The Effect of Postoperative Hepatic Fibrosis Factors on Morbidity in Mitral Valve Replacement Surgery: A Single Center Ten Years� Experience

Background: Previous studies have shown that hepatic fibrosis indices and rates can be used to predict cardiovascular mortality and morbidity. Our aim with this study was to investigate the effect of aspartate aminotransferase/alanine aminotransferase (AST/ALT) ratio and fibrosis?4 (FIB?4) index calculated with ALT, AST, and platelet biomarkers, which are simple, fast, and relatively inexpensive and were used in previous studies to predict cardiovascular disease prognosis, on the prediction of postoperative morbidity and early mortality after mitral valve replacement (MVR) surgery. Methods: By scanning the hospital electronic health record system, 116 patients who underwent isolated MVR or MVR + tricuspid valve intervention were identified from 178 patients who underwent MVR with the standard sternotomy procedure between 2011 and 2021. The study was completed with 81 of these patients. Patients were divided into AST/ALT <2 (Group 1) and >2 (Group 2). In addition, the same patients were divided into FIB?4 index <3.25 (Group 3) and >3.25 (Group 4), and a total of four groups were formed. Results: The mean age of Group 2 was significantly higher than Group 1 (P = 0.049). In addition, the mean age of Group 4 was significantly higher than Group 3 (P = 0.003). Postoperative complications did not differ between Groups 1 and 2 (P > 0.05). While noninvasive mechanincal ventilation (NIMV) requirements did not differ between Groups 3 and 4 (P > 0.05), MV duration and intensive care unit stay were significantly longer in Group 4 (P < 0.05). Conclusion: The AST/ALT ratio, which has been shown to be a predictor of cardiovascular mortality in various studies, was not useful in predicting mortality and morbidity in our study. However, a high FIB?4 index, another hepatic fibrosis index, was found to be associated with increased perioperative bleeding, duration of mechanical ventilation, and cardiac intensive care unit stay, which are important criteria in the prediction of morbidity in cardiovascular surgery.

A Case of Redo-Mitral Valve Replacement for a Björk-Shiley Delrin Valve Implanted 47 Years Previously / 日本心臓血管外科学会雑誌

We report a case of redo mitral valve replacement (MVR) for a Björk-Shiley Delrin valve implanted 47 years previously. A 71-year-old man initially underwent MVR for mitral regurgitation at our hospital at the age of 16 years. Following the operation, follow-up examinations were performed at the outpatient clinic and annual transthoracic echocardiogram findings showed only mild mitral regurgitation, with no adverse events noted. However, a transthoracic echocardiogram examination performed 45 years after the operation revealed mild to moderate mitral regurgitation, while dyspnea with exertion was also noted at that time. As part of a more detailed examination, transesophageal echocardiogram results showed moderate transvalvular leakage. Redo MVR was subsequently performed under the diagnosis of prosthetic valve dysfunction. Analysis of the explanted prosthetic valve revealed wear of the Delrin disk, and widening of the gap between the disk and strut, which were presumed to be the cause of transvalvular leakage. A half century has passed since introduction of the Björk-Shiley valve and the present is a rare case of valve malfunction. Presented here are related details, along with a review of existing literature and results of Björk-Shiley valve use at our hospital.

Annual progress of transcatheter mitral valve intervention in 2022 / 中国胸心血管外科临床杂志

@#Mitral regurgitation is the most common heart valvular disease at present. In the past, mitral regurgitation was mainly treated by surgical mitral valve repair or replacement. However, with the progress of transcatheter interventional techniques and instruments in recent years, transcatheter mitral valve interventional therapy has gradually shown its advantages and benefited patients. The purpose of this article is to review the progress of transcatheter mitral valve intervention in this year, and to provide prospects for the future of transcatheter mitral valve treatment.

