Aortic and Mitral Valve Stenosis with Regurgitation: Not Due to Rheumatic Heart Disease

The patient is a 13‐year‐old Mexican–American immigrant who had no previous medical care. Upon arrival to the United States she was diagnosed with severe mitral valve stenosis and regurgitation. In addition she had severe aortic stenosis with mild to moderate aortic valve regurgitation, which was thought to be rheumatic heart disease. On the basis of the clinical and echocardiographic findings she was taken to the operating room for both mitral and aortic valve replacement. Her operation was complicated by the discovery that her aorta was completely calcified, as were her coronary arteries, mitral valve and aortic valve. She underwent aortic and mitral valve replacement as well as replacement of her aortic arch. Her coronary arteries were patch augmented and reimplanted into the newly created ascending aorta. Based on the pathologic examination of the surgical tissue a diagnosis of Gaucher disease was made. (Echocardiography 2011;28:E24‐E27)     

Transcatheter Aortic Valve Replacement in Rheumatic Aortic Stenosis: A Comprehensive Review

Rheumatic heart disease (RHD) mainly affects people in developing, low-income countries. However, due to globalization and migration, developed countries are now seeing more cases of RHD. In RHD patients who develop severe symptomatic aortic stenosis, surgical aortic valve replacement remains the treatment of choice. In the past decade, there has been an extension of transcatheter aortic valve replacement (TAVR) to intermediate-risk and lower-risk patients with aortic stenosis. This review suggests the possible utility of TAVR for the treatment of rheumatic aortic stenosis. Rheumatic aortic stenosis has been excluded from major TAVR studies due to the predominantly noncalcific pathology of the rheumatic aortic valve. However, there have been case reports and case series showing successful implantation of the valve even in patients with and without significant leaflet calcification. In this review article, we summarize the latest evidence of severe rheumatic aortic stenosis treated with TAVR and discuss the procedure's impact on patient care, safety, and efficacy.     

Coronary Arteriography in Isolated Aortic and Mitral Valve Disease

Abstract: Coronary arteriography in isolated aortic and mitral valve disease. A. Saltups. Aust. N.Z. J. Med., 1982, 12 , pp. 494–497.
Coronary arteriographic findings in 200 patients with isolated aortic and mitral valve disease were reviewed to examine the relationship between obstructive (>50% diameter stenosis) coronary artery disease (CAD) and angina pectoris (AP).
Of 100 patients with aortic valve disease, 30 had CAD of whom 20 gave a history of AP. Thirty-two of 52 patients (61%) with AP did not have CAD and 10 of 48 (21%) had CAD without AP. CAD was evenly distributed among patients with aortic stenosis, incompetence and mixed aortic valve disease.
CAD was found in 23 of 100 patients with mitral valve disease. Sixteen of 32 patients with mitral incompetence had CAD of whom four had AP. Seven of 68 patients with mitral stenosis or mixed mitral valve disease had CAD. AP was noted by four of these seven patients but by none of the 61 with normal coronary arteriograms (p <0.0001). Asymptomatic CAD was more common among patients with mitral incompetence (12/28 vs 3/64 P<0.005).
AP was an unreliable marker for CAD in aortic valve disease or mitral incompetence. Conversely, CAD was uncommon without AP in mitral stenosis or mixed mitral valve disease.
Coronary arteriography seems indicated in the pre-operative assessment of patients aged40 years with aortic valve disease or mitral incompetence. Its value is limited in patients with mitral stenosis or mixed mitral valve disease without AP.     

风湿性心脏病二尖瓣病变患者瓣膜替换术后肺功能的改变

目的：了解风湿性心脏病二尖瓣病变患者二尖瓣替换术（ＭＶＲ）后肺功能的改变。方法：观察２６例风湿性心脏病二尖瓣病变患者ＭＶＲ术前和术后３～１２个月的肺功能改变。结果：ＭＶＲ后３个月的肺功能与术前相比，无明显好转。术后６～１２个月，患者的各通气功能指标均有明显增加（Ｐ＜０．０５～Ｐ＜０．０１），但肺的一氧化碳弥散功能（ＤＬＣＯ）术后不但无增加，反而有下降的趋势。结论：ＭＶＲ术后３个月患者的肺功能与术前相比，无明显好转，可能与剖胸手术创伤有关。随着心功能的改善，术后６～１２个月，患者的通气功能逐渐改善，但ＤＬＣＯ并不增加，推测可能与患者术后肺泡毛细血管容量减少以及肺组织结构损害不可逆性改变有关。     

Prediction of Coronary Artery Disease in Patients Undergoing Operations for Rheumatic Aortic Valve Disease

