tricuspid valve procedures were performed, of which 420 were repairs and 4 were replacements. Indications were either isolated severe TR or moderate or greater TR, concomitant with other surgery. In the repair cohort, we identified those that had a patch augmentation, and the database was interrogated for preoperative characteristics. The resulting patients had outpatient assessment (clinical and echocardiography) at 6 weeks and at a later interval. Additionally, a comparison was made between those who had good and poor results (moderate or greater TR or cardiac death). Results: In the repair cohort, 19 patients underwent complex tricuspid valve repair with CorMatrix anterior leaflet augmentation. Preoperative characteristics were as follows: age, 65.5 ± 13.5 years; New York Heart Association (NYHA) class, 3.5 ± 0.5; left ventricular ejection fraction, 48.3% ± 5.9%; tricuspid annular plane systolic excursion, 17.1 ± 3.7 mm; right ventricle (good, mild, moderate, poor), 10, 5, 4, 0; annulus size, 40.9 ± 6.9 mm; mean tethering distance, 1.00 ± 0.3 cm; and mean tethering area, 1.53 ± 1.16 cm2. Mean follow-up was 2.1 ± 1.9 years, and survival at 2 years was 73.8%. There were 2 in-hospital deaths. Mean NYHA class was 1.0 ± 0.5 (6 weeks) and 1.5 ± 0.6 (later follow-up); mean residual TR grade was 0.5 ± 0.6 (6 weeks) and 1.3 ± 1.4 (follow-up). Ten of 13 survivors had a good result at last follow-up (TR 0 to 1). We compared the preoperative and operative data of this group versus those with poor results (TR >1 or cardiac mortality). Significant univariate predictors of poor results were larger preoperative tethering area (1.18 ± 0.43 versus 2.4 ± 1.5 cm2; P = .02), longer tethering distance (0.87 ± 0.21 versus 1.2 ± 0.19 cm; P = .007), or the presence of mild or greater TR at 6 weeks (0.2 ± 0.4 vs 1.25 ± 0.5; P = .03). Conclusions: CorMatrix anterior leaflet augmentation produces successful, stable repair in the majority of this complex population. The presence of even mild TR at 6 weeks’ follow-up predicts a poor result. When the tethering area or the tethering distance is significantly high, replacement is probably a better option.

Cone reconstruction for Ebstein’s anomaly, although effective, is challenging in neonatal cases. Very few reports have discussed recurrent regurgitation. Herein, we report a successful redo tricuspid valve repair for recurrent regurgitation 5 years after cone reconstruction. A 5-year-old boy underwent cone reconstruction for Ebstein’s anomaly in the neonatal period. Although tricuspid regurgitation reduced initially, it subsequently worsened. The mechanisms of regurgitation are dilatation of the anteroseptal commissure, indentation in the septal leaflet, and foreshortening of the anterior leaflet. Augmentation of the anterior leaflet using an elliptic autologous pericardium and mending of the gaping commissure and indentation markedly reduced the regurgitation.

A rare case of congenital mitral insufficiency characterized by a fenestration in the anterior leaflet of mitral valve is reported. At operation, the mitral valve was successfully repaired by closure of unusual valvular tissue orifice with bovine pericardium and suture of the free edge between A1 and A2 without a ring annuloplasty.

Blunt chest trauma could lead to the cardiac valves damage. Flail anterior leaflet with severe tricuspid regurgitation is usually due to blunt chest trauma. This condition is very rare and can lead to deformation and failure of the right ventricle. The tricuspid regurgitation is usually easily diagnosed with transthoracic echocardiography. In this study, we want to present a case with delayed tricuspid damage following blunt chest trauma.

Background We evaluated a novel formula using preoperative transesophageal echocardiographic measurements to determine neochordae length for repair of degenerative mitral regurgitation (MR). Methods The formula is based on measuring the distance from the adjacent papillary head to the intended coaptation zone of the flail/prolapsing leaflet segment and subtracting the redundant leaflet length. Between 2008 and 2017, 264 consecutive patients underwent mitral valve repair (82.2% endoscopic, minimally invasive approach and 17.8% sternotomy) with neochordae loop reconstruction (68.6% posterior, 6.4% anterior, and 25% bileaflet repair). Mean patient age was 63 ± 13.6 years, 73.5% were men, and mean left ventricular ejection fraction was 63.1% ± 6.7%. Results Mitral valve repair was successful in 100% of patients, with no patient requiring conversion to replacement. Neochordae length measurement was accurate in 259 patients (98%), with 4 patients requiring conversion to resection and 1 patient requiring longer anterior leaflet neochordae. Median anterior and posterior neochordae lengths were 27 mm (range, 18-32) and 17 mm (range, 9-27), respectively. Intraoperative transesophageal echocardiography demonstrated no or trace residual MR in 254 patients and mild residual MR in 10 patients. In-hospital mortality occurred in 1 patient, and complications included respiratory failure (2.7%) and renal failure (1.8%). At the median follow-up of 12.6 months (interquartile range, 11.1), 98.9% of patients remained free from ≥2+ MR, whereas freedom from reoperation was 100%. Conclusions Preoperative transesophageal echocardiographic measurements can accurately and reproducibly predict the required length of neochordae loop reconstruction for degenerative mitral valve repair with good results. Longer-term follow-up is necessary.

