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Background: Valve-in-Valve (VIV) Transcatheter Aortic Valve Replacement (TAVR) is now the treatment of choice in high-surgical-risk patients with failing aortic bioprosthesis. Although less performed, VIV-Transcatheter Mitral Valve Replacement (TMVR) is a valid treatment option for selected high-risk patients with degenerated mitral bioprostheses. Several cases of elective ViV- TAVR and -TMVR have been reported but only few were performed in critical hemodynamic conditions., Case Presentation: We report the case of a patient underwent balloon-expandable transapical mitral valve-in-valve implantation in an emergency setting due to a severe stenosis of a bioprosthesis in mitral position. The procedure was successfully performed, with no residual mitral regurgitation or paravalvular leaks, and uneventful., Conclusion: Transcatheter transapical mitral valve-in-valve implantation could represent a feasible and effective strategy even in critical setting.

Factors correlating to mitral annulus calcification (MAC) include risk factors predisposing to atherosclerosis. In patients with mitral valve (MV) prolapse (MVP), other anatomic or mechanical factors have been supposed to facilitate MAC. The aims of this study were, in patients with MVP undergoing MV repair, (1) to describe the prevalence and characteristics of MAC, (2) to correlate MAC with clinical risk factors, coronary involvement, and aortic valve disease, and (3) to describe prevalence, site, and extension of MAC in fibroelastic deficiency (FED) versus Barlow's disease (BD) and correlate MAC to surgical outcomes (repair vs replacement). In 410 consecutive patients with MVP suitable for surgical MV repair, detailed clinical and echocardiographic data were collected to characterize MAC in BD and FED. MAC was found in 99 patients (24%). Age, female gender, coronary artery disease, and cardiovascular risk factors were correlated with MAC. MAC was equally distributed in FED and BD groups despite patients with FED being older with more cardiovascular risk factors. The most common localization of MAC was annular involvement adjacent to P2 (75%), P1 (31%), and P3 (35%). The presence of MAC affected surgical outcomes in both groups (8% patients with MAC underwent replacement after a first attempt of repair vs 3% without MAC). MAC is a common finding in patients undergoing MV repair, and several clinical characteristics correlate with MAC either in FED or BD. In conclusion, despite very high percentage of repairability, MAC influences surgical outcomes and very detailed echo evaluation is advocated., (Copyright © 2014 Elsevier Inc. All rights reserved.)

Background: The levels and fine structure of complex polysaccharides, glycosaminoglycans (GAGs), were determined in segments of the posterior mitral valve leaflet (MVL) taken from 15 patients affected by mitral regurgitation and degenerative disease and were compared with segments from 15 multiorgan donors., Methods: MVL GAGs were analyzed by agarose gel electrophoresis, and by HPLC and fluorophore-assisted carbohydrate electrophoresis to evaluate disaccharide patterns after treatment with chondroitinase ABC., Results: GAGs from the control group were composed of approximately 37% hyaluronic acid and 63% chondroitin sulfate/dermatan sulfate with a charge density of approximately 0.61. Chondroitin sulfate/dermatan sulfate polymers contained approximately 23% of the disaccharide sulfated in position 6 on N-acetyl-galactosamine, approximately 38% of the 4-sulfated disaccharide and approximately 2% of the non-sulfated disaccharide (with a 4-sulfated/6-sulfated ratio of 1.7). The total amount of GAGs was 0.66 microg/mg tissue. The total amount of GAGs in patients suffering from mitral regurgitation and degenerative disease was approximately 51.5% higher (although the difference was not significant, probably because of the low number of subjects enrolled in the study). However, significantly higher hyaluronic acid content (approx. +38%, p<0.05) and lower sulfated GAG content (approx. -21%, p<0.005) were demonstrated. As a consequence, the total charge density decreased by approximately 23% (p<0.005). This macro-modification of GAG composition was also followed by a micro-alteration of the structure of the sulfated polysaccharides, in particular with a significant decrease in the 4-sulfated disaccharide (and a parallel increase in hyaluronic acid content) with no modification of the percentage of the 6-sulfated and non-sulfated disaccharides (with a significant decrease in the 4-/6-sulfated ratio)., Conclusions: We assume that changes in the relative amount and distribution of GAGs in posterior MVL in subjects suffering from mitral regurgitation and degenerative disease are consistent with a decrease in the tension to which these tissues are subjected and with an abnormal matrix microstructure capable of influencing the hydration and of conditioning the mechanical weakness of these pathological tissues.

