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Objectives: There is a paucity of data on the outcome of left-sided cardiac valve surgery for infective endocarditis in South Africa. It is hypothesized that outcomes may be poorer compared to international standards due to differences in disease burden, timing of surgery, organism prevalence, and co-morbidities. Method: This is a retrospective study of 160 patients with left heart valve endocarditis who underwent cardiac surgery from January 2010 to December 2019. Demographic, operative, and admission-related parameters were assessed to determine their association with all-cause mortality during the early post-operative (<30 days) and late post-operative (>30 days) periods. Results: Early post-operative mortality (<30 days) was 8.8% and late post-operative mortality (>30 days) was 13.1%. Late survival showed 77.5% of the patients were alive with a mean follow-up period of 41 months. Increased age (p = 0.04), critical illness (p < 0.001), and higher urgency of intervention (p < 0.001) were associated with higher early post-operative mortality. Peri-operative organ failure, including cardiac (p = 0.025), renal (p = 0.016), and respiratory failure (p < 0.001), contributed significantly to both early and late mortality. Pre-operative antibiotics for fewer days (p = 0.024), ongoing sepsis (p = 0.022), and para-valvular extension (p = 0.046) were associated with higher early mortality. Conclusions: Infective endocarditis is a common indication for cardiac valve surgery in South Africa. Goal-directed medical management and clinical optimization prior to surgery were crucial to achieving better outcomes. Salvage procedures and critical illness with organ failure prior to surgery were associated with poorer outcomes. Despite unique challenges, cardiac surgery for infective endocarditis at Tygerberg Hospital compares favorably to international standards. [ABSTRACT FROM AUTHOR]

OBJECTIVES Severe functional tricuspid regurgitation (FTR) is associated with subvalvular remodelling, but leaflet tissue alterations may also contribute. We set out to investigate molecular mechanisms driving leaflet remodelling in chronic ovine FTR. METHODS Thirteen adult sheep (55 ± 4 kg) underwent left thoracotomy, epicardial echocardiography and pulmonary artery banding to induce right heart failure and FTR. After 16 weeks, 13 banded (FTR) and 12 control animals underwent median sternotomy for epicardial echocardiography and were subsequently sacrificed with each tricuspid leaflet tissue harvested for RNA-seq and histology. RESULTS After 16 weeks, 7 animals developed severe, 2 moderate and 4 mild tricuspid regurgitation. Relative to control, FTR animals had increased pulmonary artery pressure, tricuspid regurgitation, tricuspid annular diameter and right atrial volume, while tricuspid annular plane systolic excursion and right ventricle fractional area change decreased. FTR leaflets exhibited altered constituents and an increase in cellularity. RNA-seq identified 85 significantly differentially expressed genes with 17, 53 and 127 within the anterior, posterior and septal leaflets, respectively. RRM2 , PRG4 and CXCL8 (IL-8) were identified as differentially expressed genes across all leaflets and CXCL8 was differentially expressed between FTR severity grades. RRM2 , PRG4 and CXCL8 significantly correlated with tricuspid annular plane systolic excursion, and this correlation was consistent regardless of the anatomical location of the leaflet. CONCLUSIONS Pulmonary artery banding in our ovine model resulted in right ventricle failure and FTR. Leaflet RNA-seq identified several differentially expressed genes, specifically RRM2 , PRG4 and CXCL8 , with known roles in tissue remodelling. These data, along with an overall increase in leaflet cellularity, suggest tricuspid leaflets actively remodel in FTR. [ABSTRACT FROM AUTHOR]

Background & objectives: Rigid ring and Flexible band are techniques used to repair tricuspid valve regurgitation. The comparison between both techniques' effectiveness is controversial in the literature. We conducted this systematic review and meta-analysis to compare the safety and efficacy of rigid ring versus flexible band for tricuspid valve repair in patients with tricuspid valve regurgitation. Methods: We conducted a PRISMA-compliant systematic review and meta-analysis. A systematic search was performed in major databases, including PubMed, Scopus, Web of Science, and Cochrane CENTRAL to identify relevant published studies. Data were extracted and analyzed using Stata (version 17 for Mac) and Revman (version 5.4 for Windows). Results: Twelve studies were included in this meta-analysis. Total number of patients was 4259. The rigid ring wasn't superior to the flexible band in terms of postoperative tricuspid regurgitation RR 0.74, 95 % CI (0.43–1.27) (P = 0.29). However, the results were not homogeneous. After employing sensitivity analysis, the significance of the pooled effect estimate didn't change, showing no significant difference between the two annuloplasty RR 0.72, 95%CI (0.45–1.15). On the other hand, the rigid ring was associated with a higher bypass time than the flexible band (RR 4.85, P = 0.00). There were no differences between the two groups in terms of hospital stay, ICU stays, prolonged ventilation, mechanical ventilation time, annuloplasty size, stroke, concomitant mitral valve surgery, concomitant aortic valve surgery, atrial fibrillation, pacemaker implantation, low cardiac output, in-hospital death, or late death (all P > 0.05). Conclusion: Our study findings suggested no difference between rigid ring compared to flexible band regarding the rates of postoperative tricuspid regurgitation; however, rigid ring may encompass a higher bypass time. Therefore, further research is required to ensure our findings.

Mitral valve repair clip detachment and embolization is a rare phenomenon, with few reported cases. We describe a case of subacute transcatheter mitral valve repair clip embolization presenting as an inferior ST-segment elevation myocardial infarction, with subsequent successful percutaneous device retrieval. (Level of Difficulty: Intermediate.).

Abstract Background Alpha-gal syndrome is an allergic condition in which individuals develop an immune-mediated hypersensitivity response when consuming red meat and its derived products. Its diagnosis is important in individuals undergoing cardiac surgery, as patients frequently require large doses of unfractionated heparin or the insertion of surgical implants, both of which are porcine or bovine in origin. There are currently no guidelines for heparin administration in alpha-gal patients, with even less knowledge regarding the long-term clinical implications of these patients after receiving bioprosthetic valve replacements or other prostheses. Case presentation We present the case of a 31-year-old male who underwent cardiac surgery in the setting of alpha-gal syndrome for a large atrial septal defect (ASD) and mitral valve prolapse (MVP). The patient continues to do well one year after undergoing a mitral valve repair, tricuspid valve repair and an ASD closure using bovine pericardium. He sustained no adverse reaction to the use of heparin products or the presence of a bovine pericardial patch. This rare case was managed by a multidisciplinary team consisting of cardiothoracic surgery, cardiac anesthesiology, and allergy/immunology that led to an optimal outcome despite the patient’s pertinent allergic history. Conclusions This case highlights that the use of bovine pericardium and porcine heparin to close septal defects in patients with milder forms of alpha-gal allergy can be considered if other options are not available. Further studies are warranted to investigate the long-term outcomes of such potential alpha-gal containing prostheses and heparin exposure and establish the optimal decision making algorithm and prophylactic regimen.

