Urgent transcatheter aortic valve replacement for severe acute aortic regurgitation following open mitral valve surgery

Transcatheter aortic valve replacement (TAVR) is not currently approved for pure native valve aortic incompetence, and is typically performed on a compassionate basis in selected patients who are at high risk for conventional surgery. We describe the first use of TAVR to treat iatrogenic severe acute pure aortic incompetence following mitral valve surgery. A 71‐year‐old gentleman developed life‐threatening acute aortic regurgitation (AR) within hours of a very challenging fifth open heart mitral valve replacement. Careful inspection of echocardiographic and computed tomographic imaging identified the cause as a disrupted left coronary cusp at the commissure caused by the surgical mitral annular reconstruction. Medical management with afterload reduction failed with recurrent pulmonary edema, and a sixth open heart surgery was deemed prohibitively high risk. The lack of aortic annular calcium onto which anchors a transcatheter valve was a concern for TAVR. However, we postulated that the struts of the mitral valve bioprosthesis would offer some support to the TAVR valve. We opted for a self‐expanding system because of concerns about potential unfavorable interaction between the balloon onto which balloon‐expandable bioprosthesis is mounted and the struts of the mitral bioprosthesis, and because the Evolut R system has additional anchoring points at the crown which might enhance transcatheter valve stability in the non‐calcified annulus, compared with the Edwards Sapien system. Transfemoral TAVR, performed with a Medtronic Evolut R 34 mm system under general anesthesia and using moderately rapid ventricular pacing, was successful with minimal residual AR. On follow‐up 1 month later the patient was asymptomatic, and the aortic and mitral bioprostheses were functioning normally on echocardiogram.     

重度主动脉瓣关闭不全合并中度功能性二尖瓣反流的临床研究

目的 探讨中度功能性二尖瓣反流（FMR）在重度主动脉瓣关闭不全患者中的处理原则及其近中期疗效。方法 分析2019年10月至2020年10月南京医科大学附属南京医院心胸血管外科16例重度主动脉瓣关闭不全合并中度功能性二尖瓣反流患者经手术治疗的临床资料。结果 所有术后患者围手术期无死亡,术后随访（2.9±1.7）个月,术后超声心动图提示FMR程度与术前相比较有所减轻,同时左心房内径（LAD）（P=0.01）、左心室舒张末期内径（LVEDD）（P=0.025）及左心室收缩末期内径（LVESD）（P=0.045）明显缩小,但LVEF较术前反而有所下降,但无统计学意义（P=0.259）。术后3~6个月随访,所有患者无复发,无需再次手术,复查超声心动图与术前比较LAD（P=0.022）、LVEDD（P=0.006）、LVESD（P=0.043）呈进行性缩小, 接近正常水平,EF较术前相比明显改善,有显著统计学差异（P=0.029） ,且FMR同步明显减轻。截至最后一次随访,5例二尖瓣无反流,7例微量反流,4例少量反流,手术成形效果满意。结论 重度主动脉瓣关闭不全合并中度的FMR建议积极行二尖瓣成形术处理,能够保留二尖瓣瓣膜的持久性和功能性,可获得较满意的近中期疗效。     

Impact of TAVI on Mitral Regurgitation: A Prospective Echocardiographic Study

Objective: This study aims to assess changes in mitral regurgitation (MR) severity after transcatheter aortic valve implantation (TAVI). Background: Existing data on MR after TAVI are contradictory. Methods: Thirty‐five patients with MR graded ≥ 2+ were followed after undergoing TAVI with either the Edwards Sapien or CoreValve device. Echocardiography was performed the week before and 3 months after the procedure. MR was graded on a scale of 0 to 4+, classified as organic or functional, and the effective regurgitant orifice area (EROA) and MR index were calculated. Results: At baseline, MR was graded 4+ in 4 (11.4%) patients, 3+  in 10 (28.6%), and 2+ in 21 (60%). At follow‐up, MR was graded at 3+ in 4 (11.4%) patients, 2+ in 8 (22.9%), and 1+ in 19 (54.3%); 4 (11.4%) exhibited no MR. EROA (24.4 ± 11.5 mm² pre‐TAVI vs. 11.2 ± 10.3 mm² post‐TAVI, P < 0.001) and MR index (1.9 ± 0.3 pre‐TAVI vs. 1.3 ± 0.7 post‐TAVI, P < 0.001) were reduced with TAVI, independent of the etiology. MR decreased by at least 1 grade in 28 (80%) patients, with a reduction ≥2 grades in 10 (28.6%) patients; no patient showed a worsened condition. Subgroup analyses showed that the reduction in MR was significant in patients treated with the Edwards Sapien device but not in patients treated with the CoreValve device. Conclusions: This multiparametric echocardiographic evaluation showed that MR improved significantly after TAVI and that this result may be related to the type of valve implanted.     

