"Carcinoid-like" tricuspid valvulopathy associated with nephrogenic systemic fibrosis

We present a case of a patient with end-stage renal disease and nephrogenic fibrosing dermopathy (NFD) whose echocardiogram demonstrated rare tricuspid valve abnormality with malcoaptation due to tethering and restricted motion of the leaflets causing severe tricuspid regurgitation. The cardiac abnormalities developed 3 years after her initial diagnosis of NFD was made by skin biopsy. The echocardiographic appearance of the tricuspid valve resembled that seen in patients with carcinoid heart disease; however, an evaluation for carcinoid tumor in our patient was negative. Myocardial biopsy performed at the time of right heart catheterization demonstrated trace gadolinium within the lysosomes of one cardiac fibroblast. This report is the first to describe the association between nephrogenic systemic fibrosis and severe valvular heart disease requiring valve replacement.     

Balloon valuloplasty prior to transcatheter valve‐in‐valve implantation in a degenerated mitroflow aortic bioprosthesis

Transcatheter valve‐in‐valve implantation is an emerging treatment option for high‐risk patients with failing aortic bioprostheses. The presence of the prosthesis stents is thought to prevent coronary artery obstruction, a known complication of transcatheter aortic valve implantation in the native aortic valve. The Sorin Mitroflow aortic bioprosthesis (Sorin Group, Saluggia, Italy) has a particular design in that the pericardial leaflets are mounted outside the valve stent. As a consequence, the pericardial leaflets of this prosthesis may be displaced well away from the stents during the deployment of transcatheter valves. This might explain why both the cases of coronary occlusion following valve‐in‐valve implantation reported to date occurred in patients with a malfunctioning Mitroflow bioprosthesis. We describe a patient with a malfunctioning 25 mm Mitroflow bioprosthesis successfully treated by percutaneous transcatheter valve‐in‐valve implantation, and discuss the role that balloon aortic valvuloplasty plays in the performance of this delicate procedure. © 2012 Wiley Periodicals, Inc.     

风湿性心脏病并发缩窄性心包炎的外科治疗

目的:总结风湿性心脏病并发缩窄性心包炎患者施行瓣膜置换及心包剥除术外科治疗经验。方法:回顾性分析1992-06-2010-02期间对13例风湿性心脏病并发缩窄性心包炎患者施行瓣膜置换及心包剥除术的临床资料。结果:术后死亡1例,死亡原因为重度低心排血量,病死率7.69%。术后不同程度低心排血量6例,术后再次开胸止血1例。13例心包病理检查均为风湿性。随访3个月～8年,心功能Ⅰ～Ⅱ级10例,Ⅲ级2例。结论:对风湿性心脏病并发缩窄性心包炎患者,同期行瓣膜置换和心包剥除手术,积极有效的围术期处理能达到理想的治疗效果。     

Bioprosthetic aortic valve leaflet disruption with high energy electrocautery to prevent coronary artery obstruction during valve‐in‐valve transcatheter aortic valve replacement

Transcatheter aortic valve replacement (TAVR) is well‐established for the treatment of bioprosthetic aortic valve stenosis (AS) in high surgical risk patients. Coronary artery obstruction from displacement of the bioprosthetic valve leaflets during valve‐in‐valve (VIV) TAVR is a rare, but potentially fatal, complication. Recently, the bioprosthetic aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction (BASILICA) procedure was developed as a method for disrupting bioprosthetic leaflets in patients undergoing VIV TAVR at high risk for coronary obstruction. This case describes a successful VIV TAVR utilizing a simplified concept of the BASILICA technique in a patient where the full procedure could not be completed.     

无支架自体心包瓣置换主动脉瓣术后左心功能评价

目的 :评价无支架自体心包瓣植入后血液动力学特性。　　方法 :观察无支架自体心包瓣 (自体心包瓣组 )置换主动脉瓣病人 10例围术期血液动力学指标及术后近期左心功能变化 ,并与双叶机械瓣 (双叶机械瓣组 )置换主动脉瓣病人比较。　　结果 :自体心包瓣组病人围术期血液动力学指标优于双叶机械瓣组 ,而且术后瓣膜有效开口面积大 ,跨瓣压差小 ,病人左心室功能和构型恢复较快 ,2年心包瓣膜功能良好。　　结论 :无支架自体心包瓣具有良好的血液动力学特性 ,手术近期效果满意 ,远期效果有待进一步随访。     