Clinical efficacy and survival analysis of totally thoracoscopic redo mitral valve replacement / 中国胸心血管外科临床杂志

@#Objective     To analyze the clinical efficacy and survival outcome of totally thoracoscopic redo mitral valve replacement and evaluate its efficiency and safety. Methods     The clinical data of patients with totally thoracoscopic redo mitral valve replacement in Guangdong Provincial People’s Hospital between 2013 and 2019 were retrospectively analyzed. Survival analysis was performed using the Kaplan-Meier method. Univariate and multivariate Cox regression analyses were used to determine the risk factors for postoperative death. Results     There were 48 patients including 29 females and 19 males with a median age of 53 (44, 66) years. All the procedures were performed successfully with no conversion to median sternotomy. A total of 15, 10 and 23 patients received surgeries under non-beating heart, beating heart and ventricular fibrillation, respectively. The in-hospital mortality rate was 6.25% (3/48), and the incidence of early postoperative complications was 18.75% (9/48). Thirty-five (72.92%) patients had their tracheal intubation removed within 24 hours after the operation. The 1- and 6-year survival rates were 89.50% (95%CI 81.30%-98.70%) and 82.90%(95%CI 71.50%-96.20%), respectively. Age>65 years was an independent risk factor for postoperative death (P=0.04). Conclusion     Totally thoracoscopic redo mitral valve replacement is safe and reliable, with advantages of rapid recovery, reducing blood transfusion rate, reducing postoperative complications and acceptable long-term survival rate. It is worthy of being widely popularized in the clinic.

Mitral Surgery for Severe Mitral Annular Calcification: Calcium Resection or Exclusion Procedure / 日本心臓血管外科学会雑誌

Background: Extensive calcification of the mitral annulus (MAC) represents a problem for mitral surgery due to a technical difficulty for implanting prosthetic valves, because the calcium does not allow placing direct sutures through the annulus and para-prosthetic leakage or cardiac rupture may result. We describe our experience with mitral valve surgery with or without decalcification of the annulus. Methods: Since 2005, we performed mitral valve operations in 1,327 patients and among them, severe mitral annular calcification was present in 25 (1.9%). Results: The mean age was 75±9 years and there were 6 men and 19 women, with hemodialysis in 4. Mitral valve replacement (MVR) was performed in all patients. A concomitant operation was aortic valve replacement in 19 and coronary artery bypass grafting in 4 patients. The MAC was resected in 14 (Group-R) and was excluded in 11 (Group-E). In-hospital mortality was four patients in Group-R. The cause of death was congestive heart failure in two, cerebellar infarction in one, and respiratory failure in one. Postoperative morbidity included one patient with reexploration and one with prolonged respiratory failure The aortic cross clamp time was a mean of 180±44 min (range 108∼266 min) in Group-R and 139±32 min (range 61∼186 min) in Group-E (p=0.009). The size of the prosthetic mitral valve was 24.3±1.0 mm in Group-R and 24.6±0.8 mm in Group-E (p=0.618). The postoperative echocardiography showed no abnormal mean pressure gradient of mitral valve prosthesis nor para-valvular leak in any patients in either group. Conclusions: The mitral valve replacement without annular decalcification in a severely calcified mitral annulus is a safe and an effective approach in an elderly patient.

Clinical Effects of Surgical Left Atrial Reduction and Concomitant Mitral Valve Replacement in Patients with Giant Left Atrium

