Mitral Valve Insufficiency / surgery

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Editorial

Mitral Regurgitation and Transcatheter Aortic Valve Replacement: Are There Any Other Prognostic Implications?

There is a variable prevalence of moderate to severe mitral regurgitation (13 to 74%) in patients with severe degenerative aortic stenosis.^– In elderly and frail patients, this association can generate clinical dilemmas in cardiological practice: should I submit my patient to combined valve surgery, exposing him to higher morbidity and mortality, or contemplate only the severe aortic stenosis with a less aggressive treatment represented by the transcatheter aortic valve replacement (TAVR)? The variable degrees of severity associated with the commonly functional etiology (up to 80%) of the associated mitral regurgitation, places aortic valve stenosis in a high prominent position at this clinical hierarchy, with a resultant predilection for performing TAVR in these scenarios. In fact, some studies showed an improvement in the mitral regurgitation severity after TAVR, especially in patients with functional etiology and without pulmonary hypertension or atrial fibrillation.^–

The impact of baseline mitral regurgitation on patients undergoing TAVR is still controversial. Toggweiler et al. found that moderate to severe baseline mitral regurgitation in patients undergoing TAVR was associated with higher early mortality rates (first 30 days), with no difference in late mortality. Conversely, Barbanti et al., using data from the randomized Placement of Aortic Transcatheter Valve (PARTNER) trial cohort A, found that moderate to severe baseline mitral regurgitation was associated with higher late mortality only in the surgical aortic valve replacement group, with no prognostic implication in the TAVR group.

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Editorial

Histopathological Characterization of Mitral Valvular Lesions in Patients With Rheumatic Heart Disease: Is Inflammation Also to Blame for Chronic Valvular Heart Disease Progression?

Vitor Emer Egypto Rosa

Rheumatic fever (RF) and rheumatic heart disease (RHD) remain highly prevalent, affecting approximately 40 million people, mostly in low- and middle-income countries, but also in select marginalized populations in higher-income countries.^, Brazilian data regarding RF prevalence is scarce mainly due to (a) difficulties in acute RF diagnosis, (b) cost of RHD screening and (c) the fact that reported data on surgery or death may represent RF incidence from 2 decades ago. The most feared consequence of RF is valvular heart disease, which leads to a worsening in the quality of life, hospitalizations and need for surgical procedure, primarily in young people.^, Therefore, there is an urgent need to better understand the factors that influence valvular heart disease (VHD) progression. In this context, Gomes et al. studied the histopathological changes in mitral valves of patients with RHD undergoing mitral valve replacement.

Inflammation in one of the key components of VHD in patients with RF. In the acute stage of infection, the histopathological findings are the presence of dense valvular inflammatory infiltrates and Aschoff nodules, characterized as collagen fibrinoid degeneration surrounded by lymphocytes, macrophages, giant cells, plasma cells, and palisades of fibroblasts.^– Chronic RHD usually presents with cuspid calcification, fibrosis and commissural fusion. However, the role of inflammation in chronic VHD is still under study.

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Editorial

Mitral Valve Repair in Young Rheumatic Patients

Pablo Maria Alberto Pomerantzeff

Mitral valve repair surgery presents excellent immediate and late results in young patients with valve disease resulting from chronic rheumatic heart disease such as those reported in the article by Cruz et al. in this issue.

There is agreement in the literature on the lower morbidity and mortality of patients submitted to mitral repair surgery in relation to valve replacement, but there is no uniformity of results of mitral valve reconstruction in patients with lesions resulting from rheumatic fever, perhaps, due to the recurrence of new rheumatic episodes in the evolution of these patients.

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Original Article

Predictors of Unfavourable Outcomes in Children and Adolescents Submitted to Surgical Mitral Valvuloplasty Secondary to Chronic Rheumatic Heart Disease

Renata Cristina Castro Cruz et al. Bruna Silva Cordeiro Felipe de Souza Santos Caroline Rodrigues Fernandes … Julia Maria Alves Gama Ana Marice Teixeira Ladeia

Abstract

Background:

Mitral valve repair in paediatric patients with chronic rheumatic heart disease is superior to valve replacement and has been used with good results.

Objective:

To identify predictors of unfavourable outcomes in children and adolescents submitted to surgical mitral valvuloplasty secondary to rheumatic heart disease.

Methods:

Retrospective study of 54 patients under the age of 16 operated at a tertiary paediatric hospital between March 2011 and January 2017. The predictors of risk for unfavourable outcomes were: age, ejection fraction, degree of mitral insufficiency, degree of pulmonary hypertension, presence of tricuspid insufficiency, left chamber dilation, preoperative functional classification, duration of cardiopulmonary bypass, duration of anoxia, presence of atrial fibrillation, and duration of vasoactive drug use. The outcomes evaluated were: death, congestive heart failure, reoperation, residual mitral regurgitation, residual mitral stenosis, stroke, bleeding and valve replacement. For all analyzes a value of p < 0.05 was established as significant.