A guide to fluoroscopic identification and design of bioprosthetic valves: A reference for valve‐in‐valve procedure

Surgical aortic valve replacement remains the therapy of choice in majority of patients with aortic stenosis. Bioprosthetic heart valves are often preferred over mechanical valves as they preclude the need for anticoagulation with its associated risks of bleeding and thromboembolism. However, bioprosthetic heart valves undergo structural deterioration and eventually fail. Reoperation is the standard treatment for structural failure of the bioprosthetic valve, stenosis or regurgitation but can carry a significant risk, especially in elderly patients with multiple comorbidities. Transcatheter aortic valve implantation has recently been established as a feasible alternative to conventional valve surgery for the management of high‐risk elderly patients with aortic stenosis. This treatment modality has also been shown to be of benefit in the management of degenerated aortic bioprosthesis as a valve‐in‐valve procedure. The success of this procedure depends on a good understanding of the failing bioprostheses. This not only includes the device design but its radiological/fluoroscopic appearance and how it correlates with the implanted valve, as transcatheter aortic valve implantation is performed under fluoroscopic guidance. Here we illustrate the fluoroscopic appearance of 11 commercially available surgical bioprostheses and two commercially available transcatheter heart valves and discuss important aspects in their design which can influence outcome of a valve‐in‐valve procedure. We have also collated relevant information on the aspects of the design of a bioprosthetic valve, which are relevant to the valve‐in‐valve procedure. © 2012 Wiley Periodicals, Inc.     

Prolapse of the "floppy" aortic valve as a cause of aortic regurgitation. A clinico-morphologic study

A clinico-pathologic study was performed in 25 patients undergoing aortic valve replacement because of regurgitation, caused by myxoid degeneration of the valve leaflets. Associated cardiac anomalies were floppy mitral valve (2 cases), floppy mitral valve and idiopathic hypertrophic subaortic stenosis (1), left atrial myxoma (1), and aortic coarctation at the isthmus (1). Three patients died (2 immediately and 1 on the 30th postoperative day). Pathological studies of the explanted valves showed deformities characterized by redundant thin leaflets which appeared soft and gelatinous. On histologic examination the fibrous layer of the leaflets was seen to be infiltrated by myxomatous tissue. Echocardiography showed the aortic root to be dilated in 13 patients and normal in the others. In those with normal aortic root, the histological examination of aortic wall disclosed minimal cystic medial necrosis in two cases. In contrast, more severe forms of cystic medial necrosis were evident in all patients having a dilated aortic root. Aortic valve replacement was performed in all cases. It was accompanied by a Bentall procedure (1 case), repair of ascending aorta dissection (2), replacement of the ascending aorta (1), mitral valve replacement (2), mitral valve replacement and apico-ascending aorta conduit (1) and excision of a left atrial myxoma (1). Our experience suggests that prolapse of the aortic valve due to floppy leaflets is a common degenerative disease which is generally associated with noninflammatory aortic root degeneration. This, together with aortic root dilatation, contributes to valve insufficiency. Nevertheless, the disease, when isolated (with normal aortic root), is liable in itself to produce aortic regurgitation. The need for early diagnosis is stressed, so as to be able to perform valve replacement.     

Systolic intra-cavitary gradients following aortic valve replacement: an echo-Doppler study.

Systolic left ventricular flow was studied by pulsed and continuous wave Doppler in 41 patients following aortic valve replacement for severe stenosis (mean valvular area: 0.58 cm2; range 0.3-0.75 cm2). Maximal left ventricular velocities by continuous wave Doppler study, were higher than 2.5 m.s-1 with a sharp peak at end-systole in five patients in basal condition and in four others after amyl nitrite inhalation. Pulsed Doppler study showed that the high velocities started from the apex or mitral papillary muscle level with a marked chamber narrowing at two-dimensional echography. Only one patient had a systolic anterior motion (SAM) of the anterior mitral leaflet with mitral-septal contact. The left ventricular dimensions, as measured by M-mode echography were compared in the various patient groups. High velocities seemed statistically associated with the smaller systolic and diastolic diameters of the left ventricle and outflow tract and the larger relative thickness of the posterior wall. The highest pressure gradients disappeared after correction of hypovolaemia (one patient), clearance of pericardial effusion (one patient), or beta-blocker treatment (three patients). The present study confirms that left intra-ventricular dynamic gradients can occur after clearance of fixed outflow obstruction, for which Doppler examination is a reliable and innocuous diagnostic means. Haemodynamically, this syndrome resembles hypertrophic obstructive cardiomyopathy, but the scarcity of the systolic anterior motion of the mitral leaflets is suggestive of a different mechanism that could be cavity obliteration or mid-ventricular obstruction.     