ABSTRACT Introduction: A giant left atrium may cause respiratory dysfunction and hemodynamic disturbance postoperatively. This retrospective study aimed to evaluate clinical effects of surgical left atrial reduction in concomitant cardiac valves operations. Methods: One hundred and thirty-five patients with heart valve diseases and giant left atriums from January 2004 to July 2021 were enrolled into this research. They were divided into the folded group (n=63) and the unfolded group (n=72). Patients in the folded group had undergone cardiac valve operations concomitantly with left atrial reductions. The perioperative characteristics were compared between both groups, and subgroup analysis was performed. Results: There were five deaths in the folded group and 25 deaths in the unfolded group (P<0.001). Complications including pneumonia, sepsis, multiple organs dysfunction syndrome, low cardiac output syndrome, and the use of continuous renal replacement therapy were significantly fewer in the folded group. The receiver operating characteristic curve of left atrial max. diameter predicting mortality was significant (area under the curve=0.878, P=0.005), and the cutoff point was 96.5 mm. The stratified analysis for sex showed that more female patients died in the unfolded group. Logistic regression for mortality showed that the left atrium unfolded, left atrial max. diameter, cardiopulmonary bypass time, and mechanical ventilation time increased the risk of death. Conclusion: Surgical left atrial reduction concomitantly with valves replacement could decrease mortality and was safe and effective in giant left atrium patients.

The effect of mitral valve repair for rheumatic mitral stenosis / 中华胸心血管外科杂志

Objective:To retrospectively evaluate the clinical effect of mitral valve repair for rheumatic mitral stenosis.Methods:We retropectively analyze the clinical datd of 50 rheumatic mitral disease patients undergoing mitral valve repair from January 2016 to March 2019, the clinical outcome was compaired with those of patients undergoing mitral valve replacement. The operation time, cardiopulmonary bypass time, blood loss, ICU time, hospital stay, and postoperative cardiac function were analyzed, and followed up for 2 years to assess mitral regurgitation, cardiac function, and complication rates.Results:The time of cardiopulmonary bypass and ascending aorta occlusion in the valve repair group were longer than those in the valve replacement group ( P<0.05), and the postoperative ventilator assistance time, ICU stay time, and hospital stay were shorter than those in the valve replacement group ( P<0.05). After 2 years of follow-up, no patients died in the two groups. The rehospitalization rate in the valve repair group was lower than that in the replacement group ( P<0.05), and there was no significant difference in the reoperation rate between the groups ( P>0.05); There was 1 case (2%) of moderate mitral valve regurgitation in the mitral valve repair group, no moderate or severe mitral valve stenosis, no paravalvular leakage in the mitral valve replacement group, and no significant difference between the two groups ( P>0.05). The left ventricular end-diastolic diameter and left ventricular ejection fraction in the mitral valve repair group were significantly better than those in the mitral valve replacement group ( P<0.05). Conclusion:Mitral valve repair is effective in treating rheumatic mitral stenosis. It is beneficial to protect heart function, reduce postoperative anticoagulation complications, and does not increase the rate of reoperation. It is a safe, effective and feasible treatment.

Treatment of moderate functional mitral regurgitation during aortic valve replacement in patients with aortic valve disease: A retrospective cohort study / 中国胸心血管外科临床杂志

@#Objective    To evaluate the impact of different surgical strategies for moderate functional mitral regurgitation (FMR) at the time of aortic valve replacement (AVR) on patients' prognosis. Methods    A total of 118 AVR patients, including 84 males and 34 females, aged 58.1±12.4 years, who were complicated with moderate FMR were retrospectively recruited. Patients were divided into three groups according to the treatment strategy of mitral valve: a group A (no intervention, n=11), a group B (mitral valve repair, n=51) and a group C (mitral valve replacement, n=56). The primary endpoint was the early and mid-term survival of the patients, and the secondary endpoint was the improvement of FMR. Results    The median follow-up time was 29.5 months. Five patients died perioperatively, all of whom were from the group C. Early postoperative FMR improvement rates in the group A and group B were 90.9% and 94.1% (P=0.694). The mid-term mortality in the three groups were 0.0%, 5.9% and 3.9%, respectively (P=0.264), while the incidences of major cardiovascular and cerebrovascular events were 0.0%, 9.8% and 17.7%, respectively (P=0.230). Improvements of FMR in the group A and group B were 100.0% and 94.3% at the mid-term follow-up (P>0.05). Conclusion    For patients receiving AVR with moderate FMR, conservative treatment or concurrent repair of mitral valve may be more reasonable, while mitral valve replacement may increase the incidence of early and mid-term adverse events.