Intra-operative mitral valve repair failure is a common condition in patients with complex myxomatous disease requiring aortic re-clamping and application of a fast and easy surgical technique to correct the residual imperfection. Herein we describe a reproducible method of artificial chord reconstruction which preserves the previous accomplished acts and allows for accurate chordal length measurement basing on the annuloplasty as the reference level. [ABSTRACT FROM AUTHOR]

Preservation of right ventricle vascularization that is dependent on left coronary network collateral development is essential during left ventricular assist device implantation to avoid postoperative right heart failure. Our technique was performed on a patient who underwent implantation as a bridge to transplantation; the technique is characterized by providing a moderate lateral and inferior displacement of the inflow cannula position, which achieves both the objectives of respecting the apical course of a left anterior descending coronary artery supplying an occluded right coronary and of maintaining a sufficient orientation degree toward the plane of the mitral valve for correct left ventricular unloading. [ABSTRACT FROM AUTHOR]

Aims Mitral valve (MV) repair is the preferred treatment for mitral regurgitation associated with organic MV prolapse (MVP). Our goals were to describe by transthoracic real-time 3D echocardiography (RT3D TTE) the pre-operative changes in mitral annulus (MA) dynamic morphology related to MVP, compared with a normal population, and to evaluate the differential long-term effects induced by annuloplasty, using either an incomplete flexible band or a complete semi-rigid ring. Methods and results Forty-four patients (62 ± 11 years) with organic MVP and ejection fraction >55% were studied by RT3D TTE the day before MV repair, and 3 and 6 months after (23 patients received a complete rigid ring—CAR, 21 an incomplete flexible band—COS). An age-matched group of 20 normal subjects (57 ± 9 years) was studied as control. After initialization, the MA was tracked frame-by-frame in 3D, and several parameters computed. Differences in MVP vs. controls, vs. pre-surgery, and between rings were tested (P < 0.05). MVP showed enlarged MA resulting in greater area and height during the cardiac cycle, with reduced planarity compared with controls. Annuloplasty resulted in reduced MA area in both CAR and COS, with minimal area change, and planar shape (more evident in CAR than COS). Conclusion The main factor affecting MA function after annuloplasty appears to be the undersizing of the MA dimensions, and not the choice of the ring. This methodology could represent the basis for further evaluation of implanted rings, to provide the surgeon with additional information to be used in the pre-surgical planning and ring selection. [ABSTRACT FROM AUTHOR]

The Commando procedure is challenging, and aims to replace the mitral valve, the aortic valve and the aortic mitral curtain, when the latter is severely affected by pathological processes (such as infective endocarditis or massive calcification). Given the high complexity, it is seldomly performed. We aim to review the literature on early (hospitalization and up to 30 days) and long-term (at least 3 years of follow-up) results. Bibliographical research was performed on PubMed and Cochrane with a dedicated string. Papers regarding double valve replacement or repair in the context of aortic mitral curtain disease were included. The metaprop function was used to assess early survival and complications (pacemaker implantation, stroke and bleeding). Nine papers (540 patients, median follow-up 41 (IQR 24.5–51.5) months) were included in the study. Pooled proportion of early mortality, stroke, pacemaker implant and REDO for bleeding were, respectively 16.2%, 7.8%, 25.1% and 13.1%. The long-term survival rate ranged from 50% to 92.2%. Freedom from re-intervention was as high as 90.9% when the endocarditis was not the first etiology and 78.6% in case of valvular infection (one author had 100%). Freedom from IE recurrences reached 85% at 10 years. Despite the high mortality, the rates of re-intervention and infective endocarditis recurrences following the Commando procedure are satisfactory and confirm the need for an aggressive strategy to improve long-term outcomes. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study, undertaken in patients who underwent mitral valve (MV) repair surgery, was to evaluate the feasibility and accuracy of 3-dimensional (3D) transthoracic (TTE) and transesophageal (TEE) echocardiography in the evaluation of MV pathology. Background: A pre-operative assessment of MV anatomy is essential to surgical design in patients undergoing MV repair. Although 2-dimensional (2D) echocardiography provides precise information regarding MV anatomy, 3D TTE and 3D TEE could increase the understanding of MV apparatus and individual scallop identification. Methods: One-hundred-twelve consecutive patients with severe mitral regurgitation due to MV prolapse underwent a complete 2D and 3D TTE the day before surgery and a complete 2D and 3D TEE in the operating room. Echocardiographic data obtained by the different techniques were compared with surgical inspection. Results: Three-dimensional techniques were feasible in a relatively short time (3D TTE: 7 ± 4 min; 3D TEE: 8 ± 3 min), with good (3D TTE 55%; 3D TEE 35%) and optimal (3D TTE 21%; 3D TEE 45%) imaging quality in the majority of cases. Three-dimensional TEE allowed more accurate identification (95.6% accuracy) of all MV lesions in comparison with other techniques. Three-dimensional TTE and 2D TEE had similar accuracies (90% and 87%, respectively), whereas the accuracy of 2D TTE (77%) was significantly lower. Conclusions: Three-dimensional TTE and TEE are feasible and useful methods in identifying the location of MV prolapse. They were superior in the description of pathology in comparison with the corresponding 2D techniques and should be regarded as an important adjunct to standard 2D examinations in decisions regarding MV repair. [Copyright &y& Elsevier]