Transcatheter Laceration of Aortic Leaflets to Prevent Coronary Obstruction During Transcatheter Aortic Valve Replacement: Concept to First-in-Human

Objectives

This study sought to develop a novel technique called bioprosthetic or native aortic scallop intentional laceration to prevent coronary artery obstruction (BASILICA).

人工腱索植入术对二尖瓣置换术后患者左心功能的影响

目的:探讨人工腱索植入术对风湿性心脏病患者二尖瓣置换术后左心功能的影响。方法:回顾性分析50例因患风湿性心脏病而需要进行二尖瓣置换手术(mitral valve replacement,MVR)患者的临床资料,根据术中对二尖瓣不同处理方式分为两组:A组(n=26),切除全部瓣膜及瓣下结构组;B组(n=24),为需切除全部瓣膜及瓣下结构的患者实行人工腱索植入术重建瓣下结构。分别于术后3个月对患者进行彩色多普勒超声心动图检查,测量患者左心功能,比较两组间各项指标的差别。结果:术后3个月B组患者左心室射血分数(LVEF)改变优于A组(P0.05)。结论:二尖瓣置换术中,人工腱索植入重建瓣下结构的技术安全有效,对患者术后短期左心功能的恢复有良好改善,长期效果仍需进一步观察。     

经股动脉经导管主动脉瓣置换术治疗单纯主动脉瓣关闭不全

【摘要】 目的 探讨Venus-A支架瓣膜行经股动脉经导管主动脉瓣置换术治疗单纯主动脉瓣关闭不全患者的可行性。方法 回顾性调阅2018年12月至2019年12月在阜外医院接受经股动脉经导管主动脉瓣置换术的15例单纯主动脉瓣关闭不全患者的床资料。其中男性12例, 女性3例,年龄68—83岁,平均年龄(74.65±5.52)岁。患者术前均有左心功能不全症状,且术前心脏超声诊断均为单纯主动脉瓣重度返流。结果 患者行经股动脉经导管主动脉瓣置换术。所有病例成功植入Venus-A支架瓣膜。全组病例无死亡。出院前对患者进行临床评估和超声心动图检查。术中行瓣中瓣治疗3例,少量瓣周返流2例。其余病人均无明显瓣周返流,并且顺利出院。结论 经股动脉经导管主动脉瓣置换术治疗单纯主动脉瓣关闭不全患者是可行的,术后早期结果满意。     

左心瓣膜术后心房颤动与三尖瓣反流的关系

目的:研究左心瓣膜术后三尖瓣反流与术后心房颤动(房颤)的关系。方法:随访2002年3月至2008年11月接受主动脉瓣置换术或二尖瓣置换术,且未行三尖瓣成形术或三尖瓣置换术的患者374例,其中男性151例,女性223例,年龄23～79岁,平均(52±11)岁。所有患者均经过术前和术后彩色多普勒超声心动检查及心电图检查。单因素分析组间使用χ2检验。危险因素采用Logistic回归模型分析。结果:左心瓣膜术后房颤是术后发生三尖瓣反流的独立危险因素。Logistic多因素分析结果为:术后房颤、女性及术后左心房扩大,是术后三尖瓣反流的独立危险因素;术时年龄、术后左心室大小、术后右心室大小及术后射血分数这4项不是三尖瓣反流的危险因素。结论:左心瓣膜术后房颤是术后发生三尖瓣反流的独立危险因素。对于术后房颤应该引起重视,积极治疗。     

瓣中瓣置入术治疗二尖瓣关闭不全16例报告

二尖瓣关闭不全患者行常规二尖瓣置换术后常有左室功能恶化，有人推测术中二尖瓣结构的破坏是导致术后左室功能不全的主要机制之一。从１９９１年５月～１９９５年５月，我们对１６例二尖瓣关闭不全患者实施了一种新的二尖瓣置换术，即“瓣中瓣”置入术。术中保留全部二尖瓣瓣叶及瓣下结构，人工瓣置入固定后，前、后瓣叶均卷缩折叠于缝合环下。术后所有患者病情平稳，仅３例需要很少量的正性肌力药物支持，且都能在术后３６小时内脱离呼吸机。经超声心动图测定，术后左室功能很快恢复，所有患者均痊愈出院。结果表明：对二尖瓣关闭不全及其合并轻度狭窄者采用瓣中瓣置入术，有利于术后左室功能的恢复，瓣中瓣置入术是一种安全和有效的手术方法。     