Re-repair Mitral Valve Replacement for Paravalvular Leaks Unsuitable for Catheter Treatment / 日本心臓血管外科学会雑誌

We report a case of re-repair mitral valve replacement (MVR) for paravalvular leaks that were unsuitable for catheter treatment. Three years ago, a 67-year-old woman, who had undergone MVR for rheumatic mitral valve replacement at the age of 33 years and undergone re-MVR at the age of 47 years, was admitted with hemolytic anemia. We performed paravalvular leak (PVL) repair directly with 5-0 polypropylene sutures because of calcifications in the annulus. Three years after the operation, she presented with dyspnea on exertion, and transthoracic echocardiography revealed several paravalvular leaks. We consulted with cardiologists in our and other institutions, and these leaks were determined to be unsuitable for catheter treatment. We removed the artificial valve, and found the calcifications and residual cuffs from the first or second artificial valves. These residual cuffs were removed with Cusa® and Harmonic Synergy®. We performed re-repair MVR without reconstruction of the annulus. She was discharged on postoperative day 39 with no complications and did not experience any recurrence of PVL for 2 years. Residual cuffs from the artificial valve may cause PVLs, and Cusa® and Harmonic Synergy® are useful for removing residual cuffs and calcifications.

Valve in Valve transcatheter mitral valve replacement by a transvenous, transseptal access: A case report / 中国胸心血管外科临床杂志

@#Reoperation due to degenerated bioprostheses is an important factor of high-risk thoracic surgeries. In 2020 ACC/AHA guideline, Valve in Valve (ViV) was recommended for high-risk patient instead of surgical mitral valve replacement. This report described a 77-year-old male patient with a failed mitral bioprosthetic valve, evaluated at high risk of surgery, received a transvenous, transseptal transcatheter mitral valve replacement (TMVR). Tracheal intubation was removed at CCU 3 h after surgery without discomfort such as polypnea. The patient was transferred out of the CCU and discharged on the 3rd day. Compared with transapical access, transvenous transseptal access was less invasive, with shorter duration in CCU and hospitalization.

Implante Percutâneo Transeptal de Bioprótese em Disfunção de Prótese Valvar Cirúrgica Mitral - Experiência Multicêntrica Brasileira / Percutaneous Transseptal Bioprosthetic Implantation in Failed Prosthetic Surgical Mitral Valve - Brazilian Multicenter Experience

Resumo Fundamento A intervenção percutânea em pacientes com disfunção de prótese biológica mitral apresenta-se como uma alternativa ao tratamento cirúrgico convencional. Objetivo Relatar a primeira experiência brasileira de implante transcateter de bioprótese valve-in-valve mitral via transeptal (TMVIV-via transeptal). Métodos Foram incluídos pacientes portadores de disfunção de bioprótese cirúrgica submetidos ao TMVIV-transeptal em 12 hospitais brasileiros. Foram considerados estatisticamente significativos valores de p<0,05. Resultados Entre junho/2016 e fevereiro/2019, 17 pacientes foram submetidos ao TMVIV-via transeptal. A mediana de idade foi 77 anos (IIQ,70-82), a mediana do escore STS-PROM foi 8,7% (IIQ,7,2-17,8). Todos os pacientes tinham sintomas limitantes de insuficiência cardíaca (CF≥III), tendo 5 (29,4%) sido submetidos a mais de uma toracotomia prévia. Obteve-se sucesso do TMVIV-via transeptal em todos os pacientes. A avaliação ecocardiográfica demonstrou redução significativa do gradiente médio (pré-intervenção, 12±3,8 mmHg; pós-intervenção, 5,3±2,6 mmHg; p<0,001), assim como aumento da área valvar mitral (pré-intervenção, 1,06±0,59 cm2; pós-intervenção, 2,18±0,36 cm2; p<0,001) sustentados em 30 dias. Houve redução significativa e imediata da pressão sistólica de artéria pulmonar, com redução adicional em 30 dias (pré-intervenção, 68,9±16,4 mmHg; pós-intervenção, 57,7±16,5 mmHg; 30 dias, 50,9±18,7 mmHg; p<0,001). Durante o seguimento, com mediana de 162 dias (IIQ, 102-411), observou-se marcada melhora clínica (CF≤II) em 87,5%. Um paciente (5,9%) apresentou obstrução de via de saída de ventrículo esquerdo (VSVE), evoluindo para óbito logo após o procedimento, e outro morreu aos 161 dias de seguimento.Conclusão: A primeira experiência brasileira de TMVIV-transeptal demonstra a segurança e a efetividade dessa nova técnica. A obstrução da VSVE é uma complicação potencialmente fatal, reforçando a importância da seleção dos pacientes e do planejamento do procedimento. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)

