Reparación valvular mitral resectiva vs. implante de neocuerda en la insuficiencia mitral de origen degenerativo: resultados en el seguimiento alejado según la técnica quirúrgica utilizada / Chordal Replacement for Degenerative Mitral Regurgitation: Long-term Outcomes According to the Technique Used

RESUMEN Introducción: La reparación de la válvula mitral (RM) es actualmente la técnica de elección para el tratamiento de la insuficiencia mitral (IM) de origen degenerativo. La RM resectiva ha demostrado excelentes resultados en el mediano y largo plazo; no obstante, todavía hay discrepancias en la bibliografía sobre la técnica ideal en la reparación entre técnicas resectivas o conservadoras. Objetivos: Principal: comparar la durabilidad de la RM y la sobrevida libre de reoperación en la IM de origen degenerativo con la técnica de resección cuadrangular/triangular vs. la de implante de neocuerdas. Secundario: analizar los resultados técnico-quirúrgicos, las complicaciones posoperatorias tempranas y el punto final combinado de mortalidad, reoperación y/o progresión a la IM significativa de los pacientes sometidos a reparación de la IM. Material y métodos: Estudio de cohorte retrospectivo, incluyendo pacientes en los que se efectuó RM a causa de IM grave de origen degenerativo (técnica resectiva o neocuerdas) durante el período enero de 2005 a diciembre de 2017. Los 154 pacientes incluidos se dividieron en dos grupos: grupo resectivas (aquellos sometidos a cirugías resectivas; n = 78) y grupo neocuerdas (aquellos sometidos a implante de neocuerdas; n = 76). Diez pacientes tuvieron ambos procedimientos y fueron excluidos del análisis. Resultados: El promedio de edad de los pacientes fue de 66,4 ± 13,9 años (p=0,3). En el 29,8% de ellos pudo realizarse un abordaje miniinvasivo. La mortalidad a los 30 días fue de 1,2% en el grupo resectivas vs. 1,3% en el grupo neocuerdas (p = 0,31), y en el seguimiento alejado fue de 2,4% vs. 1,3%, respectivamente (p = 0,62). Los tiempos de circulación extracorpórea fueron superiores en el grupo neocuerdas (160,3 ± 51,3 minutos, vs. 130,4 ± 42,4 minutos, p < 0,001), al igual que las reparaciones anteriores (17,1% vs. 3,8%, p = 0,007) y bivalvares (17,1% vs. 3,8%, p < 0,001). Considerando la totalidad de pacientes evaluados en el seguimiento alejado, la sobrevida libre de reoperación alcanzó el 97,4% y la sobrevida libre de IM ≥ moderada superó el 90%, con una sobrevida global a 7 años de 97,4%. La complicación más frecuente fue la fibrilación auricular (5,8%). Conclusiones: Ambas técnicas tuvieron excelentes resultados, los que fueron similares en términos de mortalidad, sobrevida libre de reoperación y libre de IM ≥ moderada.

ABSTRACT Background: Mitral valve repair (MVR) is the technique of choice for the treatment of degenerative mitral regurgitation (MR). Leaflet resection has demonstrated excellent mid-term and long-term outcomes, but there are still disagreements in the literature at the moment of choosing between resection or conservative techniques. Objective: The primary outcome was to compare the durability of MVR and freedom from reoperation of the quadrangular and triangular leaflet resection techniques versus chordal replacement in degenerative MR. The secondary outcome was to analyze the results of the surgical techniques, the incidence of early postoperative complications and a composite outcome of mortality, reoperation or progression to significant MR in this population. Methods: We conducted a retrospective cohort study in patients with degenerative MR undergoing MVR (leaflet resection or chordal replacement) between January 2005 and December 2017. A total of 154 patients were included: 78 in the leaflet resection group and 76 in the chordal replacement group. Ten patients underwent both procedures and were excluded from the analysis. Results: Mean age was 66.4±13.9 years (p=0.3) A minimally invasive approach was used in 29.8% of cases. Mortality at 30 days was 1.2% in the leaflet resection group vs. 1.3% in the chordal replacement group (p=0.31), and it was 2.4% vs. 1.3%, respectively, in the long-term follow up (p=0.62). Cardiopulmonary bypass time was longer in the chordal replacement group (160.3±51.3 minutes vs. 130.4±42.4 minutes, p<0.001), as well as the number of anterior leaflet (17.1% vs. 3.8%, p=0.007) and both leaflet repairs (17.1% vs. 3.8%, p<0.001). At the long-term follow-up, freedom from reoperation was 97.4%, freedom from significant MR was over 90% and survival at 7 years was 97.4% in the entire cohort. Atrial fibrillation was the most common complication (5.8%). Conclusions: Both techniques had excellent and similar results in terms of mortality, freedom from reoperation and freedom from significant MR.

