Effects of valve replacement for aortic stenosis on mitral regurgitation

We aimed to prospectively and quantitatively assess the effects of aortic valve replacement (AVR) for aortic stenosis (AS) on mitral regurgitation (MR) and to examine the determinants of the changes in MR. Fifty-two patients with AS scheduled for AVR were included if holosystolic MR not being considered for replacement or repair was detected. MR was quantified using the proximal isovelocity surface area method before and 8 +/- 4 days after surgery. Mitral valvular deformation parameters did not change significantly, but the mitral effective regurgitant orifice (ERO) and regurgitant volume decreased from 11 +/- 6 mm(2) to 8 +/- 6 mm(2) and from 20 +/- 10 ml to 11 +/- 9 ml, respectively (both p <0.0001). Using multiple linear regression analysis, preoperative severity of MR, mitral leaflet coaptation height, and end-diastolic volume decrease were independently associated with postoperative reduction in MR, whereas changes in mitral valve morphology after surgery were not. MR etiology did not predict the reduction in MR. In conclusion, the decrease in MR observed in most patients after AVR is associated with the magnitude of acute left ventricular reverse remodeling. As the reduction in left ventricular systolic pressure contributes to the decrease in regurgitant volume, the preoperative quantitative assessment of MR should best be performed by measurement of the ERO.     

Clinical and anatomic observations in patients having mitral valve replacement for mitral stenosis and simultaneous tricuspid valve replacement

Certain clinical and morphologic findings are described in 67 patients (aged 23 to 76 years [mean 52]; 55 women [82%]) who had mitral valve replacement for mitral stenosis (with or without associated regurgitation), and simultaneous tricuspid valve replacement for pure tricuspid regurgitation (58 patients) or tricuspid stenosis (all with associated regurgitation; 9 patients). Of the 58 patients with pure tricuspid regurgitation, 21 had anatomically normal and 37 had anatomically abnormal (diffusely fibrotic leaflets) tricuspid valves. Among these 58 patients, no clinical or hemodynamic variable was useful before surgery in distinguishing the group without from that with anatomically abnormal tricuspid valves. All 9 patients with stenotic tricuspid valves had anatomically abnormal tricuspid valves. The latter group had a lower average right ventricular systolic pressure (tricuspid valve closing pressure) than those with pure tricuspid regurgitation, and none had severe pulmonary arterial hypertension (present in 20 [30%] of the 58 patients with pure tricuspid regurgitation).     

Simultaneous transapical transcatheter aortic valve replacement and transcatheter mitral valve replacement for native valvular stenosis

Transcatheter aortic valve replacement (TAVR) is well established for patients who cannot undergo surgery (Leon et al., N Engl J Med 2010;363:1597) or are high risk for surgery (Smith et al., N Engl J Med 2011;364:2187–2198). Experience with the TAVR procedure has led to recent reports of successful transcatheter mitral valve replacement (TMVR) procedures (Cheung et al., J Am Coll Cardiol 2014;64:1814; Seiffert et al., J Am Coll Cardiol Interv 2012;5:341–349) separately or simultaneously with the TAVR. However, these reports were of simultaneous valve‐in‐valve procedures (Cheung Anson, et al. J Am Coll Cardiol 2013;61:1759–1766). A recent report from Portugal also reported simultaneous transpical implantation of an inverted transcatheter aortic valve‐in‐ring in the mitral position and transcatheter aortic valve (Hasan et al., Circulation 2013;128:e74–e76). There has been an experience of TMVR only in native mitral valve for mitral valve stenosis, but none in both aortic and mitral valves. We report the first in human case of simultaneous transapical TAVR and TMVR in native valves secondary to valvular stenosis. Our patient was not a candidate for percutaneous balloon mitral valvuloplasty secondary to a high Wilkins Score. Sizing of the aortic valve was based on the transesophageal echocardiogram (TEE), whereas sizing of the mitral valve was based on TEE measurements and balloon inflation during left ventriculography. © 2015 Wiley Periodicals, Inc.     

二尖瓣狭窄患者肺功能改变及瓣膜置换术对其影响

目的了解风湿性心脏病二尖瓣狭窄(MS)患者行瓣膜置换术前后肺功能指标的变化,进而评价手术疗效。方法共入选26例,男14例,女12例。全部患者测术前及随访最大呼气中期流速(MMF)、50%肺活量用力呼气流速(V50)、25%肺活量用力呼气流速(V25)、NYHA分级、生活质量及心胸比值(CTR)。结果26例随访1~10(5.7±4.6)年。术后心肺功能均有不同程度改善,术前综合心功能指标较差者,术后随访V50、V25恢复较好(P<0.05)。结论MS患者心肺功能变化密切相关,以小气道功能为代表的肺功能指标可较好反映手术后长期疗效。     

Effect of aortic valve replacement for aortic stenosis on severity of mitral regurgitation

The severity of mitral regurgitation (MR) was determined by color Doppler echocardiography in 44 adult patients with severe symptomatic aortic stenosis before and after isolated aortic valve replacement. Preoperative MR was absent in 17, mild in 14, moderate in 11 and severe in 2 patients. Three to 388 (mean 58) days after surgery, 14 patients continued to have no MR. In the other 30 patients, MR decreased in 18 (60%), remained unchanged in 8 (27%) and increased in only 4 (13%). Furthermore, in 13 patients with significant (moderate or severe) MR, the severity decreased in 12 (92%). Thus, the severity of MR often decreases after aortic valve replacement for aortic stenosis.     