Background: Alpha-gal syndrome is an allergic condition in which individuals develop an immune-mediated hypersensitivity response when consuming red meat and its derived products. Its diagnosis is important in individuals undergoing cardiac surgery, as patients frequently require large doses of unfractionated heparin or the insertion of surgical implants, both of which are porcine or bovine in origin. There are currently no guidelines for heparin administration in alpha-gal patients, with even less knowledge regarding the long-term clinical implications of these patients after receiving bioprosthetic valve replacements or other prostheses. Case presentation: We present the case of a 31-year-old male who underwent cardiac surgery in the setting of alpha-gal syndrome for a large atrial septal defect (ASD) and mitral valve prolapse (MVP). The patient continues to do well one year after undergoing a mitral valve repair, tricuspid valve repair and an ASD closure using bovine pericardium. He sustained no adverse reaction to the use of heparin products or the presence of a bovine pericardial patch. This rare case was managed by a multidisciplinary team consisting of cardiothoracic surgery, cardiac anesthesiology, and allergy/immunology that led to an optimal outcome despite the patient's pertinent allergic history. Conclusions: This case highlights that the use of bovine pericardium and porcine heparin to close septal defects in patients with milder forms of alpha-gal allergy can be considered if other options are not available. Further studies are warranted to investigate the long-term outcomes of such potential alpha-gal containing prostheses and heparin exposure and establish the optimal decision making algorithm and prophylactic regimen. [ABSTRACT FROM AUTHOR]

Transcatheter pulmonary valve replacement is a minimally-invasive alternative treatment for right ventricular outflow tract dysfunction and has been rapidly evolving over the past years. Heart valve prostheses currently available still have major limitations. Therefore, one of the significant challenges for the future is the roll out of transcatheter tissue engineered pulmonary valve replacement to more patients. In the present study, biodegradable poly-ε-caprolactone (PCL) nanofiber scaffolds in the form of a 3D leaflet matrix were successfully seeded with human endothelial colony-forming cells (ECFCs), human induced pluripotent stem cell-derived MSCs (hMSCs), and porcine MSCs (pMSCs) for three weeks for the generation of 3D tissue-engineered tri-leaflet valved stent grafts. The cell adhesion, proliferation, and distribution of these 3D heart leaflets was analyzed using fluorescence microscopy and scanning electron microscopy (SEM). All cell lineages were able to increase the overgrown leaflet area within the three-week timeframe. While hMSCs showed a consistent growth rate over the course of three weeks, ECFSs showed almost no increase between days 7 and 14 until a growth spurt appeared between days 14 and 21. More than 90% of heart valve leaflets were covered with cells after the full three-week culturing cycle in nearly all leaflet areas, regardless of which cell type was used. This study shows that seeded biodegradable PCL nanofiber scaffolds incorporated in nitinol or biodegradable stents will offer a new therapeutic option in the future. [ABSTRACT FROM AUTHOR]

Valve-sparing procedures have been established as a durable option for treatment of patients with aortic root pathology. Complex cases where aortic valve-sparing root replacement (VSRR) is applied require specific surgical techniques to ensure good outcomes. Herein, we review main concepts of VSRR and aortic valve repair. In addition, we provide three complex clinical scenarios: treatment of neo-aortic dilation after a Ross procedure, acute aortic insufficiency in a type A dissection, and chronic aortic insufficiency with a bicuspid aortic valve. Technical suggestions to achieve a safe and durable result are set forth. [ABSTRACT FROM AUTHOR]

Isolated tricuspid ring annuloplasty remains the surgical standard for functional tricuspid regurgitation repair but offers suboptimal results when right ventricular dilation and remodeling along with papillary muscle displacement is present. Addressing subvalvular remodeling with papillary muscle approximation may improve clinical outcomes. Functional tricuspid regurgitation and biventricular dysfunction were induced in 8 healthy sheep by rapid ventricular pacing (200-240 bpm) for 27 ± 6 days. Subsequently, animals underwent cardiopulmonary bypass for implantation of sonomicrometry crystals on the tricuspid annulus, right ventricle, and papillary muscle tips. Papillary approximation sutures were anchored between anterior-posterior and anterior-septal papillary muscles and externalized through right ventricular free wall to epicardial tourniquets. After weaning from cardiopulmonary bypass, sequential papillary muscle approximations were performed. Simultaneous hemodynamic, sonomicrometry, and echocardiographic data were collected at baseline and after each papillary muscle approximation. With rapid pacing, right ventricular fractional area change decreased from 59 ± 6% to 38 ± 8% (P <.001), whereas tricuspid annulus diameter increased from 2.4 ± 0.3 cm to 3.3 ± 0.6 cm (P =.003). Tricuspid regurgitation (0-4+) increased from +0 ± 0 to +3.3 ± 0.7 (P <.001). Both anterior–posterior and anterior–septal papillary muscle approximation significantly reduced functional tricuspid regurgitation from +3.3 ± 0.7 to +2 ± 0.5 and +1.9 ± 0.6, respectively (P <.001). Reduction of tricuspid insufficiency with both subvalvular interventions was associated with decreased distance of the anterior papillary muscle to the annular centroid. Papillary muscle approximations were effective in reducing severe ovine functional tricuspid regurgitation associated with right ventricular dilation and papillary muscle displacement. Further studies are needed to evaluate efficacy of this adjunct to ring annuloplasty in repair of severe functional tricuspid regurgitation. [Display omitted] [ABSTRACT FROM AUTHOR]

While mitral valve (MV) repair remains the preferred clinical option for mitral regurgitation (MR) treatment, long-term outcomes remain suboptimal and difficult to predict. Furthermore, pre-operative optimization is complicated by the heterogeneity of MR presentations and the multiplicity of potential repair configurations. In the present work, we established a patient-specific MV computational pipeline based strictly on standard-of-care pre-operative imaging data to quantitatively predict the post-repair MV functional state. First, we established human mitral valve chordae tendinae (MVCT) geometric characteristics obtained from five CT-imaged excised human hearts. From these data, we developed a finite-element model of the full patient-specific MV apparatus that included MVCT papillary muscle origins obtained from both the in vitro study and the pre-operative three-dimensional echocardiography images. To functionally tune the patient-specific MV mechanical behavior, we simulated pre-operative MV closure and iteratively updated the leaflet and MVCT prestrains to minimize the mismatch between the simulated and target end-systolic geometries. Using the resultant fully calibrated MV model, we simulated undersized ring annuloplasty (URA) by defining the annular geometry directly from the ring geometry. In three human cases, the postoperative geometries were predicted to 1 mm of the target, and the MV leaflet strain fields demonstrated close agreement with noninvasive strain estimation technique targets. Interestingly, our model predicted increased posterior leaflet tethering after URA in two recurrent patients, which is the likely driver of long-term MV repair failure. In summary, the present pipeline was able to predict postoperative outcomes from pre-operative clinical data alone. This approach can thus lay the foundation for optimal tailored surgical planning for more durable repair, as well as development of mitral valve digital twins. [ABSTRACT FROM AUTHOR]

