BACKGROUND Tetralogy of Fallot(TOF)is one of the most common congenital heart defects,and surgery is the primary treatment.There are no precise guidelines on the treatment protocol for tricuspid regurgitation(TR)as a ...BACKGROUND Tetralogy of Fallot(TOF)is one of the most common congenital heart defects,and surgery is the primary treatment.There are no precise guidelines on the treatment protocol for tricuspid regurgitation(TR)as a common complication of TOF repair.The timing for treatment in patients presenting with valve regurgitation after TOF repair is often difficult to determine.Here,we report the first case of sequential treatment of pulmonary and TR using interventional therapy.CASE SUMMARY We present the case of a 52-year-old female patient,who had a history of TOF repair at a young age.A few years later,the patient presented with pulmonary and tricuspid regurgitation.The symptoms persisted and TR worsened following percutaneous pulmonary valve implantation.Preoperative testing revealed that the patient’s disease had advanced to an intermediate to advanced stage and that her general health was precarious.Because open-heart surgery was not an option for the patient,transcatheter tricuspid valve replacement was suggested.This procedure was successful,and the patient recovered fully without any adverse effects.This case report may serve as a useful resource for planning future treatments.CONCLUSION Treatment of both valves should be considered in patients with tricuspid and pulmonary regurgitations following TOF repair.The interventional strategy could be an alternative for patients with poor general health.展开更多
BACKGROUND Mitral regurgitation(MR)is commonly seen in patients with severe aortic stenosis(AS)undergoing aortic valve replacement(AVR).But the long-term implications of MR in AS are unknown.AIM To investigate MR’s i...BACKGROUND Mitral regurgitation(MR)is commonly seen in patients with severe aortic stenosis(AS)undergoing aortic valve replacement(AVR).But the long-term implications of MR in AS are unknown.AIM To investigate MR’s impact on survival of patients undergoing surgical AVR for severe AS.METHODS Of the 740 consecutive patients with severe AS evaluated between 1993 and 2003,287 underwent AVR forming the study cohort.They were followed up to death or till the end of 2019.Chart reviews were performed for clinical,echocardiographic,and therapeutic data.MR was graded on a 1-4 scale.Mortality data was obtained from chart review and the Social Security Death Index.Survival was analyzed as a function of degree of MR.RESULTS The mean age of the severe AS patients who had AVR(n=287)was 72±13 years,46%women.Over up to 26 years of follow up,there were 201(70%)deaths,giving deep insights into the determinants of survival of severe AS who had AVR.The 5,10 and 20 years survival rates were 75%,45%and 25%respectively.Presence of MR was associated with higher mortality in a graded fashion(P=0.0003).MR was significantly associated with lower left ventricular(LV)ejection fraction and larger LV size.Impact of MR on mortality was partially mediated through lower LV ejection fraction and larger LV size.By Cox regression,MR,lower ejection fraction(EF)and larger LV end-systolic dimension were independent predictors of higher mortality(χ^(2)=33.2).CONCLUSION Presence of greater than 2+MR in patients with severe AS is independently associated with reduced survival in surgically managed patients,an effect incremental to reduced EF and larger LV size.We suggest that aortic valve intervention should be considered in severe AS patients when>2+MR occurs irrespective of EF or symptoms.展开更多
Background: Isolated tricuspid valve disease remains a controversial indication for surgical intervention. Many patients referred for surgery already have a poor clinical condition and an advanced New York Heart Assoc...Background: Isolated tricuspid valve disease remains a controversial indication for surgical intervention. Many patients referred for surgery already have a poor clinical condition and an advanced New York Heart Association functional class. There is no consensus on the optimal surgical technique for this condition, including on whether to perform the procedure on a beating or an arrested heart and whether to perform valve repair or replacement. Methods: We analyzed four case series between 2015 and 2022 in which patients with secondary tricuspid regurgitation (TR) underwent valve repair on a beating heart and right atrial plication for a dilated right atrium. The TRI-SCORE was calculated for each patient. Results: All patients experienced a favorable postoperative course with significant improvements in heart failure symptoms. TR was markedly reduced;however, in one patient with concomitant mitral regurgitation (MR) and a high TRI-SCORE, MR worsened postoperatively. This patient later died from unknown causes due to multiple comorbidities in the late phase. Conclusions: Tricuspid valve repair on a beating heart was effective for improving the cardiac function, and the TRI-SCORE proved useful as a preoperative risk assessment tool. The underlying mechanism by which TR exacerbates MR requires further investigation.展开更多
Functional mitral regurgitation is a common finding among heart failure patients with ischemic and non-ischemic dilated cardiomyopathies.The presence of moderate or severe mitral regurgitation is associated with highe...Functional mitral regurgitation is a common finding among heart failure patients with ischemic and non-ischemic dilated cardiomyopathies.The presence of moderate or severe mitral regurgitation is associated with higher morbidity and mortality.Heart failure patients meeting electrocardiogram and left ventricle function criteria are good candidates for cardiac resynchronization therapy,which may reduce the degree of functional mitral regurgitation in the short and long term,specifically targeting myocardial dyssynchrony and inducing left ventricle reverse remodeling.In this article,we analyze data from the literature about predictors of mitral regurgitation improvement after cardiac resynchronization therapy implantation.展开更多