Mitral valve (MV) repair for infective endocarditis (IE) is sometimes challenging. We investigated the durability of repair associated with the location of the infected lesion.The study comprised 83 patients (55 ± 18 years; active, 66; healed, 17) who underwent MV repair at our institution. Patients were categorized into 5 types based on the location of the main lesion: type I, posterior leaflet (n = 36); type IIC, clear zone of anterior leaflet (n = 12); type IIR, rough zone of anterior leaflet (n = 28); and type III, annulus (n = 7). Type IIR was divided into 2 subgroups: IIR-large (1 segment involvement, n = 9) and IIR-small (1 segment, n = 19).Follow-up was 95.2% completed for 7.2 ± 5.2 years. The rate of recurrent moderate or severe mitral regurgitation (MR) was 2.8% in type I, 0% in type IIC, 28.6% in type IIR, and 14.3% in type III. The freedom from recurrent moderate or severe MR was significantly lower in type IIR compared with the other types (63.1% ± 10.6% vs 96.8 ± 3.2% at 5 years, P .001). Moreover, the recurrence rate was higher in type IIR-large (55.6%) than in type IIR-small (15.8%, P = .068). Type IIR was an independent predictor of recurrent MR (hazard ratio, 11.1, 95% confidence interval, 2.52-78.2; P = .001).The durability of MV repair for IE was satisfactory in posterior leaflet infection without annulus invasion and in clear zone infection of the anterior leaflet. However, rough zone infection of the anterior leaflet, especially with more than 1 segment involvement, was associated with a high risk of recurrent MR.

Background and aim Second-order chord tethering of the anterior leaflet is a risk factor for failure of posterior leaflet prolapse repair. Materials and methods We describe two cases of second-order chord tethering of the anterior leaflet associated with severe mitral regurgitation due to prolapse or chordal rupture of the anterior leaflet, causing early and late failure of repair. Results We described two cases where this phenomenon happened. Conclusions Our cases demonstrate that the second-order chords of the prolapsing AL can be tethered and that this aspect should be carefully evaluated before surgery, as it can progress over time, affecting the results of surgical repair.

Background: Although systolic anterior motion (SAM) of the mitral valve anterior leaflet is well-known to cause hemodynamic perturbation in many anesthetic situations, the prevalence and clinical implication of SAM of mitral chordae tendineae (chordal SAM) in liver transplantation (LT) has not been evaluated. We aimed to assess the impact of chordal SAM on intraoperative postreperfusion syndrome and short and long-term all-cause mortality.Methods: We retrospectively evaluated 1751 LT recipients from January 2011 to June 2017 who had preoperative echocardiography. Echocardiography-derived parameters and the prevalence of post-reperfusion syndrome between those with chordal SAM and without chordal SAM were compared. The cumulative mortality rate according to the presence of chordal SAM was evaluated by the Kaplan-Meier survival curve. Results: Of the enrolled recipients, 21 (1.2%) had chordal SAM in preoperative echocardiography. Compared to those without chordal SAM, patients with chordal SAM had a smaller end-systolic volume index (median 18 ml/m2 vs. 22 ml/m2, P = 0.015) and end-diastolic volume index (median 52 ml/m2 vs. 63 ml/m2, P = 0.011). However, there was no difference in systolic and diastolic function in echocardiography. The prevalence of intraoperative post-reperfusion syndrome did not show any difference (42.9% vs. 45.3%, P = 1.000). Over the mean 4.8-year follow-up, cumulative 90-day and overall mortality also did not show a difference (Log rank P > 0.05, both).Conclusions: Preoperative screening of echocardiography in LT recipients detects 1.2% of chordal SAM. It is found with small left ventricular volume, but is not related with intraoperative post-reperfusion syndrome and short- and long-term postoperative all-cause mortality in LT.

Rothia species are gram positive, round to rod-shaped bacteria that are normally oral and respiratory tract flora. They were first isolated in 1967 from dental caries. We present a 69-year-old male with no risk factors for aforementioned bacteria however was found to have thickened anterior leaflet of the mitral valve with a small isoechoic lesion consistent with vegetation on Transthoracic echocardiogram. Blood cultures grew pan sensitive Rothia dentocariosa. Patient was treated with long-term antibiotics. This case adds to the limited number of cases of Rothia dentocariosa Endocarditis.

Mitral valve systolic anterior motion and associated regurgitation remain a challenging problem in mitral valve plasty. A simple procedure to correct intraoperative systolic anterior motion using sutures applied between the tip of the anterior leaflet and the posterior annulus is presented. This technique reduces the movement of the anterior leaflet toward the septum while maintaining sufficient valve orifice area.

Degenerative mitral regurgitation repair using a measured algorithm could increase the precision and reproducibility of repair outcomes.Direct and echocardiographic measurements guide the repair to achieve a coaptation length of 5 to 10 mm and minimize the risk of systolic anterior motion. Leaflet reconstruction restored the normal 2 to 1 ratio of anterior to posterior leaflet length without residual prolapse or restriction. The choice of ring size was based on anterior leaflet length, the distance from the leaflet coaptation point to the septum, and the anterior-posterior ring dimension. Freedom from reoperation and mitral regurgitation recurrence were based on multistate models.One thousand fifty-one patients had mitral surgery and 1026 (97.6%) were repaired. A2 length was 27.2 ± 4.5 mm; and the reconstructed posterior leaflet was 13.9 ± 2.3 mm. Median ring size was 34 mm and strongly correlated to A2 length (R = 0.76; P .001). The coaptation length at P2 after repair was 6.4 ± 1.7 mm and 87% of measurements were between 5 and 10 mm. Results at predischarge and 10 years, respectively, included mild regurgitation (7.5% and 26.1%), moderate (0.7% and 15.6%), moderate to severe (0% and 1.4%), and severe (0% and 0%), with mean mitral gradient values 3.5 ± 1.5 and 2.9 ± 1.2 mm Hg, respectively. Systolic anterior motion at discharge and last follow-up were 0.2% and 1.1%, respectively. Ten-year freedom from mitral valve reoperation was 99.7%.A simple, reproducible, measured algorithm for degenerative mitral valve repair provides excellent early and late results and is a useful adjunct to established surgical techniques.