Abstract Background Percutaneous intervention in patients with bioprosthetic mitral valve dysfunction is an alternative to conventional surgical treatment. Objectives To report the first Brazilian experience with transseptal transcatheter bioprosthetic mitral valve-in-valve implantation (transseptal-TMVIV). Methods Patients with surgical bioprosthetic dysfunction submitted to transseptal-TMVIV in 12 Brazilian hospitals were included. The significance level adopted was p<0.05. Results From June/2016 to February/2019, 17 patients underwent transseptal-TMVIV. Their median age was 77 years (IQR,70-82) and median Society of Thoracic Surgeons predicted risk of mortality (STS-PROM) score was 8.7% (IQR,7.2-17.8). All patients had limiting symptoms of heart failure (FC≥III) and 5 (29.4%) had undergone more than one previous thoracotomy. Transseptal-TMVIV was successful in all patients. Echocardiographic assessment showed a significant reduction in mean mitral valve gradient (pre-intervention, 12±3.8 mmHg; post-intervention, 5.3±2.6 mmHg; p<0.001), in addition to an increase in mitral valve area (pre-intervention, 1.06±0.59 cm2; post-intervention, 2.18±0.36 cm2; p<0.001) sustained for 30 days. There was a significant and immediate reduction in the pulmonary artery systolic pressure, with an additional reduction in 30 days (pre-intervention, 68.9±16.4 mmHg; post-intervention, 57.7±16.5 mmHg; 30 days, 50.9±18.7 mmHg; p<0.001). During follow-up (median, 162 days; IQR, 102-411), significant clinical improvement (FC≤II) was observed in 87.5% of the patients. One patient (5.9%) had left ventricular outflow tract (LVOT) obstruction and died right after the procedure, and another died at 161 days of follow-up. Conclusion The first Brazilian experience with transseptal-TMVIV shows the safety and effectivity of the new technique. The LVOT obstruction is a potentially fatal complication, reinforcing the importance of patients' selection and of procedural planning. (Arq Bras Cardiol. 2020; [online].ahead print, PP.0-0)

Estenosis mitral con calcificación severa del anillo mitral: reemplazo mitral con prótesis OnX Conform en posición supraanular / Mitral stenosis with severe annular calcification: mitral valve replacement with an OnX Conform prosthesis in a supra annular position

Abstract A 68-year-old man previously subjected to radiotherapy had a prior aortic valve replacement due de radiation induced calcification of the aortic valve. Presently the patient developed severe calcification of the mitral valve ring leading to critical mitral valve stenosis. A supra annular implantation of an On X Conform valve was successfully achieved. The clinical course was uneventful, and the echocardiographic evaluation demonstrated a normal function of the valve. Different alternatives for the surgical management of this complication are discussed.