Objective:To evaluate the feasibility,safety and efficacy of transcathcter closure of ventricular septal defect(VSD)in patients with aortic valve prolapse(AVP)and mild aortic regurgitation(AR).Methods:Between January ...Objective:To evaluate the feasibility,safety and efficacy of transcathcter closure of ventricular septal defect(VSD)in patients with aortic valve prolapse(AVP)and mild aortic regurgitation(AR).Methods:Between January 2008 and July 2014,transcatheter closure of VSD was attempted in 65 patients.Results:The total intermediate closure successful rate in all subjects was 96.9%.During the perioperative period,no death,major bleeding,pericardial tamponade,occluder dislodgement,residual shunt or hemolysis occurred.Two procedures had been forced to suspend due to significant aggregation of device related aortic regurgitation,three cases of transient complete left bundle branch block occurred but did not sustain.At 1-year followup,no patients had residual shunts and complications.Furthermore,grade of residual AR were relieved in 61.9%(39/63)cases and degree of AVP were ameliorated in 36.5%(23/63)patients;Conclusions:Transcatheter closure VSD in selected patients with AVP and mild AR is technically feasible and highly effective.Long term safety and efficacy needs to be assessed.展开更多
AIM:To investigate the prevalence of clinically unrecognized mitral regurgitation(MR) in lone atrial fibrillation(AF).METHODS:We studied the prevalence and severity of MR by transesophageal echocardiography(TEE) in pa...AIM:To investigate the prevalence of clinically unrecognized mitral regurgitation(MR) in lone atrial fibrillation(AF).METHODS:We studied the prevalence and severity of MR by transesophageal echocardiography(TEE) in patients with "lone" AF as compared to a matched cohort of patients in normal sinus rhythm(NSR) undergoing TEE for other indications besides recognized valvular heart disease.RESULTS:A total of 157 subjects(57 in the AF group and 100 in the NSR group) with structurally normal cardiac valves were included in the study.In the AF group,moderate MR or more was noted in 66% of thepatients,mild MR in 18%,trace or no MR in 16%.In the control group,moderate MR was noted in 6% of patients,mild MR 31%,trace or no MR in 63 % of patients.Moderate MR or greater was significantly more prevalent in the AF group compared to the NSR group(66% vs 6%,P < 0.0001).CONCLUSION:Clinically unrecognized moderate MR is prevalent in "lone" AF-either as an etiologic factor leading to "lone" AF or developing after onset of AF.展开更多
Ischemic mitral regurgitation(IMR) represents a common complication after myocardial infarction. The valve is anatomically normal and the incompetence is the result of papillary muscles displacement and annular dilata...Ischemic mitral regurgitation(IMR) represents a common complication after myocardial infarction. The valve is anatomically normal and the incompetence is the result of papillary muscles displacement and annular dilatation, causing leaflets tethering. Functionally the leaflets present a restricted systolic motion due to tethering forces that displaces the coaptation surface toward the left ventricle apex. The patients present poor left ventricular function at the time of surgery and the severity of the mitral regurgitation increases the risk of mortality. Currently there is general agreement to treat surgically severe IMR nevertheless strong evidences for patient with moderate insufficiency remains poor and proper treatment debated. The most effectivesurgical approach for the treatment of IMR remains debated. Some authors demonstrated that coronary artery bypass graft(CABG) alone is beneficial in patients with IMR. Conversely, in most patients, moderate IMR will persist or worsen after CABG alone which translate in higher long-term mortality as a function of residual mitral regurgitation severity. A probable reason for this unclear surgical management of functional MR is due to the contemporary suboptimal results of reparative techniques. The standard surgical treatment of chronic IMR is CABG associated with undersized annuloplasty using complete ring. Though, the recurrence of mitral regurgitation remains high(> 30%) because of continous left ventricle remodeling. To get better long term results, in the last decade, several subvalvular procedures in adjunct to mitral anuloplasty have been developed. Among them, surgical papillary muscle relocation represents the most appreciated option capable to restore normal left ventricle geometry. In the next future new preoperative predictors of increased mitral regurgitation recurrence are certainly needed to find an individual time period of treatment in each patient with moderate IMR.展开更多
Chronic ischemic mitral valve regurgitation is a result of disturbed left ventricular geometry secondary to myocardial ischemia in the absence of intrinsic mitral valve pathology. It is a common complication after myo...Chronic ischemic mitral valve regurgitation is a result of disturbed left ventricular geometry secondary to myocardial ischemia in the absence of intrinsic mitral valve pathology. It is a common complication after myocardial infarction, and patients who have ischemic mitral regurgitation(IMR) have a worse prognosis compared to patients who have ischemic heart disease alone, and this is directly related to the severity of IMR. Medical therapy has limited efficacy, and surgical options including various repair techniques and valve replacement had been tried with variable success. Still there is intense debate among surgeons whether to interfere with moderate degree IMR at the time of coronary artery revascularization.展开更多
Chronic functional mitral regurgitation(FMR) is a frequent finding of ischemic heart disease and dilated cardiomyopathy(DCM), associated with unfavourable prognosis. Several pathophysiologic mechanisms are involved in...Chronic functional mitral regurgitation(FMR) is a frequent finding of ischemic heart disease and dilated cardiomyopathy(DCM), associated with unfavourable prognosis. Several pathophysiologic mechanisms are involved in FMR, such as annular dilatation and dysfunction, left ventricle(LV) remodeling, dysfunction and dyssynchrony, papillary muscles displacement and dyssynchrony. The best therapeutic choice for FMR is still debated. When optimal medical treatment has already been set, a further option for cardiac resynchronization therapy(CRT) and/or surgical correction should be considered. CRT is able to contrast most of the pathophysiologic determinants of FMR by minimizing LV dyssynchrony through different mechanisms: Increasing closing forces, reducing tethering forces, reshaping annular geometry and function, correcting diastolic MR. Deformation imaging in terms of two-dimensional speckle tracking has been validated for LV dyssynchrony assessment. Radial speckle tracking and three-dimensional strain analysis appear to be the best methods to quantify intraventricular delay and to predict CRT-responders. Speckle-tracking echocardiography in patients with mitral valve regurgitation has been usually proposed for the assessment of LV and left atrial function. However it has also revealed a fundamental role of intraventricular dyssynchrony in determining FMR especially in DCM, rather than in ischemic cardiomyopathy in which MR severity seems to be more related to mitral valve deformation indexes. Furthermore speckle tracking allows the assessment of papillary muscle dyssynchrony. Therefore this technique can help to identify optimal candidates to CRT that will probably demonstrate a reduction in FMR degree and thus will experience a better outcome.展开更多