The strut chordae (SC) have a unique structure and play an important role in reinforcing the tunnel-shaped configuration of the mitral valve (MV) at the inflow and outflow tracts. We investigated the effect of varying the SC insertion location on normal MV function and dynamics to better understand the complex MV structures. A virtual parametric MV model was designed to replicate a normal human MV, and a total of nine MV modes were created from combinations of apical and lateral displacements of the SC insertion location. MV function throughout the full cardiac cycle was simulated using dynamic finite element analysis for all MV models. While the leaflet stress distribution and coaptation showed similar patterns in all nine MV models, the maximum leaflet stress values increased in proportion to the width of the SC insertion locations. A narrower SC insertion location resulted in a longer coaptation length and a smaller anterior coaptation angle. The top-narrow MV model demonstrated the shortest anterior leaflet bulging distance, lower stresses across the anterior leaflet, and the lowest maximum stresses. This biomechanical evaluation strategy can help us better understand the effect of the SC insertion locations on mechanism, function, and pathophysiology of the MV.

To investigate the frame of reference with the downward displacement of the posterior leaflet and anterior leaflet of tricuspid valve in children by ultrasound.The downward degree of anterior and posterior tricuspid valve was evaluated with tricuspid annulus and coronary sinus as reference structures under ultrasound, and the position of tricuspid regurgitation orifice was shown by color ultrasound. Color Doppler flow imaging showed that the position of tricuspid regurgitation orifice moved down obviously in all 42 children. One case showed 2.2cm from the root of the anterior valve to the tricuspid annulus in the two-chamber and four-chamber view of the apical right heart. Color Doppler can show that the position and direction of tricuspid regurgitation orifice are obviously deviated to the anterolateral side. The obvious deviation of the tricuspid regurgitation orifice to the anterolateral direction may be an ultrasonic sign for diagnosing the downward displacement of the anterior tricuspid valve in children.

Objective An auricular pseudocyst is a fluid filled cavity, characterized by a lack of epithelium, in the intra-cartilaginous space. Clinically, it presents as a painless lump on the upper anterior surface of the ear. Various treatment methods have been discussed in the literature, including aspiration, incision and drainage, or steroid injection. However, these approaches are associated with a high rate of recurrence and results are often esthetically unsatisfactory; therefore, a need for improved treatment approaches remains. Methods From March, 2015, to June, 2017, 15 patients with auricular pseudocyst were treated with surgical deroofing followed by local contour pressure dressing with a simple bolster. In addition, the structure of the auricular pseudocyst was assessed at a microscopic level. Results Patients were followed up for a mean period of 12 months, during which time there were no reports of postoperative complications or recurrence. The results were cosmetically excellent in all patients and no cartilage deformity was seen. Considering the composition of pseudocysts seen on microscopic evaluation, deroofing to remove the anterior leaflet and removal of debris from the posterior leaflet is an appropriate treatment modality. Conclusion This reliable and simple approach may be recommended as first line treatment for auricular pseudocysts to avoid recurrence and complications associated with other treatment modalities, such as cartilage deformity, skin depigmentation, and scarring.

BACKGROUND: Left ventricular outflow tract (LVOT) obstruction is a leading cause of mortality and exclusion from transcatheter mitral valve replacement (TMVR). Intentional laceration of the anterior mitral valve leaflet to prevent LVOT obstruction (LAMPOON) is a transcatheter mimic of surgical chord-sparing leaflet resection. OBJECTIVES: The purpose of this prospective multicenter trial was to study LAMPOON with transseptal (Edwards Lifesciences, Irvine, California) TMVR in annuloplasty rings or native mitral annular calcification (MAC). METHODS: Subjects at high or extreme surgical risk and prohibitive risk of LVOT obstruction from TMVR were included. Eligibility was modified midtrial to exclude subjects with threatened LVOT obstruction from a Sapien 3 valve fabric skirt. The primary endpoint was procedure survival with successful LAMPOON, with successful TMVR, without reintervention, and with LVOT gradient

Aim. To evaluate structural features of the mitral valve (MV) in patients with left ventricular hypertrophy (LVH) and to identify characteristics of MV structural remodeling in hypertrophic obstructive cardiomyopathy (HOCM) patients using three-dimensional MV quantification analysis.Material and Methods. The study included 48 patients with HOCM and 15 patients with arterial hypertension and LVH. All patients underwent standard echocardiography and real-time 3D transesophageal echocardiography, followed by MV reconstruction with quantitative analysis. Quantitative analysis of MV included assessment of the mitral annulus and cusps.Results. Differences in characteristics of three-dimensional MV model between patients with HOCM and arterial hypertension and LVH were identified. In patients with HOCM, the height of the fibrous ring of the MV was increased compared to that in patients with arterial hypertension (8.00±1.72 mm vs. 5.99±1.95 mm; p=0.02). Mitral annular height (r=-0.55; p=0.02) and area(3D) (r=-0.30; p=0.04) correlated with peak LV outflow tract (LVOT) gradient. MV nonplanarity index was higher in HOCM patients (2.37±0.47 units vs. 1.73±0.62 units; p=0.02). Mitral annular maximal velocity correlated with peak (r=0.48, p=0.002) and mean (r=0.47, p=0.01) LVOT gradients. Anterior (6.40±2.04 sm2 vs. 5.07±1.04 sm2 ; pConclusion. Compared to patients with arterial hypertension and LVH, patients with HOCM experienced more pronounced MV annular remodeling presented as an increase in the annular height, which was accompanied by an increase in the cusp areas and the anterior leaflet angle. In patients with HOCM, the annular area and the maximum mitral annular velocity correlated with LVOT gradient.