Annular reduction with prosthetic rings represents the current surgical treatment of functional tricuspid regurgitation (FTR). However, alterations of annular geometry and dynamics associated with FTR are not well characterized. FTR was induced in 29 adult sheep with either 8 weeks of pulmonary artery banding (PAB, n = 15) or 3 weeks of tachycardia-induced cardiomyopathy (TIC, n = 14). Eight healthy sheep served as controls (CTL). At the terminal procedure, all animals underwent sternotomy, epicardial echocardiography, and implantation of sonomicrometry crystals on the tricuspid annulus (TA) and right ventricular free wall while on cardiopulmonary bypass. Simultaneous hemodynamic, sonomicrometry, and echocardiographic data were acquired after weaning from cardiopulmonary bypass and stabilization. Annular geometry and dynamics were calculated from 3-dimensional crystal coordinates. Mean FTR grade (0-4) was 3.2 ± 1.2 and 3.2 ± 0.5 for PAB and TIC, respectively, with both models of FTR associated with similar degree of right ventricular dysfunction (right ventricular fractional area contraction 38 ± 7% and 37 ± 9% for PAB and TIC, respectively). Left ventricular ejection fraction was significantly reduced in TIC versus baseline (33 ± 9%, vs 58 ± 4%, P =.0001). TA area was 651 ± 109 mm2, 881 ± 242 mm2, and 995 ± 232 mm2 for CTL, FTR, and TIC, respectively (P =.006) with TA area contraction of 16.6 ± 4.2%, 11.5 ± 8.0%, and 6.0 ± 4.0%, respectively (P =.003). Septal annulus increased from 33.8 ± 3.1 mm to 39.7 ± 6.4 mm and 43.1 ± 3.2 mm for CTL, PAB, and TIC, respectively (P <.0001). Ovine FTR was associated with annular dilation and reduced annular area contraction. Significant dilation of septal annulus was observed in both models of FTR. As tricuspid rings do not completely stabilize the septal annulus, continued remodeling may contribute to recurrent FTR after repair. [Display omitted] [ABSTRACT FROM AUTHOR]

An 89-year-old woman with paroxysmal atrial tachycardia (AT) was diagnosed with severe atrial functional mitral regurgitation. On transesophageal echocardiography, the mitral regurgitation jet appeared larger during sinus rhythm and smaller during AT. During transcatheter repair of the valve, chronotropic agents were given to induce AT, assisting with leaflet capture.

We describe a rare complication of intraprocedural spontaneous thrombus formation on a transcatheter edge-to-edge repair (MitraClip; Abbott Laboratories) device in a hypercoagulable yet adequately anticoagulated patient. We also outline the novel use of a vacuum (Penumbra) aspiration system, which resulted in rapid and effective thrombus elimination.

We present the case of an 82-year-old man with a history of inferior vena cava filter implantation and concomitant severe mitral regurgitation requiring transcatheter edge-to-edge repair. Despite being deemed ineligible for transfemoral access as technically challenging, he successfully underwent mitral transcatheter edge-to-edge repair after crossing and dilatation of the inferior vena cava filter. (Level of Difficulty: Intermediate.)

Open in new tab Download slide OBJECTIVES To support clinical decision-making in children with aortic valve disease, by compiling the available evidence on outcome after paediatric aortic valve repair (AVr). METHODS A systematic review of literature reporting clinical outcome after paediatric AVr (mean age at surgery <18 years) published between 1 January 1990 and 23 December 2021 was conducted. Early event risks, late event rates and time-to-event data were pooled. A microsimulation model was employed to simulate the lives of individual children, infants and neonates following AVr. RESULTS Forty-one publications were included, encompassing 2 623 patients with 17 217 patient-years of follow-up (median follow-up: 7.3 years; range: 1.0–14.4 years). Pooled mean age during repair for aortic stenosis in children (<18 years), infants (<1 year) or neonates (<30 days) was 5.2 ± 3.9 years, 35 ± 137 days and 11 ± 6 days, respectively. Pooled early mortality after stenosis repair in children, infants and neonates, respectively, was 3.5% (95% confidence interval: 1.9–6.5%), 7.4% (4.2–13.0%) and 10.7% (6.8–16.9%). Pooled late reintervention rate after stenosis repair in children, infants and neonates, respectively, was 3.31%/year (1.66–6.63%/year), 6.84%/year (3.95–11.83%/year) and 6.32%/year (3.04–13.15%/year); endocarditis 0.07%/year (0.03–0.21%/year), 0.23%/year (0.07–0.71%/year) and 0.49%/year (0.18–1.29%/year); and valve thrombosis 0.05%/year (0.01–0.26%/year), 0.15%/year (0.04–0.53%/year) and 0.19%/year (0.05–0.77%/year). Microsimulation-based mean life expectancy in the first 20 years for children, infants and neonates with aortic stenosis, respectively, was 18.4 years (95% credible interval: 18.1–18.7 years; relative survival compared to the matched general population: 92.2%), 16.8 years (16.5–17.0 years; relative survival: 84.2%) and 15.9 years (14.8–17.0 years; relative survival: 80.1%). Microsimulation-based 20-year risk of reintervention in children, infants and neonates, respectively, was 75.2% (72.9–77.2%), 53.8% (51.9–55.7%) and 50.8% (47.0–57.6%). CONCLUSIONS Long-term outcomes after paediatric AVr for stenosis are satisfactory and dependent on age at surgery. Despite a high hazard of reintervention for valve dysfunction and slightly impaired survival relative to the general population, AVr is associated with low valve-related event occurrences and should be considered in children with aortic valve disease. [ABSTRACT FROM AUTHOR]