BACKGROUND Transcatheter aortic valve replacement(TAVR)is recommended in patients with severe aortic stenosis who have high surgical risk.However,in the pre-existing mechanical mitral valve prosthesis and natural pure...BACKGROUND Transcatheter aortic valve replacement(TAVR)is recommended in patients with severe aortic stenosis who have high surgical risk.However,in the pre-existing mechanical mitral valve prosthesis and natural pure aortic regurgitation,TAVR is relatively contraindicated.In this report,we described one case of TAVR with native aortic regurgitation in the presence of mechanical mitral valve prosthesis.CASE SUMMARY A 64-year-old man with a medical history of mitral valve replacement had severe dyspnea and was symptomatic even at rest for 3 mo.His echocardiography showed severe native pure aortic regurgitation.His euroscore was 15.A TAVR procedure with an evolut R was planned.A 34 mm evolut R was placed by transesophageal echocardiography.The mitral prosthesis was functioning normally,and mild-moderate paravalvular leakage was evident by transesophageal echocardiography.The patient recovered without any complication.At 1 mo follow up,the patient was well,and no paravalvular leakage was noted.CONCLUSION TAVR for pure aortic regurgitation in the presence of prosthetic mitral valve can be a safe procedure.展开更多
Objective To establish the mitral regurgitation swine model and study the change of hydrogen sulfide(H2S)system in chronic heart failure model.Methods Miniature pigs were randomly divided into two groups,the control g...Objective To establish the mitral regurgitation swine model and study the change of hydrogen sulfide(H2S)system in chronic heart failure model.Methods Miniature pigs were randomly divided into two groups,the control group(n=6)and mitral regurgitation group(n=6).Chronic heart failure models were established by pulling mitral chordal through a small incision extracorporeal.展开更多
Many patients with left ventricular systolic dysfunction have concomitant mitral regurgitation(MR). Their symptoms and prognosis worsen with increasing severity of MR. Percutaneous Mitra Clip® can be used saf...Many patients with left ventricular systolic dysfunction have concomitant mitral regurgitation(MR). Their symptoms and prognosis worsen with increasing severity of MR. Percutaneous Mitra Clip® can be used safely to reduce the severity of MR even in patients with advanced heart failure and is associated with improved symptoms, quality of life and exercise tolerance. However, a few patients with very poor left ventricular systolic function may experience significant haemodynamic disturbance in the peri-procedural period. We present three such patients, highlighting some of the potential problems encountered and discuss their possible pathophysiological mechanisms and safety measures.展开更多
Cardiovascular implantable electronic devices(CIEDs)are widely used in the modern era.Every year,about 730,000 permanent pacemakers and 330,000 CIEDs are implanted worldwide.CIEDs have been known to increase the life ...Cardiovascular implantable electronic devices(CIEDs)are widely used in the modern era.Every year,about 730,000 permanent pacemakers and 330,000 CIEDs are implanted worldwide.CIEDs have been known to increase the life expectancy of millions of people and improve their quality of life by controlling the heart rate and atrioventricular and interventricular synchronization and preventing sudden cardiac death.[1]The tricuspid valve consists of the annulus,leaflets,chordae tendineae,and papillary muscles.Interaction between the endocardial lead and any component of this structure can lead to tricuspid valve dysfunction,thereby resulting in tricuspid regurgitation(TR).[2]CIED-related TR has been shown to be an independent predictor of hospitalization for heart failure.[3,4]展开更多
A 57-year-old man reported experiencing dyspnea after walking 100 feet that has been progressing despite medical therapy.He has two-pillow orthopnea and occasional nighttime dyspnea but no angina.He had an anterior my...A 57-year-old man reported experiencing dyspnea after walking 100 feet that has been progressing despite medical therapy.He has two-pillow orthopnea and occasional nighttime dyspnea but no angina.He had an anterior myocardial infarction 5 years previously but did not seek medical care until 2 days after the event.Viability studies demonstrated only limited anterior wall viability.– Electrocardiogram:sinus rhythm with left bundle branch block.– Medications:furosemide,120 mg twice daily;metolazone,5 mg every other day;carvedilol,25 mg twice daily;lisinopril,40 mg daily;spironolactone,25 mg daily.展开更多
In primary mitral regurgitation there are anatomic abnormalities of the mitral valve causing backward fl ow,placing a hemodynamic burden on the left ventricle.If this burden is severe and prolonged,it leads to left ve...In primary mitral regurgitation there are anatomic abnormalities of the mitral valve causing backward fl ow,placing a hemodynamic burden on the left ventricle.If this burden is severe and prolonged,it leads to left ventricular damage,heart failure,and death.The preferred therapy is restoration of mitral competence through mitral valve repair,which is safer than mitral valve replacement.When repair is performed in a timely fashion,lifespan can be returned to that of a normal individual.Triggers for timely repair include the onset of symptoms and evidence of left ventricular dysfunction as determined by ejection fraction falling toward 60%and/or end-systolic dimension increasing toward 40 mm.展开更多