Clinical study of Perioperative Use of Levosimendan in Patients Undergoing Heart Valve Replacement

Objective To investigate the clinical effect of levosimendan in perioperative aortic and/or mitral valvereplacement. Methods Patients undergoing open heart aortic and/or mitral valve replacement in our hospitalfrom January 2018 to December 2019 were enrolled. 45 patients in the control group received routineperioperative treatment based on dopamine, while 45 patients in the research group received continuousperioperative administration of levosimendan injection for 24h on the basis of routine treatment. The leftventricular ejection fraction (LVEF), left ventricular end-diastolic diameter (LVDd) and left ventricular end-systolicdiameter (LVDs) were evaluated by color doppler echocardiography before and one week after surgery.Postoperative mechanical ventilation weaning time, length of ICU stays, number of vasoactive drugs used andwithdrawal time; indexes of liver and kidney function before and on the day after surgery to 10 days after surgery;use of in vitro support techniques such as aortic balloon pulsation (IABP), continuous renal replacement therapy(CRRT) and extracorporeal membrane oxygenation (ECMO) within 5 days of perioperative period. Results Theimprovement of LVDs and LVEF in the study group using levosimendan one week after the operation wassignificantly better than that in the control group (P value was 0.013 and 0.001, respectively), and fewer kinds ofvasoactive drugs were needed (P<0.001), and the risk of postoperative AKI in the study group was significantlylower than that in the control group (P=0.047). Conclusion The perioperative use of levosimendan can effectivelypromote the recovery of cardiac systolic function and reduce the risk of postoperative AKI.

​A Comparative Study of Changes in Left Ventricular Function after Mitral Valve Replacement in Patients with Severe Rheumatic Mitral Regurgitation with and without Mild Mitral Stenosis

Introduction: Presently off- pump CABG has proved itself tobe a safe, cheaper and effective alternative of on- pump CABG.However, it requires manipulation, displacement, positioning& mechanical stabilization of the heart during grafting whichmay cause haemodynamic alteration. Study was done withthe objective of finding out the changes in Central VenousPressure (CVP); Mean Arterial Pressure (MAP); MeanPulmonary Arterial Pressure (MPAP); Right Ventricular EndDiastolic Pressure (RVEDP) & Left Ventricular End DiastolicPressure (LVEDP) while grafting the anterior, lateral &inferior surfaces of heart during off-pump CABG.Material and methods: Over one year time, 50 patients withLVEF ≥40%, undergoing off-pump CABG were monitoredfor the above parameters at various stages of their operation,namely:- 1. During manipulation & shunt introduction,2.During anastomosis without shunt, 3.During anastomosiswith shunt & 4.After anastomosis; while grafting the anterior,lateral & inferior surfaces of heart. These results werecompared with the baseline values of CVP, MAP, MPAP,RVEDP & LVEDP, to look for statistical significance.Results: During manipulation & shunt introduction; CVP(mmHg) significantly increased during Ramus grafting - 12±1.8(p<0.047); and also during OM grafting – 12.6±1.9 (p<0.045),when compared to a baseline value of 9±1.8. The MAP(mmHg) was significantly decreased during manipulation &shunt introduction in Diagonals - 70±5.8 (p<0.046), Ramus- 70±5.8 (p<0.048), OMs - 65±5.8 (p<0.028) & in the Rightterritory - 69±5.9 (p<0.032); as compared with baselineMAP of 76±11.7. During anastomosis without shunt also, theMAP(mmHg) significantly decreased while grafting LAD- 70±3.8 (p<0.048), Diagonals - 68±3.8 (p<0.039), OMs –71.8±4.8 (p<0.039) & Right sided arteries 70.8±4.6 (p<0.039),as compared with baseline MAP values. The MPAP(mmHg)was significantly increased – 18.3±3.7 (p<0.047) as comparedto the baseline value of 16±2.4 during manipulation & shuntintroduction in the OMs.Conclusion: During OPCABG there will be significantalterations in haemodynamics mostly due to mobilizationof the heart, which is necessary to visualise the targetvessels properly & stabilisation of the concerned areawith stabiliser. However, by observing the haemodynamicvariations constantly & by making necessary mechanical &pharmacological adjustments, unnecessary conversion to Onpump technique can be avoided.