Correlation between NT-proBNP and lipase levels according to the severity of chronic mitral valve disease in dogs

Chronic mitral valve disease (CMVD) is the most common cardiovascular disease in dogs, causing decreased cardiac output that results in poor tissue perfusion and tissue damage to kidneys, pancreas, and other organs. The purpose of this study was to evaluate the relationships between heart disease severity and N-terminal pro B-type natriuretic peptide (NT-proBNP) and lipase in dogs with CMVD, as well as to evaluate longitudinal changes in these values. A total of 84 dogs participated in this 2015 to 2017 study. Serum values of NT-proBNP and lipase were analyzed; radiography was used to measure the vertebral heart score and assess various echocardiographic values. NT-proBNP showed a strong positive correlation with increasing stage of heart disease; lipase showed a mild positive correlation with heart disease stage. When the three values (NT-proBNP, lipase and month) were continuously measured at 6-month intervals, all showed a correlation with the increasing length of the disease.

Applications of 3D printing technology in the treatment of mitral valve disease / 中国胸心血管外科临床杂志

@#Mitral valve disease is the most common cardiac valve disease. The main treatment of mitral valve disease is surgery or interventional therapy. However, as the anatomy of mitral valve is complicated, the operation is particularly difficult. As a result, it requires sophisticated experiences for surgeons. Three-dimensional (3D) printing technology can transform two-dimensional medical images into 3D solid models. So it can provide clear spatial anatomical information and offer safe and personalized treatment for the patients by simulating surgery process. This article reviews the applications of 3D printing technology in the treatment of mitral valve disease.

Blood lactate increases with the progression of mitral valve disease in dogs / Aumento de lactato sanguíneo com progressão de valvopatia mitral em cães

In dogs with congestive heart failure, the upregulated sympathetic tone causes vasoconstriction that impairs peripheral blood supply, therefore causing the accumulation of lactate. In this prospective cross-sectional study with a longitudinal component, blood lactate was quantified in 10 healthy and 34 myxomatous mitral valve disease (MMVD) dogs to investigate its potential use as a diagnostic and prognostic biomarker. While there were no differences in lactate concentration between control animals and stages B1 (3.31±0.62mmol/L) and B2 (3.32±0.46mmol/L) dogs, significant differences were found between healthy (2.50±0.69mmol/L) and both C (3.99±0.47mmol/L) and D (6.97±1.23mmol/L) animals. When a cut-off of 3.35mmol/L was used, lactate was able to distinguish dogs with normal and remodeled hearts with a sensitivity of 78.2% and specificity of 63.6%. Also, significant correlations existed between lactate and indicators of cardiac remodeling. Finally, animals with blood lactate <3.5mmol/L carried a better prognosis when compared with dogs in which lactate was >5.0mmol/L. Our results suggest that the progression of MMVD results in accumulation of lactate within the bloodstream, which is likely attributable to the impaired peripheral tissue perfusion. In MMVD dogs, blood lactate may be used as a surrogate for cardiac remodeling, and an increased concentration is associated with a worse prognosis regarding the time to evolve into congestive heart failure.(AU)

Em cães com insuficiência cardíaca congestiva, o tônus simpático hiperregulado causa vasoconstrição e interfere com o suprimento sanguíneo periférico, resultando no acúmulo de lactato. Neste estudo prospectivo transversal com um componente longitudinal, o lactato sanguíneo foi quantificado em 10 cães saudáveis e 34 cães com doença mixomatosa da valva mitral (DMVM) para investigar seu potencial como biomarcador diagnóstico e prognóstico. Embora não tenham sido identificadas diferenças na concentração de lactato entre animais controle e cães com DMVM nos estágios B1 (3,31±0,62mmol/L) e B2 (3,32±0,46mmol/L), diferenças significativas foram constatadas entre os cães saudáveis (2,50±0,69mmol/L) e cães com DMVM estágio C (3,99±0,47mmol/L) ou D (6,97±1,23mmol/L). Quando utilizado o valor de corte de 3,35mmol/L, o lactato foi capaz de diferenciar cães com corações normais daqueles com corações remodelados com sensibilidade de 78,2% e especificidade de 63,6%. Além disso, correlações significativas foram encontradas entre o lactato e os indicadores de remodelamento cardíaco. Por fim, os animais com lactato sanguíneo <3,5mmol/L tiveram prognóstico melhor comparativamente aos cães com concentrações >5,0mmol/L. Nossos resultados sugerem que a progressão da DMVM resulta no acúmulo de lactato na corrente sanguínea, fato que é provavelmente atribuído à perfusão periférica prejudicada. Em cães com DMVM, o lactato sanguíneo pode ser utilizado como indicador de remodelamento cardíaco, cuja concentração elevada está associada com pior prognóstico relativo ao tempo para evoluir para insuficiência cardíaca congestiva.(AU)