Aims To characterize the dynamic nature of the left ventricular outflow tract (LVOT) geometry and flow rate in patients following transcatheter mitral valve replacement (TMVR) with anterior leaflet laceration (LAMPOON) and derive insights to help guide future patient selection. Methods and results Time-resolved LVOT geometry and haemodynamics were analysed with post-procedure computed tomography and echocardiography in subjects (N = 19) from the LAMPOON investigational device exemption trial. A novel post hoc definition for LVOT obstruction was employed to account for systolic flow rate and quality of life improvement [obstruction was defined as LVOT gradient >30 mmHg or LVOT effective orifice area (EOA) ≤1.15 cm2]. The neo-LVOT and skirt neo-LVOT were observed to vary substantially in area throughout systole (64 ± 27% and 25 ± 14% change in area, respectively). The peak systolic flow rate occurred most commonly just prior to mid-systole, while minimum neo-LVOT (and skirt neo-LVOT) area occurred most commonly in early-diastole. Subjects with LVOT obstruction (n = 5) had smaller skirt neo-LVOT values across systole. Optimal thresholds for skirt neo-LVOT area were phase-specific (260, 210, 200, and 180 mm2 for early-systole, peak flow, mid-systole, and end-systole, respectively). Conclusion The LVOT geometry and flow rate exhibit dynamic characteristics following TMVR with LAMPOON. Subjects with LVOT obstruction had smaller skirt neo-LVOT areas across systole. The authors recommend the use of phase-specific threshold values for skirt neo-LVOT area to guide future patient selection for this procedure. LVOT EOA is a ‘flow-independent’ metric which has the potential to aid in characterizing LVOT obstruction severity.

Ebstein anomaly, a rare congenital heart disease, is defined as displacement of hinge points of septal or posterior tricuspid leaflets but not anterior leaflet. Here we report a 35 year old lady with an extremely rare pattern of EA with all three tricuspid leaflets displaced downward to the apex.

We present the case of a 28 year-old lady with a history of intravenous drug use who presented to our institution with symptomatic right heart failure secondary to tricuspid valve regurgitation. She presented with infective endocarditis leading to dyspnoea and peripheral oedema secondary to torrential tricuspid regurgitation. Transthoracic echocardiography confirmed right ventricular dysfunction and congestive hepatomegaly. Intra-operatively findings an infected and destroyed anterior leaflet of the tricuspid valve with posterior leaflet prolapse was found to cause severe tricuspid regurgitation. She had complex tricuspid valve reconstruction using anterior leaflet reconstruction using Admedus Cardiocel™ patch, posterior leaflet prolapse correction and commissural reduction with a McGoon imbrication and annuloplasty ring to stabilize the repair. This case demonstrates the importance of reconstructive tricuspid valve surgery in the setting of infective endocarditis. Furthermore, this case demonstrates the possibility of anterior leaflet excision and reconstruction with an excellent durable functional result.

OBJECTIVE: Mitral valve repair is superior to replacement for degenerative disease, but long-term outcomes of anterior vs. posterior leaflet repair remain poorly-defined. We propensity-matched anterior and posterior repairs to compare long-term outcomes. METHODS: Patients undergoing first-time degenerative mitral repair between 1992–2018 were identified. Primary outcome was overall survival. Secondary outcomes were post-procedural residual mitral regurgitation (MR) and reoperation. From 1025 patients, 1:1 propensity score matching was performed, yielding 309 anterior (isolated anterior=85, bileaflet=224) and 309 isolated posterior repairs. RESULTS: Age was 58±15 years, ejection fraction was 57±10%, and matched groups were well-balanced. Anterior repairs had longer bypass (122±53 vs. 109±43 minutes, p=0.001) and cross-clamp (94±44 vs. 85±62 minutes, p=0.033) times. Mean residual MR grade was 0.44 (95% CI 0.24–0.65) for anterior and 0.30 (95% CI 0.13–0.47) for posterior repair (p=0.31). Overall 92% (569/618) of matched patients had no residual MR, with no differences in MR grade between groups (p=0.77). Survival did not differ between anterior (10-year: 72±7%; 15-year: 63±7%) and posterior (10-year: 74±7%; 15-year: 60±8%) groups (log-rank p=0.93). Linearized incidence of reoperation was 0.62% per patient-year, including 0.74% for anterior and 0.48% for posterior repairs. Cumulative incidence of reoperation at 15 years was 7.5% after anterior and 4.9% after posterior repair (Gray’s test p=0.26). CONCLUSIONS: No long-term survival or reoperation difference was found between posterior and anterior repair. Based on these findings, surgeons at centers of excellence should aim for repair of both anterior and posterior leaflet pathology with the same decision-making threshold over valve replacement for degenerative mitral disease.