Metal Allergy in Cardiovascular Surgery : a Case Report / 日本心臓血管外科学会雑誌

We present a successful case of a patient with multiple metal allergy—cobalt, nickel, chromium, and zinc—who had a past history of systemic metal dermatitis. He was a 58-year-old man who complained of exertional chest discomfort. After admission, he had a fever and his blood culture was positive with methicillin-sensitive Staphylococcus aureus. Three days later, multiple micro cerebral infraction was detected in magnetic resonance imaging. After an improvement of inflammatory reaction, he was transferred to our facility for cardiac examination. Moderate mitral regurgitation due to valve perforation and multiple coronary vessel stenosis were detected. Mitral valve replacement and coronary artery bypass grafting were planned to perform. We chose surgical materials based on a preoperative epicutaneous (patch) test and his clinical course was uneventful without any allergic reaction. Metal contact allergy is an important issue in cardiovascular surgery. A collaboration with dermatologists is essential for the preparation of surgical materials.

A Case in Which Mitral Valve Replacement Was Performed for Recurrent Severe Mitral Regurgitation by Single Leaflet Device Attachment (SLDA) after MitraClip / 日本心臓血管外科学会雑誌

After a MitraClip was implanted for mitral regurgitation (MR), we experienced a case in which mitral valve replacement was performed for recurrent severe MR because of a detached MitraClip. The case was an 82-year-old woman. The MitraClip was implanted for severe MR and regurgitation was controlled to a mild level, but one month after the operation, symptoms of heart failure appeared, and single leaflet device attachment (SLDA) with severe MR was observed on the echocardiogram. As the heart failure symptoms recurred, surgical mitral valve replacement was performed. Because of severe kyphosis, the left atrial approach with a midline sternum incision made it difficult to achieve a good operative field and this was changed intraoperatively to a transseptal approach. The MitraClip was firmly fused with the anterior leaflet A2, so it was judged that removal of the clip was difficult and valve repair was impossible ; it was thus decided to replace the valve. The mark of the MitraClip could be observed on the posterior leaflet, and it appeared to have been inserted for only about 1-2 mm. A bioprosthetic valve was implanted, preserving the posterior leaflet. There were no problems in weaning the patient from cardiopulmonary bypass. The postoperative course was uneventful, and she was discharged on the 14th day after the operation. Valve repair is difficult in a case with a merged SLDA after insertion of a MitraClip, and valve replacement needs to be performed, so it is important to pay attention to the attachment of the MitraClip.

Infective Endocarditis with an Infectious Cerebral Aneurysm Rupture and an Acute Myocardial Infarction / 日本心臓血管外科学会雑誌

A 56-year-old woman was referred to our hospital due to anorexia. An echocardiogram demonstrated severe mitral valve regurgitation and vegetation located on the valve. We diagnosed infective endocarditis and started to treat with antibiotics. During antibiotics treatment, cerebral hemorrhage was caused by rupture of an infectious cerebral aneurysm. She was treated by surgical operation. Waiting for cardiac surgery, she had sudden chest pain. Electrocardiogram examination demonstrated an anterior acute myocardial infarction. Emergency coronary angiogram revealed complete obstruction of the left anterior descending coronary artery. She was successfully treated with thrombus aspiration using a catheter device and stenting. However, she was in cardiogenic shock and her blood pressure could not be maintained with catecholamine and IABP. We performed emergency mitral valve replacement. After surgery, the circulation dynamics improved and she was discharged from the hospital.