Transcatheter aortic-valve replacement (TAVR) is increasingly being used for the treatment of aortic-valve stenosis. Therefore, the total number of patients with an aortic-valve prosthesis is increasing, causing the incidence of prosthetic-valve endocarditis to increase. Methods: Between March 2016 and July 2019, ten patients underwent surgery due to prosthetic-valve endocarditis after TAVR. They were identified in our institutional database and analyzed. Results: Infective endocarditis was diagnosed 17 ± 16 month after TAVR. Mean age was 79 ± 4.4 years. Microbiological detection showed 6/10 positive blood cultures for enterococcus faecalis. Median EuroScore II was 24.64%. The mean size of the surgically replaced aortic prosthesis was 23.6 ± 1.3 and that of the TAVR was 28.4 ± 2.3 mm. The surgically implanted aortic valves had a mean gradient of 8.5 ± 2.2 mmHg. One patient died in hospital due to septic multiorgan failure. After discharge, all patients survived with a mean follow-up of 9 ± 8 month. Conclusions: With a rising number of patients after TAVR, prosthetic-valve endocarditis will increasingly occur in patients who were previously considered high or intermediate risk. Our results show that patients with TAVR infective endocarditis can be operated on with good results. Surgical therapy should not be withheld from TAVR patients with infective endocarditis. [ABSTRACT FROM AUTHOR]

We present the case of a 66-year-old woman who developed severe mitral regurgitation from rupture of the anterior mitral valve leaflet following percutaneous balloon mitral valvuloplasty. Emergency transcatheter mitral valve repair was used to reduce the severity of mitral regurgitation and facilitate definitive surgical treatment. (Level of Difficulty: Advanced.)

Open in new tab Download slide OBJECTIVES Pathophysiology of function tricuspid regurgitation (FTR) is incompletely understood. We set out to comprehensively evaluate geometric and tissue remodelling of the tricuspid valve complex in ovine FTR. METHODS Twenty adult sheep underwent left thoracotomy and pulmonary artery banding (PAB) to induce right heart pressure overload and FTR. After 8 weeks, 17 surviving animals and 10 healthy controls (CTL) underwent sternotomy, echocardiography and implantation of sonomicrometry crystals on right ventricle and tricuspid valvular apparatus. Haemodynamic and sonomicrometry data were acquired in all animals after weaning from cardiopulmonary bypass. Leaflet tissue was harvested for pentachrome histologic analysis and biomechanical testing. RESULTS Animal weight was 62 ± 5 and 63 ± 3 kg for CTL and PAB, respectively (P = 0.6). At terminal procedure, systolic pulmonary artery pressure was 22 ± 3 and 40 ± 7 mmHg for CTL and PAB, respectively (P = 0.0001). The mean TR grade (+0–4) was 0.8 ± 0.4 and 3.2 ± 1.2 (P = 0.0001) for control and banded animals, respectively. Right ventricle volume (126 ± 13 vs 172 ± 34 ml, P = 0.0019), tricuspid annular area (651 ± 109 vs 865 ± 247 mm2, P = 0.037) and area between papillary muscle tips (162 ± 51 vs 302 ± 75 mm2, P = 0.001) increased substantially while systolic excursion of anterior leaflet decreased significantly (23.8 ± 6.1° vs 7.4 ± 4.5°, P = 0.001) with banding. Total leaflet surface area increased from 806 ± 94 to 953 ± 148 mm2 (P = 0.009), and leaflets became thicker and stiffer. CONCLUSIONS Detailed analysis of the tricuspid valve complex revealed significant ventricular, annular, subvalvular and leaflet remodelling to be associated with ovine functional tricuspid regurgitation. Durable surgical repair of severe FTR may require a multi-level approach to the valvular apparatus. [ABSTRACT FROM AUTHOR]

Management of aortic valve diseases in children is challenging owing to the quality and quantity of the native tissue for repair, limitations in the currently available biological materials to supplement the repair and to achieve a long-lasting durable repair in an annulus where there is still growth potential. The aortic valve neocuspidization (AVNeo) procedure has emerged as a versatile alternative strategy in the armamentarium of pediatric aortic valve reconstructions that are currently available. In this review article, the focus of the discussion will be on the various aortic valve repair procedures in the pediatric population, with a special emphasis on the emerging role of AVNeo procedure in pediatrics and its outcomes. [ABSTRACT FROM AUTHOR]

We present this case of a 22-year-old woman with congenital heart disease as the youngest reported patient, to the best of our knowledge, to successfully undergo treatment of medically refractory torrential tricuspid regurgitation with the MitraClip system as an adjunct to guideline directed therapy. (Level of Difficulty: Advanced.).

To define current role of the Ross operation in young patients, the outcome in those followed longer than 20 years were assessed. Between 1994 and 2020, 81 consecutive patients, 70 of 11 male and/or female, mean age 27 years underwent Ross procedure, accruing 20 years of follow-up or longer. Sixty-four had bicuspid valve (79%) and 54 (67%) aortic insufficiency, while 15 (19%) had undergone prior operations. Surgery consisted in root replacement in 53 patients, cylinder inclusion in 20 and sub-coronary graft in 8. There were 7 late deaths in 80 hospital survivors (median follow-up 21 years, IQR 20-23), with 88% ± 5% survival at 25 years. Thirty-four patients required left, 6 left and/or right and 1 right heart valve reoperation, on average 13 years after Ross procedure. Reoperation was valve-sparing in 18 (45%) patients and valve and/or root replacement in 22. Ten (24%) reoperated patients required a second reoperation 18 years after Ross procedure. Freedom from autograft reoperation was 46% ± 6%, while from autograft valve replacement was 60% ± 7%, thanks to autograft valve-sparing. Freedom from isolated right valve reoperation was 98% ± 4%. No mortality was associated with any of the 51 reoperations. Root technique was associated with reoperation (P = 0.024). Age at follow-up was 50 years (IQR 36-60), with 70 (96%) patients in NYHA class I and 6 (55%) women carrying out pregnancies. Young patients undergoing the Ross procedure enjoy unprecedented survival well into the third decade of follow-up, even when faced with reoperation. At 25 years risk of autograft reoperation is consistent, while negligible for homograft. Technical improvements at operation and valve-sparing at reoperation may prolong autograft valve durability. [Display omitted] [ABSTRACT FROM AUTHOR]

Transapical puncture for transcatheter treatment of mitral-paravalvular leak (PVL) is associated with increased risks even when the apical tract is closed with vascular plugs. A novel technique that leverages back wall support from the right or left atrium can be used to facilitate transcatheter closure of mitral PVL through an antegrade approach. (Level of Difficulty: Advanced.)

