Background: The study aim was to review the authors' experience with the surgical thrombectomy of mechanical valve thrombosis at the Heart Institute of the Medical School of São Paulo University, Brazil.

Methods: Between January 1993 and March 2014, a total of 21 patients (16 females, five males; mean age 48.2 years) with mechanical valve thrombosis was treated surgically. Of these patients, 70% were in NYHA class IV, including two in cardiogenic shock; 71% of the patients had inadequate anticoagulation levels. The median period between the initial valve replacement and valve thrombosis was 105 months. Thrombosis occurred in the mitral position in 12 patients (57%) and in the aortic position in nine (43%). Clinical and surgical data were collected from hospital records.

Results: The major surgical finding was thrombus (57.1%), and pannus formation was found in 42.9% of patients. The mean cardiopulmonary bypass time was 90 min, and aortic cross-clamp time 63 min. Operative complications occurred in three patients (14%): two patients required revisions for bleeding and one patient needed ventricular assistance and hemodialysis. The operative mortality rate was 19% (n = 4). Two of these deaths occurred in patients who had been transferred to the operating room with cardiopulmonary resuscitation, one death was due to prolonged mechanical ventilator support and sepsis, and one was due to cardiac tamponade. The 11-year actuarial survival rate was 69.3 ± 12.9%, and the actuarial rate freedom from reintervention was 85.7 ± 13.2% during an 11-year follow up period.

Conclusions: Early surgical intervention is a safe and effective treatment in patients with mechanical valve thrombosis.

How to cite: Maria Alberto Pomerantzeff, P., Padovani Steffen, S., Manuel de Almeida Brandão, C., Aparecida Lapenna, G., Tarasoutchi, F., & Biscegli Jatene, F. (2015). Surgical Thrombectomy of Mechanical Valve Thrombosis. The Journal of heart valve disease, 24(6), 780–784.

Fibroelastoma is a rare cardiac tumor. Even more rare is multilocalization of these tumors as well as their residence inside the cardiac chambers. Here, the case is reported of a 46-year-old male with three fibroelastomas of which only two were diagnosed preoperatively. The third tumor was discovered during surgery on the endocardium of the left ventricular wall, 2 cm away from the base of the anterolateral papillary muscle after a thorough examination of the ventricle had been instituted. Emphasis must be placed on the importance of performing such an examination during the excision of fibroelastomas, as a failure to address multiple lesions - although their existence is rare - might expose the patient to dangers of future embolization or reoperation.

How to cite: Diplaris, K., Sidhom, N., Berrebi, A., Malergue, M. C., & Lansac, E. (2015). Multiple Fibroelastoma: Search and You Will Find. The Journal of heart valve disease, 24(6), 776–777.

Background: Whilst echocardiography is currently the 'gold standard' for the diagnosis of infective endocarditis (IE), it has certain limitations and alternative imaging methods are being sought. The study aim was assess the usefulness of cardiac magnetic resonance (CMR) imaging when diagnosing IE.

Methods: Twenty consecutive patients with diagnosed IE were included in the study. All patients underwent CMR and transthoracic echocardiography, and 16 (80%) underwent also transesophageal echocardiography.

Results: CMR revealed vegetations in 15 patients (75%). Following echocardiography, vegetations were identified in 19 patients (95%) and valve perforation was suspected in seven (35%); vegetations were identified by CMR in six (30%) of these patients. Echocardiography identified two patients suspected of perivalvular abscess; in one patient the abscess was diagnosed also by CMR and intraoperatively, but in the second patient neither CMR nor intraoperative examination confirmed this diagnosis. Late gadolinium enhancement (LGE) was reported at CMR in eight patients (40%), associated with an extension of the inflammatory process and myocardium infiltration. The valve insufficiency fraction allowed the degree of insufficiency of the valves affected by inflammatory processes to be estimated. A positive correlation was found between the degree of valve insufficiency assessed with CMR and echocardiography.

Conclusions: CMR may serve as a useful method for diagnosing perivalvular complications in IE patients, although vegetation visualization is limited by the low spatial resolution of the method. CMR may prove superior to echocardiography in evaluating the degree of inflammatory process involvement in the myocardium. The degree of valve insufficiency and its hemodynamic significance can also be assessed.

How to cite: Zatorska, K., Michalowska, I., Duchnowski, P., Szymanski, P., Kusmierczyk, M., & Hryniewiecki, T. (2015). The Usefulness of Magnetic Resonance Imaging in the Diagnosis of Infectious Endocarditis. The Journal of heart valve disease, 24(6), 767–775.