The advantages of mitral valve repair are lower morbidity and mortality, reduced risk of thromboembolism and endocarditis, improved survival, and better preservation of left ventricular function. The most common cause of degenerative mitral regurgitation is a myxomatous valve with segmental prolapse of the posterior leaflet, a lesion that can be corrected by classical techniques such as quadrangular resection, but other lesions may require more complex surgical techniques, for instance, correction of anterior leaflet prolapse or Barlow disease. Mitral valve repair [...]

BACKGROUND Complete atrioventricular septal defects (CAVSD) include a variable spectrum of congenital malformations with different forms of clinical findings. We examined early and midterm outcomes, the need for reoperation, postoperative residual AV valve regurgitation, and other risk factors after various CAVSD repairs. METHODS Between 2014 and 2018, we have performed 89 isolated CAVSD repairs. We retrospectively reviewed the patients' medical records. Patients were divided into three groups according to their repair techniques modified one patch repair (MP) (n = 16); two patch repair (TP) (n = 49); and left anterior leaflet augmentation (ALA) technique (n = 24). RESULTS Eighty patients (89.8%) survived hospital discharge. Early mortality rates were three (18.8%) in the group MP, five (10.2%) in the group TP, and one (4.2%) in the group ALA. Thirteen patients died during the follow-up period. Late mortality rates were three (18.8%) in the group MP, four (16.6%) in the group ALA, and six (12.2%) in the group TP. The mean follow-up time was 35.9 ± 22.97 months (range: 0.3-77 months). The morbidity and mortality results were similar between-group TP and ALA but worse in the MP group. Low body weight (

Currently, the gold standard treatment for hypertrophic cardiomyopathy in its obstructive variant is a wide septal myectomy through a transaortic approach. In some cases, where mitral regurgitation is added to septal hypertrophy due to systolic anterior movement of the anterior leaflet, concomitant procedures are proposed for the resolution of both. In this tutorial, we present a case of hypertrophic cardiomyopathy with associated systolic anterior movement that was resolved with septal resection and plication of the anterior leaflet of the mitral valve via a transaortic approach.

We present the case of a previously healthy 2-year-old boy with extensive infective mitral valve endocarditis, with 2 huge, mobile vegetations attached to the anterior leaflet of the mitral valve and to the left ventricular outflow tract, and interventricular septal abscesses extending into the left ventricular outflow tract without any septal defects. He underwent mitral valve repair and simultaneous drainage of the interventricular septal abscesses excluding the inlet portion to avoid postoperative complications.

Mitral valve abscess is a well-known complication of infective endocarditis, often requiring surgical treatment. Usually, the most typical localization is postero-lateral mitral annulus or mitral-aortic curtain at the base of the anterior leaflet in aortic valve endocarditis. We describe a 64-year-old male diagnosed with the abscess on the free margins of the mitral leaflets secondary to concomitant vertebral osteomyelitis. A favorable resolution of the abscess during the intravenous dual antibiotic therapy is presented.

Rheumatic mitral valve disease remains an important cause of mitral regurgitation (MR), accounting for 7% to 15% of organic MR cases in large epidemiologic studies (1,2). Similarly, a history of radiation to the mediastinum, as is common in the treatment of several malignancies, is associated with future valve dysfunction in up to one-third of patients. Mitral valve repair (MVr) is favored over replacement for severe primary MR; this is due to a significant 30-day and mid to long-term mortality benefit, as well as a reduction in peri-operative complications (3,4). However, due to ongoing inflammation and leaflet infiltration, MVr in rheumatic or radiation-induced valvulitis may be associated with decreased durability and an increased risk of reoperation (5). In order to improve outcomes of MVr in these populations, adjunctive reparative procedures have been introduced. One such technique involves the use of autologous or bovine pericardium to reconstruct or enlarge the anterior mitral leaflet (AML) and normalize its coaptation with the posterior leaflet, with further reinforcement from a supporting annuloplasty ring (Figure 1) (6). While small studies suggest excellent mid-term survival with this approach, moderate or greater recurrent MR and reoperation occurs in 11.2% and 4.6% of patients, respectively, with rheumatic MR. Poor outcome data exists in the literature regarding MVr techniques for radiation-induced valvulitis (6,7). Herein, we provide an in-depth clinical and imaging appraisal of two such cases, with a focused review on pathophysiology and management. Open in a separate window Figure 1 MVr utilizing an annuloplasty ring and AML pericardial patch augmentation. (A) Schematic of AML pericardial patch augmentation MVr. There is a reconstructed and enlarged AML, normalized anterior and posterior leaflet coaptation, and reinforcement from a supporting annuloplasty ring; (B,C) systolic and diastolic transesophageal echocardiography mid-esophageal four-chamber views. Displayed is the augmented anterior mitral leaflet and pericardial patch (red arrow). MVr, mitral valve repair; AML, anterior mitral leaflet; PML, posterior mitral leaflet.

Blood cysts are rare cardiac tumors. Although it is considered a benign pathology, it can also be associated with embolic events. We report 42-year-old woman who admitted to our clinic with the palpitation and dyspnea on exertion. Apical diastolic murmur was present in physical examination. On echocardiography mitral valve posterior leaflet had a typical 'domed' appearance in diastole while anterior leaflet was restricted in motion with a fibrocystic formation on the ventricular side, causing mild to moderate mitral stenosis. We decided medical follow-up with the patient choice and we have been following for two years without any complications.