Results:

Of the patients evaluated, 29 (53.7%) were female, with an average of 10.5 ± 3.2 years. The functional classification of 13 patients (25%) was 4. There was no death in the sample studied. The average duration of extracorporeal circulation was 62.7±17.8 min, and anoxia 50 ± 15.7 min. The duration of use of vasoactive drug in the immediate postoperative period has an average of 1 day (interquartile interval 1-2 days). The logistic regression model was used to evaluate the predictive variables for each unfavourable outcome. The duration of use of vasoactive drug was the only independent predictor for the outcomes studied (p = 0.007). Residual mitral insufficiency was associated with reoperation (p = 0.044), whereas tricuspid insufficiency (p = 0.012) and pulmonary hypertension (p = 0.012) were associated with the presence of unfavourable outcomes.

Conclusion:

The duration of vasoactive drug use is an independent predictor for unfavourable outcomes in the immediate and late postoperative period, while residual mitral regurgitation was associated with reoperation, and both tricuspid regurgitation and pulmonary hypertension were associated with unfavourable outcomes.

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Letter to the Editor

Recommendation of Early Surgery in Primary Mitral Regurgitation: Pros and Cons

Levent Cerit

To the Editor,

I have read the article entitled “Recommendation of Early Surgery in Primary Mitral Regurgitation: Pros and Cons” by Rosa et al. with great interest, recently published in Arquivos Brasileiros de Cardiologia 2016; 107: 173-5. The investigators reported that currently, the recommendation of mitral surgery for asymptomatic patients is very controversial, since the indication of valvular intervention for symptoms, left ventricular dysfunction and dilatation, recent onset atrial fibrillation or pulmonary arterial hypertension is well consolidated in literature.

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Clinicoradiological Session

Case 1/2017 – Percutaneous Repair of Right Atrioventricular Valve Insufficiency and Blalock-Taussig Shunt after Fontan Operation in Single Ventricle

Edmar Atik et al. Renata Sá Cassar Raul Arrieta

Clinical data

Twenty-seven-year old male patient reporting tiredness during exercise for three years, after total cavopulmonary connection with extracardiac conduit fenestration and closure with stiches of the free end of right atrioventricular valve (AV) for severe failure in double inlet left ventricle, pulmonary atresia, and aorta arising from rudimentary right ventricle. The patient had undergone right and left Blalock-Taussig shunts at 17 days and 9 months, respectively, and bidirectional Glenn shunt at 19 years old. The patient had arterial oxygen saturation of 84-88% during exercise and 93% at rest.

Physical exam: eupneic, cyanotic, normal pulse rate, with no jugular vein dilation. Weight: 61 Kg, Height: 163 cm, BP: 110/70 mm Hg, HR: 97 bpm, oxygen saturation = 87%. The aorta was palpable in the supra-sternal notch (grade 2).

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Case Report

Complicated Sinus of Valsalva Aneurysm Initially Diagnosed as Atrial Myxoma

Rafael Plens Teixeira et al. Pedro Felipe Gomes Nicz Felipe Lourenço Fernandes Renner Augusto Raposo Pereira … Roney Orismar Sampaio Flavio Tarasoutchi

Introduction

Atrial myxoma and sinus of Valsalva aneurysm (SVA) are rare conditions and possibly underdiagnosed in clinical practice. We report an unusual presentation of a left SVA after an episode of infective endocarditis (IE). The SVA extrinsically compressed the left main coronary artery (LMCA), which was initially diagnosed as a left atrial myxoma.

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Original Article

Paravalvular Regurgitation: Clinical Outcomes in Surgical and Percutaneous Treatments

Carlos Passos Pinheiro et al. Daniele Rezek Eduardo Paiva Costa Edvagner Sergio Leite de Carvalho … Freddy Antonio Brito Moscoso Percy Richard Chavez Taborga Andreia Dias Jeronimo Alexandre Antonio Cunha Abizaid Auristela Isabel de Oliveira Ramos

Abstract

Background:

Paravalvular regurgitation (paravalvular leak) is a serious and rare complication associated with valve replacement surgery. Studies have shown a 3% to 6% incidence of paravalvular regurgitation with hemodynamic repercussion. Few studies have compared surgical and percutaneous approaches for repair.

Objectives:

To compare the surgical and percutaneous approaches for paravalvular regurgitation repair regarding clinical outcomes during hospitalization and one year after the procedure.

Methods:

This is a retrospective, descriptive and observational study that included 35 patients with paravalvular leak, requiring repair, and followed up at the Dante Pazzanese Institute of Cardiology between January 2011 and December 2013. Patients were divided into groups according to the established treatment and followed up for 1 year after the procedure.

Results:

The group submitted to percutaneous treatment was considered to be at higher risk for complications because of the older age of patients, higher prevalence of diabetes, greater number of previous valve surgeries and lower mean creatinine clearance value. During hospitalization, both groups had a large number of complications (74.3% of cases), with no statistical difference in the analyzed outcomes. After 1 year, the percutaneous group had a greater number of re-interventions (8.7% vs 20%, p = 0.57) and a higher mortality rate (0% vs. 20%, p = 0.08). A high incidence of residual mitral leak was observed after the percutaneous procedure (8.7% vs. 50%, p = 0.08).

Conclusion:

Surgery is the treatment of choice for paravalvular regurgitation. The percutaneous approach can be an alternative for patients at high surgical risk.

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