Background: The St. Jude Medical (SJM) Trifecta™ aortic valve was designed to face common issues such as high transvalvular pressure gradients and low effective orifice areas (EOAs), which lead to prosthesis-patient mismatch after implanting small valve sizes. To reduce the obstruction of the left ventricular outflow tract, the Trifecta™ was designed as a stented valve for supraannular placement. The aim of this study was to evaluate the early hemodynamic performance of this new valve.

Methods: Between September 2010 and February 2013, 380 patients underwent an aortic valve replacement (AVR) using the SJM Trifecta™. Patients were subsequently followed up for two years and data records were analyzed retrospectively. Mean patient age was 73 years (range 33-93 years), 58% were male. The average mean preoperative pressure gradient was 45mmHg, with an EOA of 0,73cm2. The majority of patients (62%) were in NYHA class III. Indication for AVR was valve stenosis or insufficiency in 95%, presence of endocarditis caused the AVR in 5%.

Results: The 30-day-mortality was 4% (n=16; mean log EuroSCORE 20.9%), including two intraoperative non-valve-related cardiac deaths (0.52%) and one valve-related death due to lethal aortotomy bleedings (0.26%). 25 patients died during the follow-up period, 9 of them in a valve-related manner. At discharge, no valve thromboses or prosthesis failures could be identified. The average EOA and mean pressure gradient at discharge was 1.36cm2 and 11mmHg for 19mm valves and 2.1cm2 and 7mmHg for 25mm valves.

Conclusions: The new SJM Trifecta™ demonstrates excellent early hemodynamics over all valve sizes. In particular, large EOAs and low gradients in small valves attest a satisfying outcome after implantation. Further data is needed to investigate the stableness of these results over long-term follow up.

How to cite: Kammerer, I., Wiedemann, M., & Sack, F. U. (2015). Clinical impact of a new bioprosthetic aortic valve: the St. Jude Medical Trifecta™. The Journal of heart valve disease, 24(6), 760–766.

Background: The study aim was to evaluate the immediate and long-term results of surgical treatment of isolated posterior mitral valve leaflet prolapse (PLP), focusing on survival and freedom from recurrent mitral regurgitation (MR).

Methods: Between January 1998 and December 2012, a total of 492 consecutive patients (375 males, 117 females; mean age 61.8 ± 12.1 years; range: 13-86 years) with isolated PLP [304 (61.8%) with myxomatous degeneration; 188 (38.2%) with fibroelastic deficiency] were treated at the authors' institution. Of these patients, 202 (41.1%) were in NYHA class III-IV, and atrial fibrillation was present in 104 (21.1%). Mitral valve repair was achieved in 484 patients (98.4%), resection was performed in 419 (85.2%), and prosthetic ring annuloplasty was used in 436 (88.6%). Concomitant procedures were performed in 153 patients (31.1%), including tricuspid valve repair in 50 (10.2%), aortic valve surgery in 34 (6.9%), and coronary artery bypass grafting (CABG) in 64 (13%).

Results: The hospital mortality rate was 0.2%, and the mean follow up was 7.1 ± 3.9 years. There were 71 late deaths (14.4%), and overall survival at five, 10 and 15 years was 91.7 ± 1.3%, 82.1 ± 2.3% and 64.7 ± 6.1%, respectively. There was no significant difference in long-term survival compared with the age- and gender-matched general population (p = 0.146). Multivariate Cox-proportional hazard analysis showed older age (HR 1.03 per annum), left ventricular dysfunction (HR 2.44), atrial fibrillation (HR 1.96), left ventricular end-diastolic dimension (HR 1.05 per mm) and non-use of prosthetic ring (HR 3.03) as significant predictors of late mortality. Recurrence of moderate or severe MR occurred in 31 patients, six of whom underwent mitral valve reoperation. Predictors of late recurrence of MR were fibroelastic deficiency (HR 2.38), mitral calcification (HR 5.26), posterior leaflet plication (HR 3.58), absence of complete ring annuloplasty (HR 3.84) and systolic pulmonary artery pressure at discharge (HR 1.10 per mmHg). Freedom from mitral valve reoperation at 15 years was 97.4 ± 1.1% CONCLUSIONS: Mitral valve repair in isolated PLP can be achieved in virtually all cases with a very low operative risk and a high durability of repair. Atrial fibrillation or large left ventricles are associated with a poor prognosis. Failure to use a complete ring annuloplasty carries a risk not only for the return of MR but also for survival.