Background and aim of the study The outcome of mitral valve (MV) repair for chronic ischemic mitral regurgitation (IMR) is suboptimal, due to the high recurrence rate of moderate or severe mitral regurgitation (MR) during follow-up. The MV adapts to new MR increasing its area to cover the enlarged annular area (mitral plasticity). As this process is often incomplete, we aimed to evaluate if augmenting the anterior leaflet (AL) and cutting the second-order chords (CC) together with restrictive mitral annuloplasty, a strategy we call "surgical mitral plasticity," could improve the midterm results of MV repair for IMR. Materials and methods From November 2017 to October 2019, 22 patients with chronic IMR underwent surgical mitral plasticity. Mean age was 73 ± 7 years and six were female. Mean ejection fraction was 32% ± 11%, IMR grade was moderate in 10 and severe in 12. Mean clinical and echocardiographic follow-up was 12 ± 6 months. Results There was no early death, and one patient died 6 months after surgery. Ejection fraction improved from 32% ± 15% to 40% ± 6% (P = .031). IMR was absent or mild in all patients, and none showed recurrent moderate or more IMR. Tenting area decreased significantly from 2.5 ± 0.5 to 0.5 ± 0.3 cm² and coaptation length increased from 1.9 ± 0.7 to 7.8 ± 1.6 mm. All patients were in New York Heart Association class I or II. Conclusions Mitral plasticity, if uncomplete, is ineffective in preventing IMR to become significant. Surgical mitral plasticity, by completing incomplete process of MV adaptation, has a strong rationale, which however needs to be validated with longer follow-up.

Background and aim Mitral regurgitation (MR) in Barlow's disease is complicated because of its mixed pathophysiology, leaflet billowing with or without organic prolapse, and abnormal annular dynamics that cause functional prolapse. Complex repair techniques, including aggressive leaflet resection and implantation of multiple artificial chordae, are conventionally performed; nevertheless, these are technically demanding, especially when performed using a minimally invasive approach. We aimed to standardize the repair technique for Barlow's disease and developed stepwise repair techniques. Methods Of 292 patients who underwent isolated minimally invasive mitral valve repair for MR, 29 patients (seven females, age 49 ± 10 years) were found to have Barlow's disease. Our repair technique consists of the following three steps: (a) stabilization of the mitral annulus by placing annuloplasty ring sutures; (b) distinction between organic and functional prolapse by a saline injection test; and (c) targeted repair for organic prolapse by leaflet resection or chordal replacement. Results Surgical techniques included leaflet resection in 22 patients, chordal replacement in 19 patients, and ring annuloplasty only in one patient. These procedures were applied to the anterior leaflet in one, posterior leaflet in eight, and both leaflets in 19 patients. The median annuloplasty ring size was 34 mm. The repair success rate was 100%. No patients developed moderate or greater MR during a mean follow-up period of 36 ± 21 months. Conclusions A stepwise repair strategy facilitates mitral valve repair in patients with Barlow's disease and provides excellent outcomes even via a minimally invasive approach.

Background: The aim of this study is to evaluate severe mitral regurgitation caused by so called atrial leaflet “pseudoprolapse” and verify the effect of simple annular stabilization. Methods: One-hundred-twenty-two patients underwent surgery for severe mitral regurgitation at our institute between January 2015 to July 2018. Of those, 32 cases diagnosed as anterior leaflet prolapse that underwent mitral repair were analyzed. Ten cases with pseudoprolapse, which is defined as anterior leaflet prolapse without dropping into the left atrium beyond the annular line causing eccentric regurgitation flow directed to the posterior atrium, were classified as the Pseudoprolapse Group. The other 22 cases had obvious anterior leaflet prolapse dropping into the left atrium; these cases were classified as the True Prolapse Group. We compared clinical findings between the 2 groups and reviewed pseudoprolapse cases. Results: Patients in the Pseudoprolapse Group had lower ejection fraction and lower regurgitation volume than those in the True Prolapse Group. A2 lesion as main inflow of regurgitation was more included in the Pseudoprolapse Group. All but one patient in the Pseudoprolapse Group received only simple annuloplasty, and all patients in the True Prolapse Group received leaflet repair and annuloplasty. In both groups, mid-term regurgitation grade and the reoperation rate were satisfactory. In the Pseudoprolapse Group, 6 cases were clarified as atrial functional mitral regurgitation, and 4 cases were considered to have focal posterior leaflet tethering. Conclusions: Pseudoprolapse cases could be characterized by low ejection fraction, low regurgitation volume, and A2 prolapse. For most cases with pseudoprolapse, simple annuloplasty may be enough, however further study is needed.

International audience; No abstract available

Background MitraClip is a percutaneous way of treatment of mitral regurgitation. Recent trials demonstrate its value in modifying prognosis of patients with functional mitral regurgitation. During MitraClip implant imaging with 3D TEE is mandatory to guide the procedure and monitoring the results. Unfortunately, laceration of mitral leaflets is a well-described complication of Percutaneous Mitral valve repair by implantation of MitraClip. 3D TEE can be useful even to detect complication of the procedure and in particular leaflets lacerations. Here we describe a case where 3D TEE was capable to recognize and visualize a laceration in the anterior leaflet (AL) and we assume some mechanisms leading to this complication. Methods An 83 years old man with post-ischemic severe functional mitral regurgitation underwent to MitraClip implantation. The mitral valve shows a severe tenting and annulus was deformed and dilated. The procedure was performed under fluoroscopic and 3D TEE guidance (Philips iE33). Due to the large central regurgitation and large coaptation gap, we decide to implant MitraClip XTR, this is the larger device 5 mm longer. Results A single MitraClip XTR was implanted in the central scallop (A2-P2) in the region of the larger jet, after device positioning a further jet was detected in the region of implant and the original jet was unchanged. Using 3D color complete volume and X-plane reconstructions we recognize that the jet originates between the clip and the basal aspects of AL. Without color Doppler in 3D zoom and X plane reconstruction, a continuum solution was suspected in the body of AL but the shadow of the delivery system partially masked the region. After removal of the device, perforation of AL was clearly depicted also with 3D zoom without color Doppler. The patient was surgically treated and inspection confirmed the laceration and shows a worn thin AL. The laceration of AL can be caused by the tension on a thinned tissue carried out by the large device. The severe tethering and annular dilatation with a marked distance between anterior and posterior leaflet at the tip of the device may have been a determinant factor in the tear occurrence. Conclusion 3D TEE can clearly depict lacerations of leaflets during MitraClip implantation. Preoperative extensive analysis of valve geometry and inspection of leaflets searching for a thinned region can avoid intraoperative complications. The distance between leaflets at the expected tips of the MitraClip can be a predictive parameter of tension applied on the leaflets and of the risk of tearing. Abstract 1634 Figure. Image 1