Left atrial size and contractile function in healthy dogs and dogs with chronic mitral valve disease / Tamanho e função sistólica atrial esquerda em cães sadios e com doença valvar crônica de mitral

In humans, left atrial enlargement and reduced contractile functions are associated with adverse cardiovascular events and a poor prognosis in many dilatation of the left atrium occurs with the gradual evolution of chronic mitral valve disease and is well diseases. The left atrium is the most compromised cardiac chamber in dogs with chronic mitral valve disease (CMVD). Therefore, this study aimed to compare the main parameters of left atrial enlargement (left atrium/aorta ratio, left atrial diameter and volume indices) and contractile function (transmitral flow peak velocity A wave and time velocity integral, atrial fraction, and atrial ejection force) at different stages of valve disease, and correlate the left atrial diameter, volume, and contractile function indices with echocardiographic variables predictive of heart failure in dogs (transmitral flow peak velocity E wave, E wave/IVRT ratio, E wave/E´wave ratio, and E wave/A wave ratio). The results showed that progressive characterized by the left atrium/aorta ratio and left atrium volume index. The left atrial diameter and volume indices and left atrium/aorta ratio correlated positively with the transmitral flow peak velocity E wave and E wave/IVRT ratio, which are important indices of diastolic function. The left atrial contractile function indices increased as CMVD evolved. Except for the atrial fraction, the left atrial contractile function indices correlated with the left ventricular filling pressure indices.(AU)

O tamanho e a função atrial esquerda estão relacionados em humanos com eventos cardiovasculares adversos e prognóstico nas principais cardiopatias. Na doença valvar crônica de mitral (DVCM) em cães, o átrio esquerdo é a câmara cardíaca mais comprometida. Portanto, os objetivos deste estudo foram comparar os principais parâmetros de aumento atrial esquerdo (relação átrio esquerdo/aorta, índice do diâmetro atrial esquerdo e índice do volume atrial esquerdo) e função contrátil de átrio esquerdo (velocidade máxima e integral de velocidade da onda A do fluxo transvalvar mitral, fração atrial e força de ejeção atrial) nos diferentes estágios da doença valvar; correlacionar diâmetro e volume atrial esquerdo e os índices de função contrátil atrial esquerda com as variáveis ecocardiográficas preditivas de insuficiência cardíaca em cães (velocidade máxima da onda E do fluxo transvalvar mitral, relação E/TRIV, relação E/E'par e relação E/A). Os resultados mostraram que com a evolução progressiva da doença valvar crônica de mitral, ocorre dilatação progressiva do átrio esquerdo, bem caracterizada pela relação átrio esquerdo/aorta e pelo índice de volume atrial esquerdo. O índice do diâmetro atrial esquerdo, o índice de volume atrial esquerdo e a relação átrio esquerdo/aorta correlacionam-se, positivamente, com a velocidade da onda E e com a relação E/TRIV, que são importantes índices de função diastólica. Os índices de função contrátil do átrio esquerdo aumentam à medida que a DVCM evolui. Os índices de função contrátil do átrio esquerdo apresentam correlação positiva com os índices de pressão de enchimento ventricular esquerdo, exceção feita à fração atrial.(AU)

Vasovagal tonus index in dog with myxomatous mitral valve disease / Índice de tônus vasovagal em cães com doença mixomatosa da valva mitral

The vasovagal tonus index (VVTI) is a useful and assessable index, obtained from standard ECG recordings, that is used to estimate heart rate variability (HRV), and may provide valuable information regarding the likelihood of progression into congestive heart failure (CHF). In this paperwork, we investigated how the vasovagal tonus index (VVTI) behaves in dogs with naturally-occurring myxomatous mitral valve disease (MMVD) Electrocardiographic (ECG) recordings and echocardiographic data of 120 patients diagnosed with MMVD were reviewed. The VVTI was calculated from twenty consecutive RR intervals for each dog enrolled in the study. Lower VVTI values were found in MMVD patients in American College of Veterinary Internal Medicine (ACVIM) stage C compared with stages B1 and B2. Values were also lower in patients with severe cardiac remodeling. When a cut-off value of 6.66 is used, VVTI was able to discriminate MMVD patients in stage C from B1 and B2 dogs with a sensitivity of 70 per cent and a specificity of 77 per cent. MMVD dogs in which VVTI is lower than 6.66 are 30% more likely to develop congestive heart failure (CHF).(AU)