How to cite: Correia, P. M., Coutinho, G. F., Branco, C., Garcia, A., & Antunes, M. J. (2015). Surgical Treatment of Posterior Mitral Valve Prolapse: Towards 100% Repair. The Journal of heart valve disease, 24(6), 752–759.

Background: The study aim was to examine whether concomitant atrial fibrillation (AF) surgery at the time of mitral valve surgery in the elderly results in increased operative mortality (OM).

Methods: Medicare beneficiaries aged ≥65 years undergoing primary mitral valve repair or replacement between 2004 and 2006 were included. The cohort was divided into three groups: Group 1, AF- (n = 2,705); group 2, AF+AF surgery- (n = 2,119), and group 3, AF+AF surgery+ (n = 1,832). The primary outcomes were OM and long-term survival. A secondary outcome was the association between hospital annual mitral procedure volume and OM.

Results: The unadjusted OM was 6.4% for group 1 (AF-), 10.3% for group 2 (AF+AF surgery-), and 7.1% for group 3 (AF+AF surgery+) (p = 0.0001). Adjusted OM for AF+AF surgery+ patients was not significantly different from that of AF- patients (OR 1.16, 95% CI 0.90-1.48), or from AF+AF surgery patients (OR 0.83, 95% CI 0.66-1.06). When comparisons were adjusted for differences in baseline characteristics, AF+AF surgery- patients were more likely to experience long-term mortality than AF- patients (HR 1.30, 95% CI 1.17-1.45), as well as AF+AF surgery+ patients (HR 1.17, 95% CI 1.05-1.31). An annual average mitral procedure volume ≤40 was independently predictive of OM (OR 1.42, 95% CI 1.13-1.78). The effect of institutional volume on mortality was strongest in those who received AF surgery (AF+AF surgery+) (HR 1.75, 95% CI 1.15-2.65), compared to those who did not undergo surgery (AF+AF surgery-) (OR 1.20, 95% CI 0.86-1.67).

Conclusions: Elderly patients undergoing mitral valve surgery do not appear to have an increased mortality when clinical judgment favored the performance of concomitant AF surgery.

How to cite: Tsuda, P. S., McNeely, C. A., Markwell, S. J., Hazelrigg, S. R., & Vassileva, C. M. (2015). Mitral Valve Surgery in The Elderly: Should We Treat Atrial Fibrillation Too?. The Journal of heart valve disease, 24(6), 736–743.

Background: Regions of turbulence downstream of bioprosthetic heart valves may cause damage to blood components, vessel walls, and also to aortic valve leaflets. Stentless aortic heart valves are known to possess several hemodynamic benefits such as a larger effective orifice area and a lower aortic transvalvular pressure difference compared to their stented counterparts. To date, turbulence analysis downstream of a stentless valve prosthesis has been investigated exclusively indirectly, using magnetic resonance imaging or in animal settings only. The study aim was to investigate turbulence using direct Doppler ultrasonography measurements in subcoronary stentless and stented valves in human subjects.

Methods: Either stented pericardial valve prostheses (Mitroflow) or stentless valve prostheses (Solo) were implanted in 15 patients in a randomized fashion. Following surgery, blood velocity was measured in the cross-sectional area downstream of the valves using 10 MHz ultrasonic probes connected to dedicated pulsed Doppler equipment. As a measure of turbulence, Reynolds normal stress (RNS) values were calculated, as well as two-dimensional maps of the turbulence distribution. Preoperative and perioperative data were collected prospectively, and postoperative data retrospectively, from hospital records.

Results: The median follow up was 1,624 days. No differences were found in perioperative or postoperative clinical data. Implantation of the Mitroflow valve was significantly faster than that of the Solo valve (p <0.05). Neither was any difference found in the mean or max RNS between the two valve groups. However, the turbulence profiles showed a large variation in the Solo valve compared to the more uniform profiles of the Mitroflow valve.

Conclusions: Comparable turbulent flow values were found between the two valve types, although the Solo group exhibited a large variation in turbulence profiles. As no clear clinical advantages were shown to exist for stentless valves, a normal stented valve should be the first choice in most cases.

How to cite: Amstrup Funder, J., Christiansen, R., Græsvig Sandahl, O., Hjortdal, V., Nygaard, H., & Michael Hasenkam, J. (2015). Subcoronary Stentless Aortic Valves are Not Superior to Supra-Annular Stented Valves Regarding Turbulent Stress. The Journal of heart valve disease, 24(6), 722–728.