Resumen: Presentamos el inusual caso de un paciente adulto con diagnóstico de canal auriculoventricular intermediario y válvula auriculoventricular izquierda con músculo papilar único potencialmente en paracaídas, denominada así porque previamente a la reparación la entrada al ventrículo izquierdo está preservada a través de la hendidura o zona de aposición. La incidencia de esta combinación varía entre el 3,8 y el 14% en diferentes series de pacientes reparados en la infancia. La tendencia en la mayoría de los grupos es el cierre parcial o completo de la hendidura. Dependiendo de las anomalías asociadas, en la válvula auriculoventricular izquierda están descritas diferentes técnicas como el split del músculo papilar, la ampliación del velo lateral izquierdo con parche, anuloplastia posterior, resección de cuerdas tendinosas, etc. En nuestro paciente, debido a la potencial estenosis tras la reparación, se decidió realizar un split horizontal del músculo papilar único, seguido de uno vertical para dividir en dos cabezas el músculo que daba cuerdas tendinosas al borde libre de los velos puente superior e inferior. Tras esto se consideró que la entrada al ventrículo izquierdo era suficiente para realizar el cierre completo de la hendidura. Además, el velo posterior era de escaso desarrollo y presentaba cuerdas cortas, por lo que se decidió realizar anuloplastia posterior para subir el velo posterior y disminuir la distancia con el velo anterior.La evolución postoperatoria fue buena. En el momento del alta, la válvula auriculoventricular izquierda presentaba un gradiente medio de 3 mmHg e insuficiencia leve. Abstract: We present the unusual case of an adult patient with a diagnosis of intermediate atrioventricular canal and left atrioventricular valve with potentially parachute single papillary muscle, so named because, prior to repair, the inlet to the left ventricle is preserved through the cleft or zone of apposition. The incidence of this combination varies between 3.8% and 14% in different series of patients repaired in childhood. The tendency in most groups is partial or complete closure of the cleft. Depending on the associated anomalies in the left atrioventricular valve, different techniques are described, such as split of the papillary muscle, enlargement of the left lateral leaflet with a patch, posterior annuloplasty, resection of chordae tendineae, etc. In our patient, due to potential stenosis after the repair, we decided to perform a horizontal split of the single papillary muscle, followed by a vertical one to divide the muscle that gave tendinous chords to the free edge of the upper and lower bridge leaflets into two heads. After this, we considered that the entrance to the left ventricle was enough to perform complete closure of the cleft. In addition, the posterior leaflet was poorly developed and presented short cords, so we decided to perform a posterior annuloplasty to raise the posterior leaflet and decrease the distance with the anterior leaflet. The postoperative evolution was good. At discharge, the left atrioventricular valve had a mean gradient of 3 mmHg and mild insufficiency.

Resumen: El canal auriculoventricular parcial es una forma común de cardiopatías congénitas caracterizada por la presencia de una CIA ostium primum asociado a anomalías de la válvula izquierda. Durante el seguimiento la reoperación por insuficiencia valvular izquierda es la complicación más frecuente. Presentamos 2 casos. El primero es una paciente intervenida de corrección de canal parcial al año de vida que fue sometida a una nueva intervención quirúrgica por insuficiencia AV izquierda 7 años más tarde de la corrección primaria. El segundo caso es una mujer de 68 años, intervenida hace 25 de cierre de CIA ostium primum, que desarrolló insuficiencia izquierda severa e insuficiencia tricuspídea. En ambos casos se observó una persistencia del cleft mitral, por lo que se procedió al cierre completo; en el segundo caso se añadió además una reparación tricúspide con anillo rígido. En ambos casos el cierre del cleft fue suficiente para conseguir una adecuada competencia valvular. Las insuficiencias valvulares, sobre todo la izquierda tras la corrección del canal AV parcial, suponen un reto pues son la causa más frecuente de reintervención en estos pacientes. Además, estas válvulas presentan una morfología y mecanismos de insuficiencia diferentes a las valvulopatías adquiridas y por lo tanto los estándares habituales de reparación valvular mitral no son adecuados para el tratamiento de estas entidades. El cierre del cleft, aun en ausencia de insuficiencia valvular en el momento de la corrección primaria del canal parcial, es fundamental y puede ayudar en la prevención del desarrollo de una insuficiencia severa con el paso del tiempo. Abstract: Partial atrioventricular canal defect is a common form of congenital heart disease, described as the presence of OP ASD with a mitral cleft. During follow-up, reoperation for left valve regurgitation is the most frequent complication. We present two cases; a pediatric patient who underwent surgical correction of a partial atrioventricular canal defect at the age of 1 year and need a reoperation for left AV regurgitation 7 years after the primary correction. The second is a 68-year-old woman, with an OP ASD closure 25 years before, who developed severe left regurgitation and tricuspid regurgitation during follow up. In both cases, a persistence of the mitral cleft was observed, and the cleft was completely closed; with a concomitant tricuspid repair with a rigid ring in the second case. In both cases, cleft closure was sufficient to achieve adequate valve competence. Valvular regurgitation, especially the left component after partial AV septal defect correction, pose a surgical challenge since they are the most frequent cause of reintervention in these patients. Furthermore, these valves present with different morphology and mechanisms of regurgitation compared to acquired valvular disease, and therefore usual standards of mitral valve repair are not suitable for the treatment of these entities. Closure of the cleft even in the absence of valve regurgitation at the time of primary correction of the partial canal is essential and can help prevent the development of severe regurgitation during follow up.

Resumen: Introducción y objetivos: El canal auriculoventricular completo supone el 3% de las cardiopatías congénitas. Su pronóstico depende del estado de la válvula auriculoventricular izquierda post-reparación. Analizaremos nuestros resultados de morbimortalidad y necesidad de reintervención. Métodos: Estudio observacional retrospectivo, incluyendo a los pacientes con canal auriculoventricular completo intervenidos en nuestro centro entre enero de 2008 y julio de 2021. Resultados: Fueron intervenidos 57 pacientes. La mediana de edad y de peso fueron 6 meses y 5,8 kg, respectivamente (rango intercuartil 4-7 meses y 4,8-6,7 kg). La mortalidad hospitalaria fue de 3 pacientes (5,3%). El 7,2% de los pacientes necesitaron reintervención precoz sobre la válvula auriculoventricular izquierda. La supervivencia global fue del 88,6% (seguimiento mediano de 4,7 años [rango intercuartílico: 1,5-10,9]; seguimiento completo en el 93% de los pacientes). La libertad de reintervención sobre la válvula auriculoventricular izquierda fue del 83,7%. La válvula auriculoventricular izquierda presentaba regurgitación menor de III/IV en el 90,2% de los pacientes al final del seguimiento.La intervención antes de 3 meses (p = 0,001), la hipertensión pulmonar preoperatoria (p = 0,007) y la estenosis valvular auriculoventricular izquierda postoperatoria (p = 0,001) fueron factores de riesgo de mortalidad. El peso inferior a 4 kg (p

Mitral valve repair clip detachment and embolization is a rare phenomenon, with few reported cases. We describe a case of subacute transcatheter mitral valve repair clip embolization presenting as an inferior ST-segment elevation myocardial infarction, with subsequent successful percutaneous device retrieval. (Level of Difficulty: Intermediate.)