O índice de tônus vasovagal (ITVV) é uma ferramenta útil e acessível, obtida por meio de traçados eletrocardiográficos convencionais (ECG), utilizada para calcular a variabilidade da frequência cardíaca (VFC), podendo também fornecer informações valiosas referentes à probabilidade de desenvolvimento de insuficiência cardíaca congestiva (ICC). Neste trabalho, foi investigado como o ITVV se comporta em cães com degeneração mixomatosa da valva mitral (DMVM) de ocorrência natural, ECGs e exames ecocardiográficos de 120 pacientes diagnosticados com DMVM foram avaliados. O ITVV foi calculado a partir de 20 intervalos RR consecutivos para cada cão envolvido. Valores menores de ITVV foram encontrados em pacientes em estágio C de doença mitral pela classificação do American College of Veterinary Internal Medicine (ACVIM), comparado com pacientes em estágio B1 e B2. Valores também foram menores em pacientes com remodelamento cardíaco importante. Quando um valor de corte de 6,66 foi usado, o ITVV foi capaz de distinguir pacientes em estágio C de B1 e B2 com uma sensibilidade de 70 por cento e uma especificidade de 77 por cento. Cães com DMVM cujo ITVV é menor que 6,66 são 30% mais propensos a evoluírem para ICC.(AU)

Chronic atrial fibrillation ablation with harmonic scalpel during mitral valve surgery

Abstract Objective To evaluate surgical treatment of chronic atrial fibrillation with ultrasound in patients with mitral valve disease, considering preoperative clinical characteristics of patients undergoing surgical procedure and follow-up in the immediate postoperative period, in hospital and up to 60 months after discharge. Methods: We studied 100 patients with chronic atrial fibrillation and mitral valve disease who underwent surgical treatment using ultrasound ablation. Patient data were reviewed by consulting the control reports, including signs and symptoms, underlying disease, functional class, hospital stay, surgical procedure time, ablation time, immediate complications, and complications at discharged and up to 60 months later. Actuarial curve (Kaplan-Meier) was used for the study of permanence without recurrence after 12, 24, 36, 48 and 60 months. Results: 86% of the patients had rheumatic mitral valve disease, 14% had degeneration of the mitral valve, 40% had mitral regurgitation, and 36% had mitral stenosis. Main symptoms included palpitations related to tachycardia by chronic atrial fibrillation (70%), congestive heart failure (70%), and previous episodes of acute pulmonary edema (27%). Early results showed that 94% of the patients undergoing ultrasound ablation reversed the rate of chronic atrial fibrillation, 86% being in sinus rhythm and 8% in atrioventricular block. At hospital discharge, maintenance of sinus rhythm was observed in 86% of patients and there was recurrence of chronic atrial fibrillation in 8% of patients. At follow-up after 60 months, 83.8% of patients maintained the sinus rhythm. Conclusion: Surgical treatment of chronic atrial fibrillation with ultrasound concomitant with mitral valve surgery is feasible and satisfactory, with maintenance of sinus rhythm in most patients (83.8%) after 60 months of follow-up.

Retrospective study of degenerative mitral valve disease in small-breed dogs: survival and prognostic variables

Small-breed dogs (n = 168; weight < 15 kg) diagnosed with myxomatous mitral valve degeneration based on a routine clinical examination, radiology, electrocardiography, and echocardiography at the Seoul National University Veterinary Medical Teaching Hospital were included in this study. Survival periods were determined, and there were significant differences in survival rates among the three International Small Animal Cardiac Health Council classes. The mean follow-up period was 14.3 ± 12.1 months. Univariate analysis revealed that dyspnea, pulmonary edema, and vertebral heart score were significantly associated with survival time (p < 0.05). Additionally, age, left atrial-to-aortic root ratio, ejection fraction, and left ventricular end diastolic volume were associated with an increased risk of death (p < 0.1), while body weight, body condition score, systolic blood pressure, arrhythmia, syncope, fractional shortening, and end systolic volume were not associated with an increased risk of death. These results suggest that among the assessed variables dyspnea, pulmonary edema, and vertebral heart score could be useful prognostic factors for providing patient information to owners.

La cirugía mínimamente invasiva de la válvula mitral a través de toracotomía derecha es un procedimientoseguro y eficaz a corto y largo plazo. Estudio de cohortes ajustadas por nivelación del riesgo de propensión / Minimally-invasive mitral valve surgery via right thoracotomy is a safe an efficient procedure in the short and long term. Cohort study adjusted by propensity score matching

