Transcatheter mitral valve‐in‐ring implantation in prohibitive surgical risk patients: Single center initial experience in the United States

Surgical mitral annuloplasty ring failure can result in symptomatic mitral stenosis or regurgitation which carries significant morbidity and mortality. Reoperation carries high surgical risks and the feasibility of transcatheter mitral valve‐in‐ring implantation is suggested by several case reports and series. In this article, we report two MVIR procedures focusing on preprocedural planning issues and intraprocedural tips. © 2015 Wiley Periodicals, Inc.     

The design and development of a stented tissue mitral and aortic heart valve replacement for human implantation

A study was conducted into the development of a mitral and aortic heart valve replacement that caters for patients having suffered valve damage due to stenosis or rheumatic fever. The appeal of the valve is that it is constituted from a solid frame housing pericardial tissue leaflets, and allows the patient freedom from post-operative blood-thinning medication. The valve is designed to appeal to patients in developing areas of the world, as it features a clip-in mechanism to secure the valve assembly into the sewing ring, which is stitched in independently of the frame and leaflets. Re-operative valve replacement would then be made possible when the pericardial leaflets began to calcify. Novel aspects of the design added value to the science of heart valve replacements, through the use of sintered chrome cobalt in the valve components, the insights gained into mechanical testing of pericardium, and the patient benefits offered by the complete design. Further work is planned to fatigue test the assembly, undergo animal trials and make the valve available for commercial use.     

Rapid Occurrence of Giant Left Ventricular Pseudoaneurysm after Mitral Valve Replacement

Left ventricular pseudoaneurysms are an uncommon and frightening complication after mitral valve replacement. We report the case of a 54‐year old woman, having undergone a mitral valve replacement with uneventful postoperative course and normal echocardiographic predischarge control, who was readmitted to hospital, only 16 days later, for rapidly progressing dyspnea, and finally echocardiographically diagnosed to have a massive 8‐cm long pseudoaneurysm communicating with the left ventricle through a narrow communication. The patient was proposed for emergency surgery but unfortunately died preoperatively.     

Simultaneous transfemoral transcatheter aortic valve replacement and trans‐septal mitral valve‐in‐ring implantation after partial laceration of an Alfieri stitch

In patients with an Alfieri Stitch transcatheter mitral valve replacement (TMVR) may be difficult due to the double orifice configuration of the mitral valve. We report a case of simultaneous and completely percutaneous TAVR and TMVR using LAMPOON‐related techniques prior to TMVR to allow for optimal valve deployment.     

Hemoptysis,recurrent cerebrovascular accident,and emergency mitral valve replacement

Hemoptysis in mitral stenosis may occur frequently, but massive pulmonary hemorrhage is uncommon. We describe a patient with mitral stenosis who had severe hemoptysis and required anticoagulation for recurrent embolic cerebrovascular accidents. The patient underwent successful mitral valve replacement with a Hancock bioprosthesis. There was no evidence of pulmonary bleeding following operation. This case illustrated that mitral valve operation may be performed in acutely ill patients for the relief of hemoptysis.     

Mitral valve replacement in children: mortality, morbidity, and haemodynamic status up to medium term follow up

OBJECTIVE—To investigate the outcome of mechanical mitral valve replacement in children after up to 11 years of follow up.
DESIGN—Retrospective analysis of case records. Operative survivors underwent echocardiographic studies to define current haemodynamic status and prosthetic valve function.
SETTING—Tertiary referral centre.
PATIENTS—All 54 children who underwent mitral valve replacement between January 1987 and December 1997.
RESULTS—30 day mortality was 20.3% and was associated with small valve size and supra-annular position. The actuarial freedom from the following events at five years (70% confidence interval (CI)) was: death, including 30 day mortality and transplantation, 68% (70% CI 62% to 75%); bleeding, 89% (70% CI 84% to 94%); non-structural valve dysfunction and reoperation, 92% (70% CI 87% to 97%). The incidence of endocarditis and thromboembolism was low and there was no structural valve failure. Event-free survival was 52% (70% CI 45% to 60%). Low weight, young age, and small valve size increased the chance of death or reoperation. On echocardiography, left ventricular dilatation and wall motion abnormalities were often observed. A high mean gradient over the prosthesis was associated with small valve size but not with length of follow up.
CONCLUSIONS—With the use of mechanical prostheses for mitral valve replacement in children, the problem of structural valve failure is no longer an issue. However, the procedure is still associated with a high complication rate, both at surgery and during follow up, and should therefore be reserved for patients in whom valve repair is not technically feasible.


Keywords: mitral valve replacement; prosthetic mitral valve; child; outcome     

An unusual form of mitral insufficiency accompanying atrial septal defect.

An unusual case of atrial septal defect secundum type, associated with intermittent severe mitral insufficiency due to billowing anterior mitral leaflet, in a 56-year old female is described. The degree of mitral insufficiency ranged from severe to none. This phenomenon manifested itself by an intermittent systolic apical thrill and intermittent mitral regurgitation on angiocardiography. Pulling the anterior mitral leaflet at operation through the atrial septal defect demonstrated that this leaflet could be caught in the left atrium, thus causing intermittent mitral insufficiency. Closure of the atrial septal defect and replacement of the mitral valve was performed.     

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。     

Surgical timing for mitral valve regurgitation

Advances in diagnostic and surgical techniques in the management of mitral regurgitation have resulted in improved survival rates and clinical outcomes. Echocardiography is a valuable noninvasive diagnostic tool in the determination of the timing of surgical correction of mitral regurgitation. Improved surgical techniques, the growing role of mitral valve repair, low operative mortality rates, and improved long-term survival rates are important considerations for earlier surgical intervention in symptomatic patients and in asymptomatic patients with echocardiographic criteria of left ventricular dilatation. Intraoperative transesophageal echocardiography is very useful in mitral valve repair and valve replacement with preservation of chordal structures.     

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.