Echocardiography (Echo) has a primary role in the evaluation of cardiac valve regurgitation. Echo valve regurgitation assessment includes multiple qualitative and quantitative methods which require adequate image quality, comprehensive echocardiographic images and precise measurements to obtain accurate assessment. For patient management, it is also important to investigate the mechanism of valve regurgitation. Severity and mechanism of valve regurgitation determine whether continued medical follow up is optimal or surgical or percutaneous valve repair, or replacement option should be necessary. Transthoracic Echo (TTE) is the gold standard most commonly used for the assessment of valve leaflet anatomy, valve motion and regurgitation severity to determine primary versus secondary causes of valve regurgitation, however transesophageal echo (TEE) provides high resolution imaging of valve leaflets and supporting apparatus and oftentimes determines mechanism of valve regurgitation particularly for mitral and tricuspid valves when TTE is unable to determine the mechanism. By providing surgical type views in a moving heart under normal hemodynamic conditions, 3D TEE has greatly improved assessment of mechanism and etiology of valve regurgitation. Besides, TEE also allows quantitation of valve regurgitation severity by Doppler methods as well as direct 3D planimetry of valve area and regurgitant orifice area. Doppler methods are pre and after-load dependent whereas direct 3D planimetry allows assessment of location and severity of valve regurgitation irrespective of ventricular loading conditions. Pre or intraoperative 3D TEE assessment can provide valuable information for surgical planning of valve repair or replacement. This review discusses various valvular pathologies causing regurgitation and the role of TTE and TEE in improving this assessment as shown by several case examples. [ABSTRACT FROM AUTHOR]

Introduction: In India, rheumatic fever is endemic and remains one of the major causes of cardiovascular disease, accounting for nearly 25-45% of the acquired heart disease. In National Health Policy 2017, India aims to reduce premature deaths from CVDs, to 25% by 2025.The annual incidence of rheumatic fever is 100-200 times greater than that observed in developed countries and fluctuates between 100-200 per 1,00,000 children of school age (from 5 years to 17 or 18 years depending on the study).Rheumatic heart disease (RHD) is still prevalent in the Third World countries. Material & Methods: The present hospital based observational study was conducted in the Department of Cardiovascular and Thoracic Surgery, Government General Hospital, Guntur Medical College, Guntur. Study period was from August 2017 to June 2022, a prospective study conducted on consecutive Patients who underwent valve replacement Results: A total of 91 cases were included in the final analysis. Out of which 25 were Double valve replacement cases, 22 were Aortic valve replacement cases and 44 were Mitral valve replacement cases OPERATIVE PROCEDURE: 1. Cardiopulmonary bypass was established using a membrane oxygenator, moderate systemic hypothermia . 2. Aortic and bicaval cannulation for double valve replacement(DVR)&Mitral valve replacement(MVR). 3. Aortic and single venous two stage cannulation for Aortic valve replacement(AVR). Myocardial preservation was done with blood cardioplegia repeated every 20-25 minutes. 4. Deairing done with Pulmonary artery or LA venting . 5. Antegrade intermittent blood cardioplegia is done for Mitral valve replacement. 6. Alternate antegrade and retrograde intermittent blood cardioplegia for double valve replacement(DVR). 7. Selective coronary cardioplegia for AVR and DVR. TYPE OF PROSTHESIS - Mechanical bileaflet valves: SURGICAL APPROACH: 1. Standard left atrial exposure for Isolated mitral valve replacement (MVR) . 2. Right atrial with Transseptal approach was used where ever tricuspid valve repair required. 3. In patients with aortic valve disease undergoing aortic valve replacement (AVR) an oblique aortotomy was used to expose the aortic valve. 4. AVR was done with interrupted, pledgetted 2-0 braided polyester sutures ). 5. In double valve replacement DVR (AVR+MVR) after excising the aortic valve the mitral valve was excised. 6. After completing the operation and de-airing the heart cross clamp was released and patients were weaned from CPB. 7. All patients were shifted to cardiac surgical intensive care. 8. After removal of chest drains on first postoperative day, Anticoagulation Acitrom . 9. Patients were maintained on an INR ranging between 2.5-3.5. 10. All patients were assessed by 2D and colour Doppler echocardiography (Toshiba 6000 Power Vision) preoperatively and postoperatively in ICU and prior to discharge. 11. The primary endpoint was mortality (early and late). 12. Early mortality was death within 30 days postoperatively or during the same hospital admission. The secondary endpoints were early and late complication Conclusions: In patients of rheumatic heart disease having combined Mitral and Aortic valve disease DVR should be performed whenever indicated as it has similar in hospital mortality and better late survival as compared to isolated aortic or mitral valve replacement [5,6] [ABSTRACT FROM AUTHOR]

Introduction: Cardiac surgeries are generally associated with high morbidity and mortality. To prevent any adverse outcomes, it is crucial to identify patients at risk of developing postoperative complications and initiate relevant therapeutic interventions. Several biomarkers are used to determine postoperative myocardial injury but they either lack sensitivity and specificity or are elevated for a short time. In this systematic review, we evaluate postoperative troponin I as a predictor of postoperative myocardial infarction, mortality, and hospital and Intensive Care Unit stay. Methods: This systematic review was conducted in accordance with the Preferred Reporting Items for Systematic Review and Meta‐Analysis guidelines. A thorough literature search was conducted over PubMed, clinicaltrials. gov, and the Cochrane library from inception till May 24, 2022 using relevant keywords, and only articles that met the pre‐defined criteria were recruited. Results: Following a comprehensive literature search, a total of 359 articles were obtained. Following a rigid screening and full‐length review, only 13 studies met our inclusion criteria and were included. The recruited studies evaluated data from a total of 12,483 individuals and assessed troponin I as a predictor of at least one outcome. Conclusion: Troponin I has the potential to be used as a stand‐alone predictor of surgical outcomes following coronary artery bypass grafting and valvular surgeries. However, supplementing it with other markers and scores offers the best chance at timely diagnosing any complications. [ABSTRACT FROM AUTHOR]