Resumen Introducción: La cirugía cardiaca mínimamente invasiva sobre la válvula mitral ha crecido en popularidad. El objetivo del estudio es valorar la morbilidad y eficacia de la técnica a medio plazo en una serie inicial. Material y métodos: 212 pacientes fueron sometidos a cirugía sobre la válvula mitral entre los años 2009 y 2013; 44 mediante cirugía mínimamente invasiva por toracotomía y 168 por esternotomía media. Se realizó un emparejamiento estadístico para la obtención del grupo control por regresión logística y nivelación del grado de propensión considerando las principales variables de riesgo. Se registró la morbilidad y calidad de la reparación o sustitución. Se realizó un análisis univariante y multivariante para un evento compuesto de morbimortalidad, eficacia y requerimientos de hemoderivados. Resultados: Fueron incluidos 44 pacientes por grupo. La media de seguimiento fue de 26,6 (14,6) y 28,4 (1,1) meses en el grupo de estudio y control, respectivamente. Se realizó reparación de la válvula mitral en el 70,5% en el grupo estudio y en el 68,2% en el grupo control. No se encontraron diferencias en la morbimortalidad perioperatoria. El número de pacientes que desarrollaron insuficiencia mitral moderada o severa durante el seguimiento fue del 9,1% en el grupo estudio y 11,4% en el control (p = 1,0). Tanto en el análisis univariante como multivariante la cirugía mínimamente invasiva fue un predictor independiente de menor transfusión. Conclusión: La cirugía mínimamente invasiva no es inferior a la esternotomía en morbilidad hospitalaria, ni en la calidad de la técnica quirúrgica en un programa de iniciación.

Abstract Introduction: Minimally-invasive mitral valve cardiac surgery has become increasingly popular. The objective of this study is to assess morbidity and efficiency of the technique in the médium run in an initial series. Material and methods: 212 patients underwent mitral valve surgery between 2009 and 2013; 44 with minimally-invasive thoracotomy and 168 via median sternotomy. Statistical pairing was conducted to obtain the control group by means of logistic regression and propensity score matching considering the main risk variables. Morbidity and repair or replacement quality were registered. A univariate and multivariate analysis was carried out for an event comprising morbidity and mortality, efficiency and blood component requirements. Results: Each group included 44 patients. Average follow-up time was 26.6 (14.6) and 28.4 (1.1) months in the study group and control group respectively. Mitral valve repair was performed in 70.5% of patients in the study group and in 68.2% of patients in the control group. No differences were found in perioperative morbidity and mortality. The number of patients who developed moderate or severe mitral insufficiency during follow-up was 9.1% in the study group and 11.4% in the control group (p = 1.0). Minimally-invasive surgery was an independent predictor for lower transfusion in both the univariate and multivariate analyses. Conclusion: Minimally-invasive surgery is not inferior to sternotomy in hospital morbidity or in the quality of surgical technique in an initial program.

Long-Term Results of Mitral Valvuloplasty and Mitral Valve Replacement for Isolated Mitral Valve Disease in Children under 15 Years Old / 日本心臓血管外科学会雑誌

<p><b>Background</b> : There has been no ideal valve prosthesis for children from the point of view of thromboembolism and size mismatch, and the surgical repair of native mitral valve has always been our first priority in children. However, valve replacement becomes the inevitable surgical option if repair is impossible. The purpose of this study was to assess the long-term results of mitral valvuloplasty (MVP) and mitral valve replacement (MVR) for isolated mitral valve diseases in children under 15 years old. <b>Patients and Methods</b> : From 1981 to 2010, 30 patients underwent a total of MVPs (P group) and 26 consecutive patients underwent a total of MVRs (R group). The median age was 4.6 years (4 months to 16 years) in group P and 6.2 years (4 months to 13.7 years) in group R, and the median body weight was 13.4 kg (6 to 35.5 kg) in group P and 16.4 kg (4.8 to 50.7 kg) in group R. The etiology was congenital in 55 (98%) patients, and due to endocarditis in 1 (2%) patient. Isolated mitral regurgitation was present in 41 (73%) patients (group iMR), and isolated mitral stenosis was present in 15 (27%) patients (group iMS). Mechanical valves (bileaflet disc, <i>n</i>=26) were used in all initial MVR patients. <b>Results</b> : Overall hospital mortality was 0%. The median follow-up time was 9.3±7.8 years (4 months to 27.7 years). There were 6 reoperations in P group and 5 explants due to size mismatch in R group with patient growth, and no explant due to structural valve deterioration. Survival rates at 10 years were 100% in the P group and 88.0% in the R group, and there was a significant difference (<i>p</i>=0.043). Freedom from reoperation at 10 years was 77.6% in P group and 77.0% in R group. Freedom rate from cerebral events at 10 years were 100% in both groups, respectively, and there were no significant differences. Survival rates at 10 years were 100% in the iMR group and 53.3% in the iMS group, respectively, and there was a significant difference between the groups (<i>p</i><0.001). Freedom rates from reoperation at 10 years were 77.1% in the iMR group and 64.3% in the iMS group, respectively, there being no significant difference. Conclusions : The long-term results of pediatric mitral surgery were acceptable. Mitral valvuloplasty for patients with isolated mitral regurgitation were excellent. Mitral valve replacement can be performed with low initial mortality but should be reserved for medical and reconstruction failure because reoperation and late mortality are high, particularly for patients with isolated mitral stenosis.</p>