Association of aortic valve sclerosis and coronary artery disease in patients with severe nonischemic mitral regurgitation

BACKGROUND: The presence of aortic valve sclerosis accounts for a higher rate of ischemic events and increased cardiovascular mortality. It may reflect coronary artery disease (CAD) because of a shared pathologic background. HYPOTHESIS: We aimed to analyze whether the presence of aortic valve sclerosis might help in identifying patients with coronary atherosclerosis among those with severe nonischemic mitral regurgitation (MR), who undergo coronary angiography before surgery for screening, and not because of suspected ischemic heart disease. METHODS: In all, 84 patients (mean age 64 +/- 9 years; 71% men) with mitral valve prolapse and severe regurgitation underwent echocardiography and coronary angiography. Aortic valve sclerosis was defined as focal areas of increased echogenicity and thickening of the leaflets without restriction of leaflet motion on echocardiography. Coronary artery disease was defined by the presence/absence of atherosclerotic plaques, independent of the degree of stenosis. RESULTS: Coronary artery disease was diagnosed in 47.6% of patients with and 15.8% of those without aortic valve sclerosis (p = 0.008). On logistic regression analysis, the presence of aortic valve sclerosis predicted CAD (odds ratio 3.3, 95% confidence interval 1.03-10.5; p = 0.04) independent of age. In female patients, the risk ratio for CAD in the presence of aortic valve sclerosis was 9. CONCLUSIONS: Coronary artery atherosclerosis and aortic valve sclerosis are closely associated in patients with severe nonischemic MR.     

A Case of Ruptured Mitral Valve Aneurysm Complicating Long-Standing Aortic Regurgitation

A 53-year-old man with aortic regurgitation was admitted to our hospital because of fever. A diagnosis of ruptured mitral valve aneurysm was made by Doppler echocardiography. Aortic regurgitant flow along the anterior mitral leaflet may have predisposed to mitral valve endocarditis, aneurysm formation, and its rupture.     

经导管介入治疗二尖瓣疾病的研究进展

二尖瓣反流（Mitral valve regurgitation,MR）逐渐成为心脏瓣膜病中最常见的疾病之一。虽然外科手术在治疗MR中起到重要作用,但由于围手术期的风险过大、老年人基础情况较差等原因,许多患者禁忌外科手术。近年来,经导管治疗MR装置的出现,给治疗MR带来了新的选择,但同时也面临着许多挑战。本文综述了经导管治疗MR装置的技术特征及其临床试验的结果。     

Concomitant Gerbode‐Like Defect and Anterior Mitral Leaflet Perforation after Aortic Valve Replacement for Endocarditis

We present a case of concomitant left ventricle (LV) to right atrial shunt (Gerbode‐like defect) and anterior mitral leaflet perforation in a 32‐year‐old male after aortic valve replacement for infective endocarditis of bicuspid aortic valve. This case emphasises that intra‐operative transesophageal echocardiography is a sine qua non for valvular surgical procedures.     

General concepts in the morphologic assessment of operatively excised cardiac valves—Part II

This 2-part article discusses general morphologic assessment of operatively excised cardiac valves and applies these principles to functional classifications. All cardiac valves are categorized into stenotic and purely regurgitant (no element of stenosis) groups based upon structural features: presence or absence of commissural fusion, calcific deposits, and degree and location of fibrosis. Of 2,980 operatively excised cardiac valves reviewed between 1962 and 1992, the most common lesion was aortic stenosis, followed by mitral stenosis and the combination of aortic and mitral stenosis.     

General concepts in the morphologic assessment of operatively excised cardiac valves—part I

This two-part article discusses the general morphologic assessment of operatively excised cardiac valves and applies these principles to functional classifications. All cardiac valves are categorized into stenotic and purely regurgitant (no element of stenosis) groups based upon structural features: presence or absence of commissural fusion, calcific deposits, and degree and location of fibrosis. Of 2980 operatively excised cardiac valves reviewed between 1962 and 1992, the most common lesion was aortic stenosis, followed by mitral stenosis and the combination of aortic and mitral stenosis.