OBJECTIVES Saline testing is used in mitral valve (MV) surgery to evaluate the repair intra-operatively. Sometimes, saline testing shows a prolapse of the anterior leaflet, not seen on preoperative echocardiography. Our objective was to investigate the incidence, predisposing factors and consequences of this phenomenon.METHODS We retrospectively reviewed all consecutive patients undergoing surgery for posterior leaflet prolapse between 2013 and 2017. All data, including intraoperative video recordings of the repair and saline testing, were collected prospectively.RESULTS Isolated posterior leaflet repair was performed in 91 patients. In 17 patients (18.7%), saline testing showed an unexpected anterior leaflet prolapse. Patients with unexpected prolapse presented with higher body mass index (BMI) compared to the reference group (27.52.3 vs 25.0 +/- 4.2, P=0.01). Binomial logistic regression analysis showed BMI, surgical approach, number of prolapsing segments, left ventricular ejection fraction, left ventricular end systolic diameter and left atrial diameter to be predictive for unexpected anterior leaflet prolapse. In patients with unexpected anterior leaflet prolapse, no adequate saline testing was possible and repair was accomplished based on correction of the prolapse as seen on a preoperative echocardiogram. In both groups, 100% repair rate was achieved. Predischarge mitral regurgitation grading showed mild or less mitral regurgitation in all the patients in the unexpected prolapse group in comparison with 98.6% of patients in the reference group.CONCLUSIONS When saline testing shows an unexpected prolapse of the anterior leaflet, not present on preoperative echocardiography, no additional surgical techniques should be performed in order to achieve an excellent postoperative result. Further research is warranted to predict unexpected anterior leaflet prolapse preoperatively.

Traumatic tricuspid regurgitation (TR) is a rare cardiovascular complication in chest trauma. Changes in the left ventricle (LV) function after operation are unclear. A 61-year-old woman who had been involved in a traffic accident 1 month earlier presented with exertional dyspnea. Transthoracic echocardiography (TTE) showed severe tricuspid regurgitation (TR) accompanied by LV dysfunction due to anterior leaflet prolapse with papillary muscle rupture. After tricuspid plasty, the LV function improved, as evidenced by TTE and speckle tracking echocardiography. In conclusion, the early diagnosis of traumatic TR is important, and early surgical intervention might be effective for achieving ventricular function improvement.

Using in vitro models, the mechanics as well as surgical techniques for mitral valves (MV) and MV devices can be studied in a more controlled environment with minimal monetary investment and risk. However, these current models rely on certain simplifications, one being that the MV has a static, rigid annulus. In order to study more complex issues of imaging diagnostics and implanted device function, it would be more advantageous to verify their use for a dynamic environment in a dynamic simulator. This study provides the novel design and development of a dynamically contracting annulus (DCA) within an in vitro simulator, and its subsequent use to study MV biomechanics. Experiments were performed to study the ability of the DCA to reproduce the MV leaflet mechanics in vitro, as seen in vivo, as well as investigate how rigid annuloplasties affect MV leaflet mechanics. Experiments used healthy, excised MVs and normal hemodynamics; contractile waveforms were derived from human in vivo data. Stereophotogrammetry and echocardiography were used to measure anterior leaflet strain and the change in MV geometry. In pursuit of the first in vitro MV simulator that more completely represents the dynamic motion of the full valvular apparatus, this study demonstrated the successful operation of a dynamically contracting mitral annulus. It was seen that the diseased contractile state increased anterior leaflet strain compared to the healthy contractile state. In addition, it was also shown in vitro that simulated rigid annuloplasty increased mitral anterior leaflet strain compared to a healthy contraction.

Background This study investigated the consequences of recurrent mitral regurgitation (MR) after mitral valve (MV) repair in patients with degenerative MR and risk factors for recurrence.Methods and Results:From January 1990 to December 2015, 792 patients underwent MV repair due to degenerative MR. Recurrent MR was defined as moderate-to-severe MR on follow-up echocardiography. Mean follow-up duration was 8.71±5.58 years. During the follow-up period, MR recurred in 133 (16.8%) patients, and the MR recurrence-free rate at 20 years was 77.5±2.0%. In the recurrence group, the degree of MR decreased in 8 (6.0%) patients and was aggravated in 46 (34.6%) patients. Recurrent MR was associated with increased mortality and adverse left ventricular (LV) remodeling. Independent risk factors for MR recurrence were MV repair performed before 2000, preoperative atrial fibrillation, high LV end-diastolic dimension (LVEDD), prolapse of the isolated anterior leaflet or multiple segments, and absence of ring annuloplasty. Predictors of MR progression were high LVEDD and repair without artificial chordae implantation. Conclusions Recurrent MR after MV repair in patients with degenerative MR showed a tendency to progress and was associated with increased mortality and adverse LV remodeling. Early referral for MV repair before development of atrial fibrillation and LV enlargement may reduce the risk of MR recurrence. Moreover, artificial chordae implantation and ring annuloplasty may assure the long-term durability of MV repair.