Management of rheumatic mitral regurgitation in a woman contemplating pregnancy presents unique challenges for the clinician.When tasked with taking care of this type of patient,attention needs to be paid to the pati...Management of rheumatic mitral regurgitation in a woman contemplating pregnancy presents unique challenges for the clinician.When tasked with taking care of this type of patient,attention needs to be paid to the patient’s functional status to determine if symptoms are present.In addition to this clinical assessment,transthoracic echocardiography is also critical.It provides insight into the etiology of the mitral regurgitation,assesses for the presence of concomitant mitral stenosis or other valvular abnormalities,characterizes the severity of mitral regurgitation through an integrative approach and identifi es high risk findings including progressive left ventricular(LV)dilation and LV dysfunction.Surgical intervention is recommended for symptomatic patients and in asymptomatic patients with evidence of progressive LV dilation and a LV ejection fraction of less than 60%.While the presence of pulmonary hypertension and atrial fi brillation have been shown to be risk factors in degenerative mitral regurgitation,the same has not been demonstrated in rheumatic mitral valve disease.While mitral regurgitation may be reasonably well tolerated during pregnancy,symptomatic patients are at higher risk for adverse maternal and fetal outcomes,and therefore,it is recommended that mitral valve surgery be performed prior to pregnancy.Once the decision has been made to proceed to surgery,mitral repair,performed at a Heart Valve Center of Excellence is recommended if possible due to improved outcomes.Mitral valve repair is possible in>80%cases of rheumatic mitral regurgitation.If repair is not possible,replacement with either a bioprosthetic or mechanical valve are reasonable options.There are advantages and disadvantages to each approach and the choice of prosthesis should be a shared decision between the patient and her treatment team.展开更多
Functional tricuspid regurgitation(TR)primarily arises from asymmetric dilation of the tricuspid annulus in the setting of right ventricular dysfunction and enlargement in response to left-sided myocardial and valvula...Functional tricuspid regurgitation(TR)primarily arises from asymmetric dilation of the tricuspid annulus in the setting of right ventricular dysfunction and enlargement in response to left-sided myocardial and valvular abnormalities.Even if the TR is not severe at the time of mitral valve surgery,it can worsen and even appear late after successful mitral valve surgery,which portends a poor prognosis.Despite data demonstrating inferior outcomes in the presence of residual TR,surgical repair for functional TR remains underused.Acceptance of TR,in the presence of tricuspid annular dilation,may be unacceptable.Surgical repair should consist of placement of a rigid or semirigid annular ring,which has been shown to provide superior durability as compared with suture and flexible band techniques.Finally,percutaneous annuloplasty for correction of functional TR may allow treatment of patients with recurrent TR at high risk of reoperation.展开更多
The prevalence of tricuspid regurgitation(TR)increases with age,affecting 65%-85%of adults.Primary TR is caused by a congenital or acquired abnormality of the tricuspid valve apparatus(leaflets,chordae,papillary muscl...The prevalence of tricuspid regurgitation(TR)increases with age,affecting 65%-85%of adults.Primary TR is caused by a congenital or acquired abnormality of the tricuspid valve apparatus(leaflets,chordae,papillary muscles,or annulus).Secondary TR is due to insufficient coaptation from dilation of tricuspid valve annulus due to the right ventricle(RV)or right at-rium(RA)remodeling and increased RV pressures.Isolated TR is without increased RV pressures and is associated with atrial fibrillation.Mild TR is a benign disease.Moderate to severe tricuspid regurgitation has independently been associated with in-creased mortality.Most of these patients are treated medically due to poor outcomes with surgical repair of isolated TR.The in-hospital mortality rate is 8.8%,and the median length of stay in hospital is 11 days resulting in higher healthcare costs.Even if the patients undergo surgical repair or replacement,available data do not show improvement in survival.With a more detailed un-derstanding of the complex anatomy and physiology of the tricuspid valve and significant complications from untreated tricusp-id valve disease,the approach to the management of TR has shifted from a conservative approach to a process of prevention and intervention.In the past decade,transcatheter tricuspid valve interventions and tricuspid annuloplasty rings have been de-veloped,contributing to decreased mortality from surgical repair.Transcatheter tricuspid valve intervention techniques have im-proved survival,quality of life,and reduced heart failure rehospitalization.This review summarizes normal anatomy,types of TR,etiology and different mechanisms of TR,echocardiographic assessment of the severe TR,and highlights various percu-taneous transcatheter techniques for tricuspid valve repair.展开更多
BACKGROUND Infective endocarditis(IE)is an uncommon but potentially life-threatening infection,which occasionally develops into acute severe valve insufficiency leading to the onset of heart failure,and necessitates t...BACKGROUND Infective endocarditis(IE)is an uncommon but potentially life-threatening infection,which occasionally develops into acute severe valve insufficiency leading to the onset of heart failure,and necessitates timely intervention.However,the variable and atypical clinical manifestations always make the early detection of IE difficult and challenging.CASE SUMMARY A 45-year-old female who was previously healthy presented with exertional shortness of breath and paroxysmal nocturnal dyspnea.She also suffered from a significant decrease in exercise capacity,whereas her body temperature was normal.She had severe hypoxemia and hypotension along with a marked aortic valve murmur.Diffuse pulmonary edema and bilateral pleural effusion were observed on both chest X-ray and computed tomography scan.Transthoracic echocardiography was performed immediately and revealed severe regurgitation of the bicuspid aortic valve.Transesophageal echocardiography was further performed and vegetations were detected.In addition to adequate medical therapy and ventilation support,the patient underwent urgent and successful aortic valve replacement.Her symptoms were significantly relieved and the postoperative chest X-ray showed that pulmonary edema was significantly reduced.Histopathology of the resected valve and positive microorganism culture of the surgical specimen provided evidence of definite IE.CONCLUSION IE should be considered in critical patients with refractory heart failure caused by severe bicuspid aortic valve regurgitation.展开更多