Background: Degenerative mitral valve (MV) regurgitation (DMR) shows significative mitral annulus (MA) alterations; mitral valve repair (MVR) seeks to restore annular geometry and function, and the current use of flexible band seams to respect most annular mobility reducing parietal stress. Parameters of MV geometry obtained by 3D transesophageal echocardiography (3D‐TTE) analysis are crucial for surgical planning and postoperative success. The aim of this study was to assess, by means of a dedicated software, the variations of MA geometry and function in patients affected by DMR compared to controls and after MVR with flexible band. Methods: We enrolled 32 patients (cases) with severe DMR who underwent MVR using flexible band; we compare this group with 20 controls. The TEE with 3D MV images acquisition was performed in both groups and then analyzed in postprocessing by using a dedicated software. Results: There were no anthropometrics differences between cases and controls, both presented normal left ventricular ejection fraction. DMR group showed a significant increase of annulus dimensional parameters (p =.001) and alteration of nonplanarity comparing to controls (p <.05). The annuloplasty with flexible band induces a considerable reduction of MV dimensions comparing to preoperative data and restores physiological mobility and nonplanarity. There were no statistical differences between postoperative DMR and controls data, except for nonplanarity parameters (p ~.05), maybe influenced by hemodynamic settings. Conclusions: MVR with annuloplasty using flexible band appears able to reinstate a more physiological anatomic conformation of the MA, without compromising its dynamic properties. [ABSTRACT FROM AUTHOR]

The impact of mitral regurgitation (MR) from pediatric rheumatic heart disease (RHD) and its effect on left ventricular (LV) remodeling and function following surgical intervention is uncertain. The objective is to explore the impact of mitral valve (MV) surgeries on myocardial mechanics, remodeling and function and identify pre-operative predictors of post-operative dysfunction which may contribute to the optimal timing of intervention. A retrospective review of echocardiographic data was performed of eighteen pediatric patients with RHD (median 9yrs, IQR 6-12) who underwent MV surgery. Echocardiograms pre-operatively and a median of 13.5 months (IQR 10.2-15) following intervention were compared to controls. Pre-operative LV end-diastolic indexed volumes (LVEDVi) were significantly increased compared to controls and remained persistently larger post-operatively. LV ejection fraction (LVEF) (pre 62.6% ± 6.1, post 51.7% ± 9.7, p = 0.002), and global longitudinal strain (GLS) (pre - 24.3 ± 4.1, post - 18.2 ± 2.6, p < 0.001) decreased post-operatively at mid-term follow-up. Pre-operative LVEDVi was a significant predictor of post-operative LVEF, with a cut-off of ≥ 102 ml/m2 associated with LV dysfunction (LVEF < 55%; sensitivity 70%, specificity 75%). Pre-operative LVEDVi also negatively correlated with GLS (r = - 0.58, p = 0.01). LV dimensions and volumes remain persistently larger than controls while LV function decreases post-surgical alleviation of MR in paediatric RHD. Pre-operative LVEDVi predicted post-operative LV dysfunction and utilising LV indexed volumes in directing timing of surgical planning should be considered. Further studies are required to investigate whether timely alleviation of MR before significant LV dilatation and remodeling occur may substantially prevent LV dysfunction and improve outcomes. [ABSTRACT FROM AUTHOR]

Background: The hemispherical aortic annuloplasty reconstructive technology (HAART) is an internal geometric annuloplasty ring designed to restore a natural elliptical shape to the aortic annulus as part of aortic valve repair. We present four-dimensional flow hemodynamic analysis before and after implementation of the HAART ring in patients undergoing ascending aortic replacement.Methods: Aortic hemodynamics over the cardiac cycle were visualized using time-resolved three-dimensional pathlines. Velocity streamlines tangent to the time-resolved velocity vector field were used to demonstrate instantaneous aortic hemodynamics. Peak velocities, forward and retrograde flow were calculated at nine planes placed along the midline of the thoracic aorta. Systolic wall shear stress and peak viscous energy loss over the cardiac cycle were calculated.Results: HAART patients displayed similar or improved flow profiles after surgery when compared to a patient undergoing ascending aortic replacement alone.Conclusion: There may be a trend towards improved flow dynamics in patients undergoing HAART ring implantation. [ABSTRACT FROM AUTHOR]

Abstract Background Papillary muscle rupture is a rare condition. Its clinical presentation, diagnosis and management can be very challenging for the clinician. Case presentation A 73-year-old woman with hypertension presented with chest pain, ST-segment changes, and elevated serum troponin levels. Coronary angiography was normal. Echocardiography revealed normal ventricular function, flail posterior mitral leaflet, and severe mitral regurgitation. She underwent emergent mitral valve replacement. Conclusion The diagnostic and management strategies of this uncommon presentation are discussed.

Baseline right ventricular (RV) function derived from 3-dimensional analyses has been demonstrated to be predictive in patients undergoing transcatheter tricuspid valve repair (TTVR). The complex nature of these cumbersome analyses makes patient selection based on established imaging methods challenging. Artificial intelligence (AI)-driven computed tomography (CT) segmentation of the RV might serve as a fast and predictive tool for evaluating patients prior to TTVR. Patients suffering from severe tricuspid regurgitation underwent full cycle cardiac CT. AI-driven analyses were compared to conventional CT analyses. Outcome measures were correlated with survival free of rehospitalization for heart-failure or death after TTVR as the primary endpoint. Automated AI-based image CT-analysis from 100 patients (mean age 77 ± 8 years, 63% female) showed excellent correlation for chamber quantification compared to conventional, core-lab evaluated CT analysis (R 0.963–0.966; p < 0.001). At 1 year (mean follow-up 229 ± 134 days) the primary endpoint occurred significantly more frequently in patients with reduced RV ejection fraction (EF) <50% (36.6% vs. 13.7%; HR 2.864, CI 1.212–6.763; p = 0.016). Furthermore, patients with dysfunctional RVs defined as end-diastolic RV volume > 210 ml and RV EF <50% demonstrated worse outcome than patients with functional RVs (43.7% vs. 12.2%; HR 3.753, CI 1.621–8.693; p = 0.002). Derived RVEF and dysfunctional RV were predictors for death and hospitalization after TTVR. AI-facilitated CT analysis serves as an inter- and intra-observer independent and time-effective tool which may thus aid in optimizing patient selection prior to TTVR in clinical routine and in trials. • AI-based CT analysis is inter- and intra-observer-independent and can be a time-effective tool for daily clinical practice. • AI analyses demonstrated excellent agreement and correlation with manual CT data segmentation. • Reduced RVEF and dysfunctional RV were predictors for death and hospitalization after TTVR. [ABSTRACT FROM AUTHOR]