Iatrogenic mitral stenosis following transcatheter aortic valve replacement (TAVR)

A 57 year old female underwent transcatheter aortic valve replacement (TAVR) for severe aortic stenosis. Mild iatrogenic mitral stenosis was noted intraoperatively. Attempts to reposition the device were hampered by aortic angulation. One year later, severe mitral stenosis was confirmed on transoesophageal echocardiography. It is important to recognise that iatorgenic mitral stenosis due to TAVR may progress over time. Care should be taken to minimise the risk of this rare complication     

Mitral valve replacement for mitral stenosis caused by Libman-Sacks endocarditis.

A women who developed mitral stenosis from Libman-Sacks endocarditis is described. The mitral valve was replaced by a Starr-Edwards prosthesis. One year later, despite her being maintained on steroids and azathioprine, the verrucous endocarditis progressed to cause sudden, severe dysfunction of the prosthetic valve.     

A coconut left atrium 23 years after mitral valve replacement for chronic mitral stenosis

We present the case of a 65 year-old female who was admitted to the hospital because of deterioration of chronic dyspnea. Twenty-three years prior to this admission, mitral valve replacement for chronic mitral stenosis was performed using a Starr-Edwards caged-ball prosthesis. There was severe pulmonary hypertension. On transthoracic echocardiography and on cineradiography, the function of the mitral valve prosthesis was unimpaired. However, cineradiography showed extensive mural calcification of the left atrium; we report this remarkable finding.     

Mitral valve replacement for mitral stenosis caused by Libman-Sacks endocarditis.

A women who developed mitral stenosis from Libman-Sacks endocarditis is described. The mitral valve was replaced by a Starr-Edwards prosthesis. One year later, despite her being maintained on steroids and azathioprine, the verrucous endocarditis progressed to cause sudden, severe dysfunction of the prosthetic valve.     

Echocardiographic variables associated with mitral regurgitation after aortic valve replacement for aortic valve stenosis

BackgroundMitral regurgitation (MR) is frequently associated with aortic stenosis. Previous reports have shown that coexisting mitral insufficiency can regress after aortic valve replacement (AVR) while others recommend dealing with examination.AimThe study aimed to assess the severity of MR before and after aortic valve replacement for aortic stenosis and to define the determinants of its postoperative evolution.MethodsFor this purpose, 30 adult patients referred for aortic valve surgery underwent pre- and 1 month postoperative transthoracic echocardiography including 2D, MM, PW, CW and color Doppler examination.ResultsPostoperative MR improved in 68.4% of the 19 patients (63.3%) who had preoperative moderate MR (p = 0.002). The effect of the valve size on the postoperative MR was statistically insignificant (0.059) but was significant on regression of the mass (p = 0.001) and drop in mean PG (p = 0.04) across AV. Patients with persistent moderate MR after surgery were all in AF and had significantly larger left atrial size (45 ± 26 mm), compared to none and a smaller left atrial (37 ± 19 mm) in patients in whom MR regressed or disappeared after surgery; respectively, p < 0.05. The postoperative variables associated with moderate MR were peak PG across AV (29.4 ± 5.1 vs 38.0 ± 5.7 p = 0.004), mean PG (15.04 ± 4.4 vs 22.8 ± 5.8 p = 0.009) and LVMI (124.7 ± 19.3 vs 147.2 ± 31.6 p = 0.065).ConclusionPreoperative predictors of residual postoperative MR were large LA and AF while the postoperative variables were high peak and mean pressure gradient across the aortic valve and high LVMI.     

Transcatheter mitral valve replacement

Transcatheter mitral valve (MV) repair, specifically the edge-to-edge leaflet repair, is a less invasive treatment of symptomatic mitral regurgitation (MR) in patients with high or prohibitive surgical risk. In cases with severe leaflet calcification, small mitral orifice area, and/or extremely wide regurgitation across the entire MV commissure, transcatheter MV repair may rather cause suboptimal or potentially hazardous outcomes. In these cases, MV replacement can be a more suitable option. Recently, percutaneous transcatheter MV replacement has emerged as an acceptable therapeutic option for the treatment of degenerated surgical bioprosthetic disease. Moreover, several transcatheter devices for native MV replacement are under evaluation with a hope to provide more complete and reproducible restoration of MV function. In this article, we will review current status, applications, clinical outcomes, and limitations that need to be overcome for transcatheter MV replacement for both degenerated surgical bioprosthetic disease and native MV disorders.