Asymptomatic chronic traumatic aortic valve perforation with severe aortic regurgitation

Here, we present a young asymptomatic male patient incidentally diagnosed to have aortic regurgitation (AR). The patient had a history of a blunt trauma to the thorax two years back but did never have any symptoms. Transthoracic echocardiography showed a moderately dilated left ventricle with normal systolic function and severe AR with normal nondilated aortic root and tri-leaflet aortic valve. To diagnose the etiology of the AR, a transesophageal echocardiogram (TEE) was done, which revealed a perforation in the nonadjacent leaflet (NAL) and confirmed severe AR with two AR jets being clearly visualized, one through the point of incomplete coaptation and other one through the perforated area in the NAL. The patient was treated with aortic valve replacement and was doing well on follow-up.     

Incidence and treatment of severe primary mitral regurgitation in contemporary clinical practice

BackgroundMitral regurgitation (MR) is a common valvular disorder, occurring in up to 10% of the general population. Although surgery is the established treatment for primary MR, many patients do not receive appropriate therapy. The objective of this study was to determine the incidence and treatment pattern of patients with severe MR evaluated at a tertiary medical center and determine factors associated with receiving surgery.MethodsAll patients with moderate-severe and severe MR undergoing transthoracic echocardiography from 2011 to 2016 were identified. Patients with prior mitral valve surgery were excluded. Treatment recommendations were classified as referral to cardiology, referral to cardiothoracic surgery (CTS), receiving mitral valve surgery or receiving MitraClip. A multivariate logistic regression model was used to evaluate factors associated with referral to CTS or receiving surgery.ResultsDuring the study period, 1918 transthoracic echocardiogram were performed and 412 patients with moderate-severe or severe MR were identified. One hundred sixty-six patients (40%) had primary MR and 246 patients (60%) had secondary MR. For those with primary MR, 75 patients (45%) received treatment (surgery, n = 60 and MitraClip, n = 15) and 91 patients (55%) did not receive treatment. One hundred patients (60%) were referred to CTS and 128 patients (77%) were referred to cardiology. Patients undergoing surgery were younger (62.6 ± 14.2 years vs 72.0 ± 14 years, p < 0.001), with a higher prevalence of heart failure (57% vs 40%, p = 0.044) and a lower prevalence of stroke (3% vs 24%, p < 0.001) and hypertension (54% vs 74%, p = 0.012), compared to patients not undergoing surgery, respectively. Ejection fraction (60.4 ± 10.9% vs 56.3 ± 11.6%, p = 0.034), left ventricular end diastolic diameter (53.2 ± 10.3 mm vs 48.7 ± 10.9 mm, p = 0.040) and effective regurgitant orifice area (0.5 ± 0.4 cm² vs 0.3 ± 0.1 cm²) were higher in patients undergoing surgery, compared to patients not undergoing surgery, respectively. The most common reason for not receiving surgery was that MR was not addressed by the treating physician and lost to clinical follow-up. Over 50% of patients that did not receive surgery had at least 1 indication based upon current practice guidelines.ConclusionsIn contemporary clinical practice, less than half of patients with moderate-severe and severe primary MR received surgery and many were not referred for surgical consultation.     

Intermittent severe mitral regurgitation

The findings in two patients with hemodynamic evidence of intermittent severe mitral regurgitation with cyclic variation in right and left ventricular pressures are presented. Both patients had aortic and mitral valvular regurgitation of unknown etiology without definite evidence of papillary muscle dysfunction. The basis for the variation in the degree of mitral regurgitation is unclear.     

Spontaneous cyclic severe mitral regurgitation

Two patients are described with spontaneous wide fluctuations in the size of pulmonary capillary wedge pressure V waves thought to be related to cyclic spontaneous variations in the degree of mitral regurgitation over very short periods of time. The findings are thought to represent a hemodynamically distinct syndrome intermediate between chronic severe and acute severe mitral regurgitation.     

Timing of surgery in patients with chronic, severe mitral regurgitation

Patients with severe mitral regurgitation (MR) who are managed conservatively sustain excess mortality and morbidity. With improved mortality and morbidity rates being achieved with surgical management, cardiologists and cardiac surgeons are becoming more aggressive in treating patients with severe MR with surgery. Recent data indicate that even in the absence of symptoms or left ventricular dysfunction, surgery should be offered as a treatment for MR, provided that the regurgitation is severe, the valve seems to be repairable, and the surgeon is experienced in valve repair and is aided by intraoperative transesophageal echocardiography.     

Acute severe mitral regurgitation. Pathophysiology, clinical recognition, and management

Acute severe mitral regurgitation often goes unrecognized as an emergency requiring prompt, lifesaving treatment. Its causes, physical signs, natural history, echocardiographic features, and findings on chest roentgenography, electrocardiography, and nuclear scintigraphic scanning are reviewed. Acute severe mitral insufficiency can be differentiated from chronic severe mitral insufficiency by noninvasive two-dimensional echocardiography. M-mode echocardiography is a valuable tool in evaluating mitral prosthetic paravalvular regurgitation.     