AIM To investigate one-year outcomes after percutaneous mitral valve repair with Mitra Clip~? in patients with severe mitral regurgitation(MR). METHODS Our study investigated consecutive patients with symptomatic seve...AIM To investigate one-year outcomes after percutaneous mitral valve repair with Mitra Clip~? in patients with severe mitral regurgitation(MR). METHODS Our study investigated consecutive patients with symptomatic severe MR who underwent Mitra Clip~?implantation at the University Hospital Bergmannsheil from 2012 to 2014. The primary study end-point was all-cause mortality. Secondary end-points were degree of MR and functional status after percutaneous mitral valve repair.RESULTS The study population consisted of 46 consecutive patients(mean logistic Euro SCORE 32% ± 21%). The degree of MR decreased significantly(severe MR before Mitra Clip~? 100% vs after Mitra Clip~? 13%; P < 0.001),and the NYHA functional classes improved(NYHA III/IV before Mitra Clip~? 98% vs after Mitra Clip~? 35%; P < 0.001). The mortality rates 30 d and one year after percutaneous mitral valve repair were 4.3% and 19.5%,respectively. During the follow-up of 473 ± 274 d,11 patients died(90% due to cardiovascular death). A preprocedural plasma B-type natriuretic peptide level > 817 pg/m L was associated with all-cause mortality(hazard ratio,6.074; 95%CI: 1.257-29.239; P = 0.012).CONCLUSION Percutaneous mitral valve repair with Mitra Clip~? has positive effects on hemodynamics and symptoms. Despite the study patients' multiple comorbidities and extremely high operative risk,one-year outcomes after Mitra Clip~? are favorable. Elevated B-type natriuretic peptide levels indicate poorer mid-term survival.展开更多
文摘BACKGROUND Tetralogy of Fallot(TOF)is one of the most common congenital heart defects,and surgery is the primary treatment.There are no precise guidelines on the treatment protocol for tricuspid regurgitation(TR)as a common complication of TOF repair.The timing for treatment in patients presenting with valve regurgitation after TOF repair is often difficult to determine.Here,we report the first case of sequential treatment of pulmonary and TR using interventional therapy.CASE SUMMARY We present the case of a 52-year-old female patient,who had a history of TOF repair at a young age.A few years later,the patient presented with pulmonary and tricuspid regurgitation.The symptoms persisted and TR worsened following percutaneous pulmonary valve implantation.Preoperative testing revealed that the patient’s disease had advanced to an intermediate to advanced stage and that her general health was precarious.Because open-heart surgery was not an option for the patient,transcatheter tricuspid valve replacement was suggested.This procedure was successful,and the patient recovered fully without any adverse effects.This case report may serve as a useful resource for planning future treatments.CONCLUSION Treatment of both valves should be considered in patients with tricuspid and pulmonary regurgitations following TOF repair.The interventional strategy could be an alternative for patients with poor general health.
文摘BACKGROUND Mitral regurgitation(MR)is commonly seen in patients with severe aortic stenosis(AS)undergoing aortic valve replacement(AVR).But the long-term implications of MR in AS are unknown.AIM To investigate MR’s impact on survival of patients undergoing surgical AVR for severe AS.METHODS Of the 740 consecutive patients with severe AS evaluated between 1993 and 2003,287 underwent AVR forming the study cohort.They were followed up to death or till the end of 2019.Chart reviews were performed for clinical,echocardiographic,and therapeutic data.MR was graded on a 1-4 scale.Mortality data was obtained from chart review and the Social Security Death Index.Survival was analyzed as a function of degree of MR.RESULTS The mean age of the severe AS patients who had AVR(n=287)was 72±13 years,46%women.Over up to 26 years of follow up,there were 201(70%)deaths,giving deep insights into the determinants of survival of severe AS who had AVR.The 5,10 and 20 years survival rates were 75%,45%and 25%respectively.Presence of MR was associated with higher mortality in a graded fashion(P=0.0003).MR was significantly associated with lower left ventricular(LV)ejection fraction and larger LV size.Impact of MR on mortality was partially mediated through lower LV ejection fraction and larger LV size.By Cox regression,MR,lower ejection fraction(EF)and larger LV end-systolic dimension were independent predictors of higher mortality(χ^(2)=33.2).CONCLUSION Presence of greater than 2+MR in patients with severe AS is independently associated with reduced survival in surgically managed patients,an effect incremental to reduced EF and larger LV size.We suggest that aortic valve intervention should be considered in severe AS patients when>2+MR occurs irrespective of EF or symptoms.
文摘Background: Isolated tricuspid valve disease remains a controversial indication for surgical intervention. Many patients referred for surgery already have a poor clinical condition and an advanced New York Heart Association functional class. There is no consensus on the optimal surgical technique for this condition, including on whether to perform the procedure on a beating or an arrested heart and whether to perform valve repair or replacement. Methods: We analyzed four case series between 2015 and 2022 in which patients with secondary tricuspid regurgitation (TR) underwent valve repair on a beating heart and right atrial plication for a dilated right atrium. The TRI-SCORE was calculated for each patient. Results: All patients experienced a favorable postoperative course with significant improvements in heart failure symptoms. TR was markedly reduced;however, in one patient with concomitant mitral regurgitation (MR) and a high TRI-SCORE, MR worsened postoperatively. This patient later died from unknown causes due to multiple comorbidities in the late phase. Conclusions: Tricuspid valve repair on a beating heart was effective for improving the cardiac function, and the TRI-SCORE proved useful as a preoperative risk assessment tool. The underlying mechanism by which TR exacerbates MR requires further investigation.