Serum serotonin concentration in lean and obese dogs with myxomatous mitral valve disease

The aim of the present study is to investigate the potential influence of obesity as a factor in 5-hydroxytryptamine (5-HT) concentration in myxomatous mitral valve disease (MMVD) dogs. Fifty-five client-owned dogs were enrolled in a randomized trial. Dogs were classified by echocardiography into healthy (control), mild, and moderate to severe MMVD groups. Each group was subclassified by using a 9-point body condition score (BCS); lean (BCS 5–6/9) and obese groups (BCS 7.5–9/9). Dogs with moderate to severe MMVD had lower serotonin (5-HT) concentrations than the control group (p = 0.03). Dogs with moderate to severe MMVD (p = 0.017) had lower serum 5-HT concentrations than the control group in the obese group (BCS 7.5–9/9). Significant difference was found between the lean and obese groups (p = 0.015) which are not consider severe in the MMVD group. These results suggested that 5-HT concentration was decreased with the increasing severity of MMVD, and obesity might be taken into consideration when interpreting the serotonin concentration in MMVD dogs.

Short-term follow-up of exercise training program and beta-blocker treatment on quality of life in dogs with naturally acquired chronic mitral valve disease

This study aimed to evaluate the effects of carvedilol treatment and a regimen of supervised aerobic exercise training on quality of life and other clinical, echocardiographic, and biochemical variables in a group of client-owned dogs with chronic mitral valve disease (CMVD). Ten healthy dogs (control) and 36 CMVD dogs were studied, with the latter group divided into 3 subgroups. In addition to conventional treatment (benazepril, 0.3-0.5 mg/kg once a day, and digoxin, 0.0055 mg/kg twice daily), 13 dogs received exercise training (subgroup I; 10.3±2.1 years), 10 dogs received carvedilol (0.3 mg/kg twice daily) and exercise training (subgroup II; 10.8±1.7 years), and 13 dogs received only carvedilol (subgroup III; 10.9±2.1 years). All drugs were administered orally. Clinical, laboratory, and Doppler echocardiographic variables were evaluated at baseline and after 3 and 6 months. Exercise training was conducted from months 3-6. The mean speed rate during training increased for both subgroups I and II (ANOVA, P>0.001), indicating improvement in physical conditioning at the end of the exercise period. Quality of life and functional class was improved for all subgroups at the end of the study. The N-terminal pro-brain natriuretic peptide (NT-proBNP) level increased in subgroup I from baseline to 3 months, but remained stable after training introduction (from 3 to 6 months). For subgroups II and III, NT-proBNP levels remained stable during the entire study. No difference was observed for the other variables between the three evaluation periods. The combination of carvedilol or exercise training with conventional treatment in CMVD dogs led to improvements in quality of life and functional class. Therefore, light walking in CMVD dogs must be encouraged.

Serum serotonin concentration in small breed dogs with degenerative mitral valve disease / 동물의과학연구지

This study investigated the potential associations of dog characteristics with serum serotonin (5HT) concentration in dogs with degenerative mitral valve disease (DMVD). Client-owned dogs were prospectively recruited at the Veterinary Medical Teaching Hospital of Chungnam National University between 2010 and 2011. Forty-two dogs (22 females and 20 males) were enrolled in this study. DMVD dogs included Maltese (n=12), followed by Shih-tzu (n=10), mixed breed (n=5), Chihuahua (n=4), Miniature schnauzer (n=3), Miniature poodle (n=3), Miniature pinscher (n=1), Pomeranian (n=1), Yorkshire terrier (n=2), and Spitz (n=1). As inclusion criteria for the study, dogs had to show either direct or echocardiographic evidence of DMVD. Platelet count significantly differed among the three groups, as the moderate (P<0.05) and severe groups (P<0.05) showed significantly higher platelet counts than the mild DMVD group. Additionally, significantly higher LVIDd, LVIDs, fractional shortening (FS), and LA:Ao ratios were observed in dogs with moderate (P<0.05) and severe (P<0.05) DMVD compared to the mild group, respectively. Significant positive correlations between serum 5-hydroxytryptamine (5HT) concentration and platelet count (r=0.273, P=0.03), LA:Ao ratio (r=0.459, P=0.001), and LVIDd (r=0.319, P=0.013) were observed in DMVD dogs. Therefore, serum 5HT concentration may be a potential cause of DMVD progression.

Cardiac surgery during pregnancy: Continuous fetal monitoring using umbilical artery Doppler flow velocity indices.