Background: We sought to develop and validate a logistic model and a simple score system for prediction of significant coronary artery disease (CAD) in patients undergoing operations for rheumatic aortic valve disease. Hypothesis: The simple score model we established based on the logistic model was efficient and practical. Methods: A total of 669 rheumatic patients (mean age 51 ± 9 years), who underwent routine coronary angiography (CAG) before aortic valve surgery between 1998 and 2010, were analyzed. A bootstrap‐validated logistic regression model on the basis of clinical risk factors was developed to identify low‐risk (≤5%) patients, from which an additive model was derived. Receiver operating characteristic (ROC) curves were used to compare discrimination, and precision was quantified by the Hosmer‐Lemeshow statistic. Significant coronary atherosclerosis was defined as 50% or more luminal narrowing in 1 or more major epicardial vessels determined by means of coronary angiography. Results: Eighty‐eight (13.2%) patients had significant coronary atherosclerosis. Independent predictors of CAD include age, angina, diabetes mellitus, and hypertension. A total of 325 patients were designated as low risk according to the bootstrap logistic regression and additive models. Of these patients, only 4 (1.2%) had single‐vessel disease, and none had high‐risk CAD (ie, left main trunk, proximal left anterior descending, or multivessel disease). The bootstrap logistic regression and additive models show good discrimination, with an area under the ROC curve of 0.948 and 0.942, respectively. Conclusions: Our logistic regression model can reliably estimate the prevalence of significant CAD in rheumatic patients undergoing aortic valve operation, while the additive simple score system could reliably identify the low‐risk patients in whom routine preoperative angiography might be safely avoided. Clin. Cardiol. 2012 doi: 10.1002/clc.22033 The authors have no funding, financial relationships, or conflicts of interest to disclose. Dr. Guan‐xin Zhang and Dr. Bai‐ling Li have contributed equally to the work. Dr. Lin‐han is co‐corresponding author ( sh_hanlin@hotmail.com ).     

Mitral Valve Repair for Anterior/Bi-leaflet Versus Posterior Leaflet Degenerative Mitral Valve Disease: A Systematic Review and Meta-analysis

Mitral valve repair (MVr) secondary to degenerative anterior/bi-leaflet mitral valve disease is more challenging than posterior leaflet repair. However, conclusive evidence is needed to make decisions based on the outcomes rather than technical difficulties. This meta-analysis compares anterior/bi-leaflet MVr with isolated posterior leaflet repair in patients with mitral regurgitation (MR) due to degenerative mitral valve disease. The outcomes of interest were long-term (≥ 5 years) survival and freedom from re-operation and moderate-to-severe MR. Meta-analysis of 10 studies showed that there was no significant difference in long-term survival (risk ratio, RR: 1.00; 95% confidence interval, 95% CI 0.96-1.04), freedom from moderate-to-severe MR (RR: 0.95; 95% CI 0.87-1.03), and freedom from re-operation (RR: 0.96; 95% CI 0.90-1.02) between anterior/bi-leaflet MVr and posterior leaflet repair. As outcomes of anterior/bilateral repair were comparable with those of isolated posterior leaflet repair, our findings do not support the inclination towards replacement over repair for MR caused by anterior/bilateral degenerative mitral disease.     

Mitral Valve Stenosis after Transcatheter Aortic Valve Replacement: Case Report and Review of the Literature

Mitral stenosis is a rare and potentially severe complication of transcatheter aortic valve replacement (TAVR). Given the anatomic coupling and interdependence of the aortic and mitral valves, it comes by itself that procedures (either surgical or percutaneous) involving the aortic valve imply the risk of altering mitral valve function. Indeed, transcatheter aortic prostheses may impair adequate anterior mitral leaflet (AML) opening, especially when implanted in a “low” position, thus resulting in high transvalvular gradients.Hereby, we report the case of a 71-year-old male with symptomatic severe aortic stenosis and a history of previous surgical mitral valve repair who underwent TAVR with a self-expandable prosthesis. Notwithstanding an acceptable angiographic position, the prosthetic frame was shown to interfere with the AML, as evidenced by augmented transmitral gradients; nonetheless, pulmonary artery pressures remained unchanged, and the patient experienced symptomatic improvement. Therefore, a conservative approach was chosen and the patient was discharged home after medical therapy optimization.Moreover, we provide a review of the available literature regarding the incidence, predictors and possible management of this infrequent complication.     

Thoracic Aortic Disease: Endovascular Stents

Aortic disease is a serious, often life-threatening condition. The keys to instituting appropriate therapy in diseases of the aorta include accurate and rapid diagnosis and anatomical assessment. Endovascular aortic repair is a new alternative to conventional surgical approaches. Because arterial rupture is a risk of this procedure, appropriate facilities for resuscitation must be present during the procedure. This paper reviews the important aspects of aortic anatomy, echocardiographic imaging of the thoracic aorta, aortic pathology, endovascular surgery, and the role of echocardiography in the evaluation of the surgical outcome.