文摘Functional mitral regurgitation is a common finding among heart failure patients with ischemic and non-ischemic dilated cardiomyopathies.The presence of moderate or severe mitral regurgitation is associated with higher morbidity and mortality.Heart failure patients meeting electrocardiogram and left ventricle function criteria are good candidates for cardiac resynchronization therapy,which may reduce the degree of functional mitral regurgitation in the short and long term,specifically targeting myocardial dyssynchrony and inducing left ventricle reverse remodeling.In this article,we analyze data from the literature about predictors of mitral regurgitation improvement after cardiac resynchronization therapy implantation.
基金supported by National Nature Science Foundation of China(NO.81260052)Science and Technology Planning Project of Hainan Province of China(NO.812147)
文摘Objective:To evaluate the feasibility,safety and efficacy of transcathcter closure of ventricular septal defect(VSD)in patients with aortic valve prolapse(AVP)and mild aortic regurgitation(AR).Methods:Between January 2008 and July 2014,transcatheter closure of VSD was attempted in 65 patients.Results:The total intermediate closure successful rate in all subjects was 96.9%.During the perioperative period,no death,major bleeding,pericardial tamponade,occluder dislodgement,residual shunt or hemolysis occurred.Two procedures had been forced to suspend due to significant aggregation of device related aortic regurgitation,three cases of transient complete left bundle branch block occurred but did not sustain.At 1-year followup,no patients had residual shunts and complications.Furthermore,grade of residual AR were relieved in 61.9%(39/63)cases and degree of AVP were ameliorated in 36.5%(23/63)patients;Conclusions:Transcatheter closure VSD in selected patients with AVP and mild AR is technically feasible and highly effective.Long term safety and efficacy needs to be assessed.
文摘AIM:To investigate the prevalence of clinically unrecognized mitral regurgitation(MR) in lone atrial fibrillation(AF).METHODS:We studied the prevalence and severity of MR by transesophageal echocardiography(TEE) in patients with "lone" AF as compared to a matched cohort of patients in normal sinus rhythm(NSR) undergoing TEE for other indications besides recognized valvular heart disease.RESULTS:A total of 157 subjects(57 in the AF group and 100 in the NSR group) with structurally normal cardiac valves were included in the study.In the AF group,moderate MR or more was noted in 66% of thepatients,mild MR in 18%,trace or no MR in 16%.In the control group,moderate MR was noted in 6% of patients,mild MR 31%,trace or no MR in 63 % of patients.Moderate MR or greater was significantly more prevalent in the AF group compared to the NSR group(66% vs 6%,P < 0.0001).CONCLUSION:Clinically unrecognized moderate MR is prevalent in "lone" AF-either as an etiologic factor leading to "lone" AF or developing after onset of AF.
文摘Ischemic mitral regurgitation(IMR) represents a common complication after myocardial infarction. The valve is anatomically normal and the incompetence is the result of papillary muscles displacement and annular dilatation, causing leaflets tethering. Functionally the leaflets present a restricted systolic motion due to tethering forces that displaces the coaptation surface toward the left ventricle apex. The patients present poor left ventricular function at the time of surgery and the severity of the mitral regurgitation increases the risk of mortality. Currently there is general agreement to treat surgically severe IMR nevertheless strong evidences for patient with moderate insufficiency remains poor and proper treatment debated. The most effectivesurgical approach for the treatment of IMR remains debated. Some authors demonstrated that coronary artery bypass graft(CABG) alone is beneficial in patients with IMR. Conversely, in most patients, moderate IMR will persist or worsen after CABG alone which translate in higher long-term mortality as a function of residual mitral regurgitation severity. A probable reason for this unclear surgical management of functional MR is due to the contemporary suboptimal results of reparative techniques. The standard surgical treatment of chronic IMR is CABG associated with undersized annuloplasty using complete ring. Though, the recurrence of mitral regurgitation remains high(> 30%) because of continous left ventricle remodeling. To get better long term results, in the last decade, several subvalvular procedures in adjunct to mitral anuloplasty have been developed. Among them, surgical papillary muscle relocation represents the most appreciated option capable to restore normal left ventricle geometry. In the next future new preoperative predictors of increased mitral regurgitation recurrence are certainly needed to find an individual time period of treatment in each patient with moderate IMR.
文摘Chronic ischemic mitral valve regurgitation is a result of disturbed left ventricular geometry secondary to myocardial ischemia in the absence of intrinsic mitral valve pathology. It is a common complication after myocardial infarction, and patients who have ischemic mitral regurgitation(IMR) have a worse prognosis compared to patients who have ischemic heart disease alone, and this is directly related to the severity of IMR. Medical therapy has limited efficacy, and surgical options including various repair techniques and valve replacement had been tried with variable success. Still there is intense debate among surgeons whether to interfere with moderate degree IMR at the time of coronary artery revascularization.
文摘Chronic functional mitral regurgitation(FMR) is a frequent finding of ischemic heart disease and dilated cardiomyopathy(DCM), associated with unfavourable prognosis. Several pathophysiologic mechanisms are involved in FMR, such as annular dilatation and dysfunction, left ventricle(LV) remodeling, dysfunction and dyssynchrony, papillary muscles displacement and dyssynchrony. The best therapeutic choice for FMR is still debated. When optimal medical treatment has already been set, a further option for cardiac resynchronization therapy(CRT) and/or surgical correction should be considered. CRT is able to contrast most of the pathophysiologic determinants of FMR by minimizing LV dyssynchrony through different mechanisms: Increasing closing forces, reducing tethering forces, reshaping annular geometry and function, correcting diastolic MR. Deformation imaging in terms of two-dimensional speckle tracking has been validated for LV dyssynchrony assessment. Radial speckle tracking and three-dimensional strain analysis appear to be the best methods to quantify intraventricular delay and to predict CRT-responders. Speckle-tracking echocardiography in patients with mitral valve regurgitation has been usually proposed for the assessment of LV and left atrial function. However it has also revealed a fundamental role of intraventricular dyssynchrony in determining FMR especially in DCM, rather than in ischemic cardiomyopathy in which MR severity seems to be more related to mitral valve deformation indexes. Furthermore speckle tracking allows the assessment of papillary muscle dyssynchrony. Therefore this technique can help to identify optimal candidates to CRT that will probably demonstrate a reduction in FMR degree and thus will experience a better outcome.