老年心脏瓣膜病变的外科治疗体会

目的 总结老年心脏瓣膜病变的外科治疗经验.方法 回顾性分析160例老年心脏瓣膜病变外科治疗患者的临床资料.行二尖瓣置换（MVR）65例,主动脉瓣置换（AVR）45例,双瓣置换50例;同期行三尖瓣成形术108例,冠状动脉搭桥术19例,左房折叠术4例.结果 手术早期死亡6例,死亡率为3.9%.随访140例,随访时间6个月至8年,死亡2例,其余138例术后随诊复查人工瓣膜功能良好,左心室射血分数（LVEF）提高,心功能均提高1～2级,无瓣周漏、人工瓣膜心内膜炎及心脏血栓形成,没有因瓣膜原因而再次手术者.结论 术前充分调整心功能,选择适当的手术时机,加强术中心肌保护,不断改进和提高手术技巧,加强围术期管理,是提高老年心脏瓣膜病变患者手术成功率的关键因素.     

心内直视手术后三尖瓣置换临床研究

目的 :探讨心内直视手术后三尖瓣发生严重病变的原因及二次手术时三尖瓣置换的方法。　　方法 :在全麻、体外循环下完成 8例心内直视术后因严重三尖瓣病变所致三尖瓣置换术。对 7例术后存活者进行随访。　　结果 :手术死亡 1例。 7例术后存活者随访中 (0 5～ 5年 )无死亡及瓣膜相关并发症发生。　　结论 :三尖瓣置换是心内直视手术后严重三尖瓣病变有效的治疗方法     

Successful minimal approach transcatheter aortic valve replacement in an allograft heart recipient 19 years post transplantation for severe aortic stenosis: A case report

BACKGROUND Aortic stenosis is one of the rare valvular complications in a transplanted heart.Over the past 8 years, transcatheter approach for aortic valve replacement(TAVR) has been slowly evolving to be the preferred approach in these patient population when compared to the surgical approach. We report a second case in the United States with successful transfemoral minimal approach with minimal sedation for TAVR in a heart transplant recipient 19 years post transplantation for severe symptomatic calcified aortic stenosis.CASE SUMMARY We present a case of 73-year-old male who has undergone successful minimal approach transcatheter aortic valve replacement in an allograft heart. Patient had received orthotopic heart transplantation 19 years ago for non-ischemic cardiomyopathy. Follow up transthoracic echocardiograms as per routine protocol did not show any aortic valve disease until 15 years post transplantation.Aortic valve was noted to be mildly sclerotic at that time and gradually progressed to severe symptomatic aortic stenosis over the next 4 years. Patient had complaints of worsening shortness of breath that limited his functional capacity. Overall his post heart transplantation period has been mostly uneventful except for allograft non occlusive vasculopathy and aortic stenosis.His Society of Thoracic Surgery risk score was 12.205% and he was considered to be a high-risk surgical candidate by surgeon. Decision was made to undergo transcatheter aortic valve replacement.CONCLUSION With the improved survival of these patients, we think it is time to look intopathophysiology of valvular disease in transplant heart recipients. Some other unanswered questions include, underlying donor and recipient risk factors for valvular diseases in heart transplant recipients.     

Use of a photo‐realism 3D rendering technique to enhance echocardiographic visualization of the anatomical details during beating‐heart mitral valve repair

The NeoChord procedure is an innovative microinvasive, transventricular, beating‐heart chordal replacement technique for patients with severe degenerative mitral valve regurgitation resulting from prolapsed or flail leaflets. Use of three‐dimensional (3D) transoesophageal echocardiographic imaging is crucial to the physician operator for device navigation during the procedure and to assess the functional results of the repair at the end of the procedure. Photo‐realistic, 3D rendering techniques have been recently developed for medical use. Philips TrueVue (Philips Healthcare, Eindhoven, NL) is a photo‐realism technique that employs the use of a virtual light source that simulates the interaction of light on 3‐dimensional surfaces. Use of photo‐realism techniques, in conjunction with 3D echocardiography, improves the visualization of morphological characteristics of the mitral valve before, during, and after beating‐heart mitral valve repair procedures.     

Retrograde percutaneous aortic valve implantation for critical aortic stenosis.