The fetal death rate associated with cardiac surgery with cardiopulmonary bypass (CPB) is as high as 9.5‑29%. We report continuous monitoring of fetal heart rate and umbilical artery flow‑velocity waveforms by transvaginal ultrasonography and their analyses in relation to events of the CPB in two cases in second trimester of pregnancy undergoing mitral valve replacement. Our findings suggest that the transition of circulation from corporeal to extracorporeal is the most important event during surgery; the associated decrease in mean arterial pressure (MAP) at this stage potentially has deleterious effects on the fetus, which get aggravated with the use of vasopressors. We suggest careful management of CPB at this stage, which include partial controlled CPB at initiation and gradual transition to full CPB; this strategy maintains high MAP and avoids the use of vasopressors. Maternal and fetal monitoring can timely recognize the potential problems and provide window for the required treatment.

Histological and Biochemical Comparisons between Right Atrium and Left Atrium in Patients with Mitral Valvular Atrial Fibrillation

BACKGROUND AND OBJECTIVES: It has been known that the dominant driver of atrial fibrillation (AF) exists in the left atrium (LA) and the incidence of systemic thromboembolism is higher than that of pulmonary thromboembolism in patients with AF. Therefore, we hypothesized that histological and biochemical characteristics of the LA and the right atrium (RA) are different in patients with mitral valvular AF. SUBJECTS AND METHODS: We analyzed the histology and messenger ribonucleic acid (mRNA) or protein expression associated with endothelial function and thrombogenesis in 33 human atrial appendage tissues (20 LA tissues, 13 RA tissues) taken from 25 patients {57.7+/-11.3 years old, 44% males, AF: sinus rhythm (SR)=17:8} with mitral valve disease. We also performed whole mRNA quantification in 8 tissues (both LA and RA tissues from 4 patients) by using next generation sequencing (NGS). RESULTS: 1) The degree of fibrosis (p=0.001) and subendocardial smooth muscle thickness (p=0.004) were significantly greater in the LA than in the RA. 2) More advanced matrix fibrosis was found in the LA of patients with AF than in the LA of patients with SR (p=0.046), but not in the RA. 3) There was no LA-RA difference in protein (Western blot) and mRNA {quantitative real-time polymerase chain reaction (qRT-PCR)} expressions of NF-kappaB, 3-NT, CD31, E-selectin, inducible NO synthase, stromal cell-derived factor-1alpha, Endothelin-1, platelet-derived growth factor, myeloperoxidase, or NCX, except for higher mRNA expression of HCN4 in the RA (qRT-PCR, p=0.026) and that of KCNN1 in the LA (NGS, p=0.016). CONCLUSION: More advanced matrix and subendocardial remodeling were noticed in the LA than in the RA in patients with mitral valvular AF. However, the expressions of tissue factors associated with thrombogenesis were not significantly different between the RA and the LA.

Rupture of atrial septum in a Pomeranian dog secondary to advanced degenerative mitral valve disease / 동물의과학연구지

A 12-year-old spayed female Pomeranian (weighing 2.4 kg) was referred with primary complaints of acute dyspnea, cough, and lethargy. Diagnostic imaging studies found degenerative mitral valve cusps, chordae tendinae rupture, severe mitral regurgitation (5.45 m/s of peak velocity), and marked left atrial and ventricular dilation. The dog was diagnosed as having degenerative mitral valve disease (DMVD) with ISACHC stage IIIa heart failure. Her clinical condition was stabilized after administration of cardiac medication (e.g. diuretics and pimobendan). Ten months later, the dog was referred back to the clinic due to a sudden worsening of clinical signs. Echocardiographic study found pulmonary hypertension in addition to DMVD. After medication was adjusted, clinical signs were stabilized in 2 weeks. The patient was returned after 4 months for cardiac recheck and there was no obvious worsening of clinical signs. Incidental finding of a left-to-right atrial septal defect from rupture of the atrial septum secondary to marked left atrial dilation by DMVD was noted by echocardiography. To diminish left atrial volume overload, the frequencies of both furosemide and pimobendan were increased (i.e. from q 12 hr to q 8 hr) in addition to adding spironolactone (1 mg/kg q 12 hr). Based on diagnostic findings, this case was re-diagnosed as acquired atrial septal defect secondary to rupture of the atrial septum with advanced stage DMVD. The dog was then stabilized and is currently being regularly monitored.

Maternal Heart Disease and Pregnancy Outcomes.

This study was conducted to assess the presence of various types of cardiac lesions in pregnant females admitted to a tertiary care hospital of Punjab. 97 women having pregnancy and heart disease were assessed for the various etiologies, cardiac lesions, maternal and perinatal outcomes. Rheumatic heart disease (RHD) with isolated mitral stenosis was the commonest acquired lesion while mitral valve prolapse was the predominant lesion among the congenital heart disease. In the miscellaneous group, cardiomyopathy was the leading cause. Multiple cardiac lesions were diagnosed in 36 women. Majority delivered by caesarean section and some had spontaneous vaginal delivery while few required induction of labour. 19 women had cardiac complications. There were three maternal deaths.This study concluded that rheumatic heart disease in pregnancy is still predominant though acquired cardiac lesions are rising. A careful observation and management during pregnancy can improve the maternal & fetal outcomes.