文摘BACKGROUND Transcatheter aortic valve replacement(TAVR)is recommended in patients with severe aortic stenosis who have high surgical risk.However,in the pre-existing mechanical mitral valve prosthesis and natural pure aortic regurgitation,TAVR is relatively contraindicated.In this report,we described one case of TAVR with native aortic regurgitation in the presence of mechanical mitral valve prosthesis.CASE SUMMARY A 64-year-old man with a medical history of mitral valve replacement had severe dyspnea and was symptomatic even at rest for 3 mo.His echocardiography showed severe native pure aortic regurgitation.His euroscore was 15.A TAVR procedure with an evolut R was planned.A 34 mm evolut R was placed by transesophageal echocardiography.The mitral prosthesis was functioning normally,and mild-moderate paravalvular leakage was evident by transesophageal echocardiography.The patient recovered without any complication.At 1 mo follow up,the patient was well,and no paravalvular leakage was noted.CONCLUSION TAVR for pure aortic regurgitation in the presence of prosthetic mitral valve can be a safe procedure.
文摘Objective To establish the mitral regurgitation swine model and study the change of hydrogen sulfide(H2S)system in chronic heart failure model.Methods Miniature pigs were randomly divided into two groups,the control group(n=6)and mitral regurgitation group(n=6).Chronic heart failure models were established by pulling mitral chordal through a small incision extracorporeal.
文摘Many patients with left ventricular systolic dysfunction have concomitant mitral regurgitation(MR). Their symptoms and prognosis worsen with increasing severity of MR. Percutaneous Mitra Clip® can be used safely to reduce the severity of MR even in patients with advanced heart failure and is associated with improved symptoms, quality of life and exercise tolerance. However, a few patients with very poor left ventricular systolic function may experience significant haemodynamic disturbance in the peri-procedural period. We present three such patients, highlighting some of the potential problems encountered and discuss their possible pathophysiological mechanisms and safety measures.
基金This work was supported by grants from the Planned Science and Technology Project of Zhejiang Province,China(2020KY216)Hangzhou City Health Science and Technique Program(OO20190126).
文摘Cardiovascular implantable electronic devices(CIEDs)are widely used in the modern era.Every year,about 730,000 permanent pacemakers and 330,000 CIEDs are implanted worldwide.CIEDs have been known to increase the life expectancy of millions of people and improve their quality of life by controlling the heart rate and atrioventricular and interventricular synchronization and preventing sudden cardiac death.[1]The tricuspid valve consists of the annulus,leaflets,chordae tendineae,and papillary muscles.Interaction between the endocardial lead and any component of this structure can lead to tricuspid valve dysfunction,thereby resulting in tricuspid regurgitation(TR).[2]CIED-related TR has been shown to be an independent predictor of hospitalization for heart failure.[3,4]
文摘A 57-year-old man reported experiencing dyspnea after walking 100 feet that has been progressing despite medical therapy.He has two-pillow orthopnea and occasional nighttime dyspnea but no angina.He had an anterior myocardial infarction 5 years previously but did not seek medical care until 2 days after the event.Viability studies demonstrated only limited anterior wall viability.– Electrocardiogram:sinus rhythm with left bundle branch block.– Medications:furosemide,120 mg twice daily;metolazone,5 mg every other day;carvedilol,25 mg twice daily;lisinopril,40 mg daily;spironolactone,25 mg daily.
文摘In primary mitral regurgitation there are anatomic abnormalities of the mitral valve causing backward fl ow,placing a hemodynamic burden on the left ventricle.If this burden is severe and prolonged,it leads to left ventricular damage,heart failure,and death.The preferred therapy is restoration of mitral competence through mitral valve repair,which is safer than mitral valve replacement.When repair is performed in a timely fashion,lifespan can be returned to that of a normal individual.Triggers for timely repair include the onset of symptoms and evidence of left ventricular dysfunction as determined by ejection fraction falling toward 60%and/or end-systolic dimension increasing toward 40 mm.
文摘Management of rheumatic mitral regurgitation in a woman contemplating pregnancy presents unique challenges for the clinician.When tasked with taking care of this type of patient,attention needs to be paid to the patient’s functional status to determine if symptoms are present.In addition to this clinical assessment,transthoracic echocardiography is also critical.It provides insight into the etiology of the mitral regurgitation,assesses for the presence of concomitant mitral stenosis or other valvular abnormalities,characterizes the severity of mitral regurgitation through an integrative approach and identifi es high risk findings including progressive left ventricular(LV)dilation and LV dysfunction.Surgical intervention is recommended for symptomatic patients and in asymptomatic patients with evidence of progressive LV dilation and a LV ejection fraction of less than 60%.While the presence of pulmonary hypertension and atrial fi brillation have been shown to be risk factors in degenerative mitral regurgitation,the same has not been demonstrated in rheumatic mitral valve disease.While mitral regurgitation may be reasonably well tolerated during pregnancy,symptomatic patients are at higher risk for adverse maternal and fetal outcomes,and therefore,it is recommended that mitral valve surgery be performed prior to pregnancy.Once the decision has been made to proceed to surgery,mitral repair,performed at a Heart Valve Center of Excellence is recommended if possible due to improved outcomes.Mitral valve repair is possible in>80%cases of rheumatic mitral regurgitation.If repair is not possible,replacement with either a bioprosthetic or mechanical valve are reasonable options.There are advantages and disadvantages to each approach and the choice of prosthesis should be a shared decision between the patient and her treatment team.