Myocardial infarction: contemporary management strategies

Myocardial infarction (MI) is a common clinical diagnosis, associated with significant morbidity and mortality, not only in the short term, but also years following the index event. A more complete understanding of the pathophysiology of MI has ushered the era of multipronged treatment approach, with a combination of goal-directed revascularization, a broad adjunctive pharmacological therapy and aggressive secondary prevention measures. The goals of this article are to review the basic pathophysiological processes, which lead up to a clinical diagnosis of MI, to highlight the essential elements of clinical presentation and to summarize the evidence for comprehensive therapy. Emphasis has been placed on the choice of primary reperfusion therapy for ST-elevation MI, on risk-stratification of patients with non-ST elevation MI, and on rationale behind the selection of anti-ischaemic and antithrombotic therapy. Finally, evidence-based approach to secondary prevention is outlined.     

Atrioventricular reverse remodeling after valve repair for chronic severe mitral regurgitation: 1-year follow-up

Background:

Chronic severe mitral regurgitation is associated with poor clinical outcome because chronic volume overload leads to hemodynamic changes and left ventricular and left atrial remodeling. Few data are available regarding left atrial volume index regression (LAVIR) and left ventricular mass index regression (LVMIR) after valve surgery for mitral regurgitation. We aimed to identify predictive correlates of LAVIR and LVMIR and to assess the relationship between these regressions.

Hypothesis:

Volume overload in chronic severe mitral regurgitation may influence left atrial and ventricular remodeling and reverse remodeling.

Methods:

Eighty‐five patients who underwent valve repair for severe chronic mitral regurgitation were consecutively enrolled. Plasma N‐terminal fragment of the prohormone brain natriuretic peptide (NT‐proBNP) and echocardiographic measurements were performed before surgery, before discharge, and at 12 months after surgery. LAVIR and LVMIR were assessed using serial echocardiography.

Results:

There were significant decreases in left ventricular mass index (LVMI; from 125.9 ± 31.3 g/m² to 94.8 ± 28.6 g/m², P = 0.001) and left atrial volume index (LAVI; from 75.3 ± 33.5 mL/m² to 41.7 ± 16.0 mL/m², P = 0.001) after surgery. Preoperative LAVI positively correlated with preoperative LVMI (r = 0.437, P = 0.001) and LAVIR positively correlated with LVMIR (r = 0.347, P = 0.001). In multivariate stepwise linear regression analysis, preoperative LAVI, age, hypertension, and atrial fibrillation were independently predictive of LAVIR, and preoperative LVMI, hypertension, and NT‐proBNP were independently predictive of LVMIR.

Conclusions:

Volume overload in chronic severe mitral regurgitation may influence left ventricular remodeling and reverse remodeling, as well as left atrial remodeling and reverse remodeling. Preoperative lower LAVI, younger age, absence of hypertension, and absence of atrial fibrillation may predict LAVIR, and preoperative lower LVMI, lower NT‐proBNP levels, and absence of hypertension may predict LVMIR after surgery for chronic severe mitral regurgitation. Copyright © 2010 Wiley Periodicals, Inc. The authors have no funding, financial relationships, or conflicts of interest to disclose.     

Exercise echocardiographic assessment in severe mitral regurgitation

In chronic severe mitral regurgitation, minimum morbidity and mortality is achieved by applying surgical correction before left ventricular dysfunction becomes irreversible. This requires detection of subtle signs of early ventricular decompensation, for which isotonic stress echocardiography is more accurate than is use of resting indices of contractile function alone. We perform serial 6-monthly stress echocardiography for patients with severe mitral regurgitation, and recommend surgery when the exercise end-systolic volume index or ejection fraction reaches the cutoff values in Table 4 or if there is a clear adverse trend. Exercise echocardiography is more accurate than is exercise electrocardiography for detecting concomitant coronary disease prior to revascularization. Stress testing is also an objective measure of symptoms. Color-Doppler stress echocardiography can detect those patients whose mitral regurgitation worsens (or even develops de novo) with exercise, which can explain unexpected symptoms. Stress echocardiography, therefore, provides a comprehensive and cost-effective evaluation of patients with mitral regurgitation that combines functional, diagnostic, and prognostic information.     

Mechanistic insights into transient severe mitral regurgitation

Acute mitral regurgitation (AMR), a known complication of acute coronary syndromes, is usually associated with posterior papillary muscle dysfunction/rupture. In severe cases, management of AMR requires surgical intervention. Reversible severe AMR in patients in the absence of left ventricular systolic dysfunction and coronary artery stenosis may result from processes which cause transient subendocardial ischemia, such as intermittent episodes of hypotension or coronary artery vasospasm. We present two cases of reversible transient AMR due to subendocardial and/or endocardial ischemia, both of which offer insight into the mechanism of transient severe AMR.     

Cardiac amyloidosis presenting as severe mitral regurgitation

We report a patient with extensive infiltration of the left ventricle with amyloid who presented with severe mitral regurgitation which led to mitral valve replacement. The right ventricular biopsy showed minimal focal deposits of amyloid.     

Valve repair for chronic mitral regurgitation

Valve repair is the best surgical treatment for mitral regurgitation. In the present article we describe the results of mitral valve repair in patients with chronic mitral regurgitation treated at our center during the last eight years. The degree of correction of valve insufficiency, functional benefit, in-hospital morbidity and mortality, postoperative outcome of ventricular function, and middle-term overall and reoperation-free survival are analyzed.