Recently, a prosthetic aortic valve has been implanted percutaneously in several patients using an antegrade transseptal approach. This has been shown to be feasible and associated with dramatic hemodynamic improvement. We report a retrograde implantation of a percutaneous heart valve (PHV) in an 84-year-old man with critical aortic stenosis and refractory congestive heart failure after difficulties encountered with an initial antegrade approach. While attempting antegrade transseptal implantation of a PHV, the anterior leaflet of the mitral valve was tethered by the guidewire resulting in severe mitral regurgitation and pulseless electrical activity. Cardiac resuscitation was successful. Utilizing a retrograde approach, the PHV was successfully implanted in a stable position below the coronary ostia and well above the mitral valve leaflets. The aortic valve area increased from 0.55 to 1.7 cm2 with only mild paravalvular aortic regurgitation. Despite marked improvement in aortic valve function, the patient died secondary to guidewire-induced mitral valve anterior leaflet laceration, severe mitral regurgitation, and cardiogenic shock. Retrograde implantation of a PHV can be successfully performed with substantial increase in aortic valve area and an acceptable degree of aortic regurgitation. Although the retrograde approach may be associated with greater risk of vascular access site complications, it may be considerably safer by avoiding potential guidewire injury to the mitral valve. Further refinements in technique may establish the retrograde approach as the preferred means of PHV implantation in nonsurgical patients with critical aortic stenosis.     

重症心脏瓣膜病合并巨大左心室的外科治疗

目的　总结心脏瓣膜病合并巨大左心室外科治疗经验。方法　对 34例巨大左心室心脏瓣膜病人 (L VEDD>70 mm,L VESD>5 0 m m,EF<0 .5 ,FS<0 .2 5 )施行心脏瓣膜替换术。心肌保护方法分别采用冷晶体停搏液灌注 ;温氧合血持续灌注和心脏不停搏心内直视手术。瓣膜缝合采用连续缝合。结果　本组治愈 32例 ,早期死亡 2例 ,术后C/ T、L VEDD较术前明显改善 (P<0 .0 1) ;L VESD、L VESVI也较术前改善 (P<0 .0 5 )。 L VEF、L VFS与术前比较无显著差异 (P>0 .0 5 )。随访 6个月～ 7年 ,晚期死亡 2例。心功能恢复 级者 2 1例 , 级者 8例 , 级者 1例。结论　巨大左心室心脏瓣膜病人经充分的术前准备后仍应考虑手术治疗 ,选择良好的手术时机对手术的成败具有重要意义 ;温氧合血持续灌注和心脏不停搏技术的应用及保留二尖瓣瓣叶及瓣下结构对提高手术成功率有一定帮助 ;合理的围术期处理是手术成功的重要一环。     

心脏病瓣膜置换术心肌保护方法对比(附1215例报告)

目的对比心脏瓣置换手术不同心肌保护方法的效果。方法1215例瓣膜置换术中,男性585例（48．1％）,女性630例（51．9％）,年龄15-69岁,平均45岁。心功能Ⅱ级455例、Ⅲ级600例、Ⅳ级160例。术前均应用强心、利尿、扩血管药物治疗,输入极化液1-2周。手术在全麻体外循环中度低温下进行,全组1215例,其中行二尖瓣置换（MVR）804例,主动脉瓣置换（AVR）162例,二尖瓣及主动脉瓣双瓣置换（DVR）246例,三尖瓣置换（TVR）3例,合并三尖瓣关闭不全（TI）者行Devega或Kay成形术,术中行冠状动脉旁路移植术6例。心肌保护方法共4种：A组159例,应用冷晶高钾停跳液灌注;B组960例,应用温血高钾停跳液灌注;C组54例,采用不停跳心肌保护方法;D组42例,采用不阻断升主动脉低温室颤下手术的方法。结果各组间呼吸机辅助时间和ICU治疗时间差异无统计学意义,但是C组术后恢复时间比A组短。C、D组应用正性肌力药物、心律失常发生率和死亡率均较A、B组低。全组死亡29例,死亡率2．4％,其中MVR死亡21例,AVR死亡5例,DVR死亡3例。A组死亡16例（死亡率10％）,B组死亡13例（死亡率1-3％）,C组、D组无死亡病例。结论传统的冷晶高钾停跳液可以很好地保护心肌,现在应用的温血高钾停跳液心肌保护效果更好,不停跳、不阻断升主动脉方法保护心肌效果确切,可以根据患者情况个性化选择心肌保护方法。