Background: The ideal aortic valve replacement strategy in young- and middle-aged adults remains up for debate. Clinical practice guidelines recommend mechanical prostheses for most patients less than 50 years of age undergoing aortic valve replacement. However, risks of major hemorrhage and thromboembolism associated with long-term anticoagulation may make the pulmonary autograft technique, or Ross procedure, a preferred approach in select patients.Methods: Data were retrospectively collected for patients 18-50 years of age who underwent either the Ross procedure or mechanical aortic valve replacement (mAVR) between January 2000 and December 2016 at a single institution. Propensity score matching was performed and yielded 32 well-matched pairs from a total of 216 eligible patients.Results: Demographic and preoperative characteristics were similar between the two groups. Median follow-up was 7.3 and 6.9 years for Ross and mAVR, respectively. There were no early mortalities in either group and no statistically significant differences were observed with respect to perioperative outcomes or complications. Major hemorrhage and stroke events were significantly more frequent in the mAVR population (p < .01). Overall survival (p = .93), freedom from reintervention and valve dysfunction free survival (p = .91) were equivalent.Conclusions: In this mid-term propensity score-matched analysis, the Ross procedure offers similar perioperative outcomes, freedom from reintervention or valve dysfunction as well as overall survival compared to traditional mAVR but without the morbidity associated with long-term anticoagulation. At specialized centers with sufficient expertize, the Ross procedure should be strongly considered in select patients requiring aortic valve replacement. [ABSTRACT FROM AUTHOR]

A 21-year-old patient with complex cyanotic congenital heart disease and highly symptomatic severe common atrioventricular valve regurgitation was deemed too high risk for surgical intervention or transplantation. She successfully underwent transcatheter edge-to-edge repair with resulting considerable improvement in her symptoms, renal function, and quality of life., Competing Interests: Dr M.J. Mullen has received research grants from Edwards Lifesciences and Abbot Vascular; and has received proctoring fees from Abbot Vascular. Dr A. Mullen is marketing manager at Structural Heart UK and Ireland, Abbott Medical UK. Dr Turner has been a proctor and a consultant for Abbott, Edwards Lifesciences, Medtronic, and Occlutech. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose., (Crown Copyright © 2024 Published by Elsevier on behalf of the American College of Cardiology Foundation.)

The growth of transcatheter structural heart disease interventions has created a subspecialty of interventional imagers who focus on preprocedural planning and the periprocedural guidance of these complex cases. In particular interventional imagers who focus on periprocedural guidance have developed a specific expertise in interventional transesophageal echocardiography (iTEE). This nascent field has challenges in training, reimbursement, and occupational hazards which are unique to this field. This review encompasses the evolution of iTEE, current challenges, and future opportunities. [ABSTRACT FROM AUTHOR]

Background: Obesity rates globally continue to rise and in turn the body mass index (BMI) of patients undergoing cardiac surgery is set to mirror this. Patients who are Class III obese (BMI ≥ 40) pose significant challenges to the surgical teams responsible for their care and are also at high risk of complications from surgery and even death. To improve outcomes in this population, interventions carried out in the preoperative, operative, and postoperative periods have shown promise. Despite this, there are no defined best practice national guidelines for perioperative management of obese patients undergoing cardiac surgery. Aim: This review is aimed at clinicians and researchers in the field of cardiac surgery and aims to form a basis for the future development of clinical guidelines for the management of obese cardiac surgery patients. Methods: The PubMed database was utilized to identify relevant literature and strategies employed at various stages of the surgical journey were analyzed. Conclusions: Data presented identified the benefits of preoperative respiratory muscle training, off‐pump coronary artery bypass grafting where possible, and early extubation. Further randomized controlled trials are required to identify optimal operative and perioperative management strategies before the introduction of such guidance into clinical practice. [ABSTRACT FROM AUTHOR]

Tricuspid regurgitation is a frequent and serious condition but tricuspid valve (TV) surgery, that may be a valve replacement when a repair is not feasible, is rarely performed. Recent development of transcatheter TV interventions offers new options for those high-surgical risk patients, especially TV replacement for patients who are not eligible for transcatheter TV repair. In this review, we describe indications and outcome after surgical TV replacement, and devices available or in development for transcatheter TV replacement. [ABSTRACT FROM AUTHOR]

Transcatheter aortic valve replacement (TAVR) in the setting of an anomalous left circumflex coronary artery (LCX) has had a variety of outcomes. Most commonly an anomalous LCX originates as a separate ostium arising from the right coronary sinus or is found branching off of the proximal right coronary artery. The artery courses around the aortic annulus before taking the course seen in typical anatomy. Given this deviation from typical anatomy and increased aortic annulus pressure by the replacement valve, there is an increased risk of a complication such as acute coronary artery occlusion. Special consideration and preparation are needed to prevent adverse outcomes, including death. We report a case in which intraprocedural anomalous LCX rescue stenting proved to be effective for treatment of acute coronary occlusion. Follow-up angiography provided an opportunity to demonstrate long-term patency in rescue stenting during TAVR. [ABSTRACT FROM AUTHOR]

Transcatheter mitral valve repair (TMVR) is a relatively novel approach for treatment of symptomatic severe mitral regurgitation. Intra procedural thrombus formation is a rare but potential complication. Herein, we describe a case of large right atrial thrombus formation after transseptal puncture, that was successfully managed using aspiration thrombectomy. [ABSTRACT FROM AUTHOR]

Abstract Background Autologous pericardium is widely used as a plastic material in intracardiac structures, in the pulmonary artery, and in aortic valve leaflets. For aortic valve reconstruction (AVRec) using the Ozaki procedure, it has produced excellent clinical results over a 10-year period. In-body tissue architecture (iBTA), which is based on the phenomenon of tissue encapsulation of foreign materials, can be used to prepare autologous prosthetic tissues. In this preliminary study, we examined whether biosheets can be used as valve leaflet material for glutaraldehyde-free AVRec by subchronic implantation experiments in goats and evaluated its performance compared with glutaraldehyde-treated autologous pericardium for AVRec. Methods Biosheets were prepared by embedding molds for two months into the dorsal subcutaneous spaces of goats. Autogenic biosheets (n = 4) cut into the shape of the valve were then implanted to the aortic valve annulus of four goats for three months without glutaraldehyde treatment. Autologous pericardium (n = 4) was used in four goats as a control. Valve function was observed using echocardiography. Results All goats survived the three-month study period. With biosheets, the leaflet surfaces were very smooth and, on histology, partially covered with a thin neointima (including endothelial cells). Biosheets were more thoroughly assimilated into the aortic root compared with autologous pericardium. Conclusions For the first time, biosheets were used for large animal AVRec. Biosheets could function as leaflets in the aortic position and may have the ability to assimilate into native valves.

We describe the case of an 83-year-old man with a history of ischemic cardiomyopathy and severe secondary mitral regurgitation. This case highlights the role of transcatheter edge-to-edge repair with the MitraClip in the management of symptomatic functional mitral regurgitation in a surgically unfavorable patient. (Level of Difficulty: Advanced.)

Injury of the circumflex artery is an uncommon but dangerous complication during mitral valve surgery. We report the case of a patient who presented an occlusion of the circumflex artery after a minimally invasive mitral valve repair, which was treated with angioplasty in the immediate post-operative period. (Level of Difficulty: Intermediate.)