Musical murmur in a dog with acute chordae tendineae rupture / 대한수의학회지

A 6 year-old, spayed female, Maltese dog was presented with precordial thrill and mild coughing. Thoracic auscultation revealed a grade V/VI systolic murmur with maximal intensity over the left apex characterized by musical murmur. Echocardiography revealed mild myxomatous degeneration of mitral valve and ruptured chordae tendineae. Musical murmur was produced due to the vibration of ruptured piece of chordae tendineae along with regurgitant flow. After treatment with furosemide and ramipril, clinical signs resolved and precordial thrill reduced. This case report describes typical clinical signs and phonocardiogram of musical murmur in a dog with acute chordae tendineae rupture.

Prevalência da doença degenerativa valvar crônica mitral em cães / Prevalence of mitral valve chronic degenerative disease in dogs

Objetivo - A doença degenerativa da valva mitral (DDVM) é, dentre as alterações adquiridas, a cardiopatia de maior ocorrência em cães geriatras, sendo mais frequentemente observada em cães machos de pequeno e médio porte. A degeneração valvar ocasiona distorção dos folhetos, com consequente regurgitação mitral que determina sobrecarga de volume e dilatação de átrio esquerdo, com consequente insuficiência cardíaca congestiva (ICC) esquerda, ou mesmo hipertensão pulmonar secundária e ICC direita nos casos mais graves. O objetivo do presente estudo foi avaliar a predisposição etária, racial e sexual dos cães acometidos por DDVM em nosso meio. Métodos - Foram avaliados 125 cães, nos quais o diagnóstico de DDVM foi suspeitado por anamnese, auscultação cardíaca, eletrocardiografia e radiografia torácica, sendo confirmado por meio de ecocardiografia. Resultados - Observou-se, em relação à faixa etária dos cães acometidos, média e desvio padrão de 11,6 ± 2,4 anos, variando de 5 a 18 anos de idade. As raças de cães mais frequentemente acometidas foram aquelas de pequeno e médio porte, observando-se a seguinte frequência de ocorrência: Poodle (38,0%), SRD (32,0%), Pinscher (8,0%), Cocker Spaniel (5,0%), Dachshund (6,0%), Lhasa Apso, Maltês e Pastor Alemão (2,0% cada) e outras (1,0% cada). Evidenciou-se maior predisposição dos machos à DDVM, observando-se sua ocorrência em 74 machos (59,0%) e 51 fêmeas (41,0%). Conclusão - Por meio deste estudo epidemiológico, ressalta-se a importância da avaliação cardiológica periódica dos animais mais suscetíveis à DDVM, tais como os cães machos idosos de raças pequenas, buscando-se diagnosticar precocemente essa prevalente doença.

Objective - Degenerative disease of mitral valve (DDMV) is among the acquired heart disease most prevalent in geriatric dogs, being more frequently observed in small and medium male dogs. The degeneration causes distortion of the valve leaflets, with consequent mitral regurgitation that determines volume overload and dilatation of the left atrium with consequent left congestive heart failure (CHF), or secondary pulmonary hypertension and right CHF in severe cases. The aim of this study was to evaluate the age, racial and sexual predisposition of dogs affected by DDMV in our environment. Methods - A total of 125 dogs were evaluated, in whom the diagnosis of DDMV was suspected through history, cardiac auscultation, electrocardiography and chest radiography, and confirmed by echocardiography. Results - Regarding the age of affected dogs, it was encountered mean and standard deviation of 11,6 ± 2,4, ranging from 5 to 18 years old. The breeds of dogs most frequently affected were those of small and medium size, noticing the following frequency of occurrence in various breeds: Poodle (38.0%), SRD (32.0%), Pinscher (8.0%), Cocker Spaniel (5.0%), Dachshund (6.0%), Lhasa Apso, Maltese and German Shepherd (2.0% each) and others (1.0% each). It was observed a higher susceptibility of males to DDMV, identifying its occurrence in 74 males (59.0%) and 51 females (41.0%). Conclusion - This epidemiological study emphasizes the importance of regular cardiac evaluation of the animals more susceptible to DDMV, such as elderly male dogs of small breeds, seeking an early diagnosis of this prevalent disease.

Progress on application of real-time three-dimensional echocardiography in mitral valve disease of children / 国际儿科学杂志

Real-time three-dimensional echocardiography(RT-3DE) has been validated for its accurate diagnoses and quantitave mearsurement of mitral valve disease,which could act as a guide in selecting the proper therapeutic strategy for each individual in clinical setting.In this article,the recent research achievements on RT-3DE in mitral valve disease were summarized,and the application of RT-3DE in surgical approach to mitral valve disease was discussed as well.