文摘Functional tricuspid regurgitation(TR)primarily arises from asymmetric dilation of the tricuspid annulus in the setting of right ventricular dysfunction and enlargement in response to left-sided myocardial and valvular abnormalities.Even if the TR is not severe at the time of mitral valve surgery,it can worsen and even appear late after successful mitral valve surgery,which portends a poor prognosis.Despite data demonstrating inferior outcomes in the presence of residual TR,surgical repair for functional TR remains underused.Acceptance of TR,in the presence of tricuspid annular dilation,may be unacceptable.Surgical repair should consist of placement of a rigid or semirigid annular ring,which has been shown to provide superior durability as compared with suture and flexible band techniques.Finally,percutaneous annuloplasty for correction of functional TR may allow treatment of patients with recurrent TR at high risk of reoperation.
文摘The prevalence of tricuspid regurgitation(TR)increases with age,affecting 65%-85%of adults.Primary TR is caused by a congenital or acquired abnormality of the tricuspid valve apparatus(leaflets,chordae,papillary muscles,or annulus).Secondary TR is due to insufficient coaptation from dilation of tricuspid valve annulus due to the right ventricle(RV)or right at-rium(RA)remodeling and increased RV pressures.Isolated TR is without increased RV pressures and is associated with atrial fibrillation.Mild TR is a benign disease.Moderate to severe tricuspid regurgitation has independently been associated with in-creased mortality.Most of these patients are treated medically due to poor outcomes with surgical repair of isolated TR.The in-hospital mortality rate is 8.8%,and the median length of stay in hospital is 11 days resulting in higher healthcare costs.Even if the patients undergo surgical repair or replacement,available data do not show improvement in survival.With a more detailed un-derstanding of the complex anatomy and physiology of the tricuspid valve and significant complications from untreated tricusp-id valve disease,the approach to the management of TR has shifted from a conservative approach to a process of prevention and intervention.In the past decade,transcatheter tricuspid valve interventions and tricuspid annuloplasty rings have been de-veloped,contributing to decreased mortality from surgical repair.Transcatheter tricuspid valve intervention techniques have im-proved survival,quality of life,and reduced heart failure rehospitalization.This review summarizes normal anatomy,types of TR,etiology and different mechanisms of TR,echocardiographic assessment of the severe TR,and highlights various percu-taneous transcatheter techniques for tricuspid valve repair.
基金Supported by National Key Research and Development Program of China,No.2016YFC1301105。
文摘BACKGROUND Infective endocarditis(IE)is an uncommon but potentially life-threatening infection,which occasionally develops into acute severe valve insufficiency leading to the onset of heart failure,and necessitates timely intervention.However,the variable and atypical clinical manifestations always make the early detection of IE difficult and challenging.CASE SUMMARY A 45-year-old female who was previously healthy presented with exertional shortness of breath and paroxysmal nocturnal dyspnea.She also suffered from a significant decrease in exercise capacity,whereas her body temperature was normal.She had severe hypoxemia and hypotension along with a marked aortic valve murmur.Diffuse pulmonary edema and bilateral pleural effusion were observed on both chest X-ray and computed tomography scan.Transthoracic echocardiography was performed immediately and revealed severe regurgitation of the bicuspid aortic valve.Transesophageal echocardiography was further performed and vegetations were detected.In addition to adequate medical therapy and ventilation support,the patient underwent urgent and successful aortic valve replacement.Her symptoms were significantly relieved and the postoperative chest X-ray showed that pulmonary edema was significantly reduced.Histopathology of the resected valve and positive microorganism culture of the surgical specimen provided evidence of definite IE.CONCLUSION IE should be considered in critical patients with refractory heart failure caused by severe bicuspid aortic valve regurgitation.
文摘AIM To investigate one-year outcomes after percutaneous mitral valve repair with Mitra Clip~? in patients with severe mitral regurgitation(MR). METHODS Our study investigated consecutive patients with symptomatic severe MR who underwent Mitra Clip~?implantation at the University Hospital Bergmannsheil from 2012 to 2014. The primary study end-point was all-cause mortality. Secondary end-points were degree of MR and functional status after percutaneous mitral valve repair.RESULTS The study population consisted of 46 consecutive patients(mean logistic Euro SCORE 32% ± 21%). The degree of MR decreased significantly(severe MR before Mitra Clip~? 100% vs after Mitra Clip~? 13%; P < 0.001),and the NYHA functional classes improved(NYHA III/IV before Mitra Clip~? 98% vs after Mitra Clip~? 35%; P < 0.001). The mortality rates 30 d and one year after percutaneous mitral valve repair were 4.3% and 19.5%,respectively. During the follow-up of 473 ± 274 d,11 patients died(90% due to cardiovascular death). A preprocedural plasma B-type natriuretic peptide level > 817 pg/m L was associated with all-cause mortality(hazard ratio,6.074; 95%CI: 1.257-29.239; P = 0.012).CONCLUSION Percutaneous mitral valve repair with Mitra Clip~? has positive effects on hemodynamics and symptoms. Despite the study patients' multiple comorbidities and extremely high operative risk,one-year outcomes after Mitra Clip~? are favorable. Elevated B-type natriuretic peptide levels indicate poorer mid-term survival.