Background: Elective repair of bicuspid aortic valve (BAV)-associated ascending thoracic aortic aneurysm (aTAA) is recommended at lower size limits than tricuspid aortic valve (TAV)-associated aTAA. Rupture/dissection can occur when wall stress exceeds wall strength. Previously, a validated computational method was developed for determining aTAA wall stress, but to date this method has not applied to a patient-specific BAV aTAA. The study aim was to develop a patient-specific BAV aTAA computational model to determine regional wall stress, using the required zero-pressure geometry, wall thickness, material properties, and residual stress.

Methods: A BAV aTAA specimen was excised intact during elective repair, and zero-pressure geometry generated using micro-computed tomography. Residual stress was determined from the aTAA opening angle. aTAA material properties determined using biaxial stretch testing were incorporated into an Ogden hyperelastic model. Finite element analyses (FEAs) were performed in LS-DYNA to determine wall stress distribution and magnitudes at systemic pressure.

Results: The left aTAA region had the highest stiffness, followed by the right, and then anterior/posterior walls, suggesting regional variability in mechanical properties. During systole, the mean principal wall stresses were 108.8 kPa (circumferential) and 59.9 kPa (longitudinal), while peak wall stresses were 789.4 kPa (circumferential) and 618.8 kPa (longitudinal). Elevated wall stress pockets were seen in anatomic left aTAA regions.

Conclusions: To the present authors' knowledge, this was the first patient-specific BAV aTAA model based on surgical specimens to be developed. Surgical specimens serve as the 'gold standard' for determining wall stress to validate models based on in-vivo imaging data alone. Regions of maximal wall stress may indicate sites most prone to rupture, and are crucial for evaluating rupture risk based on the wall stress/strength relationship.

How to cite: Wisneski, A. D., Mookhoek, A., Chitsaz, S., Hope, M. D., Guccione, J. M., Ge, L., & Tseng, E. E. (2015). Bicuspid Aortic Valve-Associated Ascending Thoracic Aortic Aneurysm: Patient-Specific Finite Element Analysis. The Journal of heart valve disease, 24(6), 714–721.

Background: Details are provided of the authors' four-year experience with minimally invasive aortic valve replacement (AVR) through a right mini-thoracotomy, using totally central cannulation.

Methods: Between November 2011 and October 2014, a total of 248 patients (143 males, 105 females; mean age 72.6 ± 11.5 years; range: 29-93 years) underwent isolated AVR through a right anterior mini-thoracotomy with total arterial and venous central cannulation.

Results: AVR was performed through a 4- to 6-cm skin incision at the third intercostal space. The overall cardiopulmonary bypass time was 60.4 ± 16.7 min, and the aortic cross-clamp time 47.5 ± 14.1 min. A biological prosthesis was implanted in 242 patients (97.6%), using running sutures. The median intensive care unit and hospital stays were 40.5 h (IQR 24.6) and six days (IQR 6.0), respectively. In-hospital mortality was 1.2% (3/248); among 86 patients operated on during 2014 the hospital mortality was zero.

Conclusions: AVR performed via a right mini-thoracotomy with total central cannulation provided encouraging results. Adequate surgeon experience, in addition to technical expedience, are of utmost importance as demonstrated by the progressive and steady reduction in operating times. This approach may become highly competitive to a standard full sternotomy, and could become the 'new gold standard' for aortic valve surgery in the near future.

How to cite: Mikus, E., Calvi, S., Panzavolta, M., Luis Zulueta, J., Dozza, L., Cavallucci, A., & Del Giglio, M. (2015). Right Anterior Mini-Thoracotomy: A 'New Gold Standard' for Aortic Valve Replacement?. The Journal of heart valve disease, 24(6), 693–698.

The case is reported of a 25-year-old woman who presented with an episode of syncope on minimal exertion. She had undergone a repair of coarctation of the aorta at one year of age. Transesophageal echocardiography showed a unicuspid aortic valve (UAV) with critical stenosis. The patient underwent aortic valve replacement (AVR) with a bioprosthetic porcine valve. Although UAV is associated with other congenital cardiac abnormalities, its association with coarctation of the aorta is very rare. The currently available literature and treatment options are discussed. It appears that there is an association of UAV with coarctation, and the diagnosis of one condition should lead to an evaluation of the other.

How to cite: Agrawal, Y., Kalavakunta, J., & Gupta, V. (2015). A Rare Aortic Valve Congenital Abnormality in Association with Coarctation of the Aorta. The Journal of heart valve disease, 24(6), 679–682.