Suture-related injuries of the left circumflex branch are a serious and well-known complication of mitral valve surgery. Avoiding this complication is challenging, especially in an unexpected course of coronary arteries. We present a case of minimally invasive mitral valve repair in a patient with a rare anatomical variant of the main stem in direct proximity to the whole anterior leaflet.

Introduction The native pulmonary valve (PV) reconstruction is an attractive alternative to a replacement but is challenging due to the systematic underdevelopment of the valve structures in congenital heart diseases. The partial replacement of underdeveloped parts of the valve and saving of well-developed may have advantages versus replacing the whole valve in terms of durability and patient outgrowth of the prosthesis. Case presentation This report describes a case of the PV reconstruction by allograft replacement of an underdeveloped anterior leaflet in an adolescent patient who previously corrected pulmonary stenosis during the first year of her life. The normal anatomy of the right and left leaflets was revealed. The rudimental anterior leaflet determined the annular restenosis. The monocusp with the related supporting aortic wall was sewn instead of the anterior leaflet. The Z-score of the pulmonary annulus changed from minus 3, 9 before to +0.8 after the procedure. The excellent function of the PV was observed in 1-year follow-up. Discussion Valve deterioration over time will have a less negative impact on the function when it occurs in a limited area. The annular dilatation becomes unlikely if the annulus predominantly consists of natural tissues. The procedural effectiveness allows the transcatheter valve-in-valve therapy in case of late dysfunction. The expected feature of the procedure described is that the growth of the PV remains possible. Conclusion If allograft replacement of the PV is scheduled and allograft is available, the partial replacement may be superior to replacement of the whole valve in terms of durability and patient outgrowth of the prosthesis., Highlights • A pulmonary valve (PV) repair is an attractive surgical option because an ideal replacement device is still not developed. • A PV repair is a challenge due to the systematic underdevelopment of the valve structures in congenital heart diseases. • The partial replacement of the PV structures may be more beneficial in terms of durability vs whole valve replacement. • The PV leaflets at the primary operation should be saved and handled carefully. They may used for valve repair in the future.

Background: Ebstein’s anomaly (EA) has various spectrums in clinical and anatomic features. This study aimed to report the experience of two-dimensional intraoperative transesophageal echocardiography (2D-ITEE) during the EA surgery and to analyze the characteristics of the tricuspid valve (TV) by comparing the data from 2D-ITEE with the results from the surgery. Methods: 2D-ITEE data of 164 patients with EA who were operated in the First Hospital of Tsinghua University between July 2004 and April 2014 were retrospectively analyzed in this study. 2D-ITEE was applied in all patients. Downward displacement distances were measured, and the numbers of downward displacement or absent leaflets were compared with that of the surgery and with that of the two-dimensional-transthoracic echocardiogram (2D-TTE). Data comparison was performed using the Chi-square test. Results: The anterior leaflet partial or total downward displacement was 37.76 ± 17.50 mm in 54 cases, absent in one patient; septal leaflet downward displacement was 29.07 ± 12.34 mm in 134 cases, absent in 17 cases; and posterior leaflet downward displacement was 43.18 ± 19.16 mm in 115 cases, absent in 34 cases. Statistically, there was no significant difference between the results from 2D-ITEE and that of 2D-TTE. The consistency rates of 2D-ITEE with operation for septal and posterior leaflets were 93.2% and 96.1%, respectively, while the rate for anterior was only 40.1%, which was significantly different. Color Doppler flow image showed severe regurgitation in 150 cases and moderate in 14 cases. After surgical correction, moderate regurgitation of TV was found in 58 cases with 2D-ITEE, repair was performed again until the effect was satisfied. No complication occurred relating to the use of 2D-ITEE. Conclusions: 2D-ITEE could help diagnose anterior leaflet, evaluate the effect of TV repair, increase operational success rate, and reduce complication. Key words: Ebstein’s Anomaly; Echocardiography; Two-dimensional-transesophageal Echocardiography

Objective To assess differences in morphology of the mitral valve (MV) between healthy dogs and dogs affected by myxomatous mitral valve disease (MMVD) using real-time transthoracic three-dimensional echocardiography (RT3DE). Animals Thirty-four were normal dogs and 79 dogs were affected by MMVD. Methods Real-time transthoracic three-dimensional echocardiography mitral datasets were digitally recorded and analyzed using dedicated software. The following variables were obtained and compared between healthy dogs and dogs with MMVD at different stages: antero-posterior annulus diameter, anterolateral-posteromedial annulus diameter, commissural diameter, annulus height, annulus circumference, annulus area, anterior leaflet length, anterior leaflet area, posterior leaflet length, posterior leaflet area, non-planar angle, annulus sphericity index, tenting height, tenting area, tenting volume, the ratio of annulus height and commissural diameter. Results Dogs with MMVD had a more circular MV annulus compared to healthy dogs as demonstrated by an increased annulus sphericity index (p=0.0179). Affected dogs had a less saddle-shaped MV manifest as a decreased annulus height to commissural width ratio (p=0.0004). Tenting height (p