Clinical research on radiofrequency ablation of atrial fibrillation with mitral valve replacement under totally thoracoscopic surgery / 中国胸心血管外科临床杂志

@#Objective    To investigate the feasibility, safety and effectiveness of radiofrequency ablation of atrial fibrillation with mitral valve replacement under totally thoracoscopic surgery. Methods    The clinical data of 107 patients with rheumatic mitral disease and atrial fibrillation who underwent mitral valve replacement and radiofrequency ablation at the same time in our hospital from January 2014 to October 2018 were retrospectively analyzed. The patients were divided into two groups: a totally thoracoscopic surgery group (n=51, including 20 males and 31 females, aged 50.57±5.24 years) and a median sternotomy group (n=56, including 21 males and 35 females, aged 52.12±5.59 years) according to the surgical methods. The preoperative, intraoperative and postoperative data of the patients were compared. Results    All operations were successfully completed without death. In terms of bleeding volume, drainage volume, ventilator-assisted breathing time, hospital stay and incision length, the totally thoracoscopic surgery group was better than the median sternotomy group, and the difference was statistically significant (P<0.05). The cardiopulmonary bypass time and radiofrequency ablation time in the totally thoracoscopic surgery group were longer than those in the median sternotomy group (P<0.05). There was no significant difference in the operation time, aortic occlusion time, postoperative complications, left ventricular ejection fraction, left atrial diameter and sinus rhythm maintenance between the two groups (P>0.05). There was no atrioventricular block, pulmonary vein stenosis, atrioesophageal fistula, coronary artery injury, stroke or hemorrhage during the follow-up. Conclusion    Radiofrequency ablation of atrial fibrillation with mitral valve replacement under totally thoracoscopic surgery is safe and effective, and it is worthy of clinical application.

Síndrome de Takotsubo con disfunción grave de ventrículo izquierdo en el postoperatorio de reemplazo valvular mitral / Postoperative Takotsubo syndrome with severe left ventricular dysfunction following mitral valve replacement

RESUMEN El síndrome de Takotsubo, descrito por vez primera en Japón a fines de 1989 y principios de 1990, caracteriza un conjunto de pacientes con discinesia apical transitoria y conservación de la contractilidad hacia la base del ventrículo izquierdo, que recuerda la forma de la vasija usada por los pescadores para atrapar pulpos. Habitualmente se observa en situaciones que impliquen elevación de catecolaminas y su cuadro clínico es similar al de un infarto agudo de miocardio. El caso que se presenta ocurrió, sorprendentemente, en el postoperatorio de una cirugía cardiovascular y probablemente sea el primero encontrado en Cuba en esta circunstancia: isquemia perioperatoria tras reemplazo valvular mitral, que se recuperó en aproximadamente 72 horas, aunque su recuperación total fue más tardía. Se muestran las imágenes angiográficas.

ABSTRACT Takotsubo syndrome was first described in Japan in late 1989 and early 1990 and featured a group of patients with transient apical dyskinesia and preservation of basal left-ventricular contractility, which resembled the vessel used by fishermen to catch octopus. It is usually seen in situations involving catecholamine release and its clinical picture mimics that of acute myocardial infarction. The case presented occurs, surprisingly, in the postoperative period of cardiovascular surgery and is probably the first one found in this circumstance in Cuba: perioperative ischemia after mitral valve replacement, which recovered within nearly 72 hours, although complete recovery occurred later. Angiographic images are shown.

Aortic dissection after mitral valve replacement: the role of intraoperative echocardiography in this diagnosis / Dissecção de aorta pós-troca valvar mitral: o papel da ecocardiografia intraoperatória no diagnóstico

Abstract According to the most recent guidelines, the use of intraoperative transesophageal echocardiography in valvular surgeries is well established, as well as its use in the diagnosis, management, and rescue of perioperative complications. The aim of this case report is to illustrate a condition in which its intraoperative use had a positive influence on the outcome.

Resumo O uso da ecocardiografia transesofágica no intraoperatório em cirurgias valvulares é bem estabelecido de acordo com os guidelines mais recentes, assim como o seu uso no diagnóstico, manuseio e resgate de complicações perioperatórias. O objetivo deste relato de caso é ilustrar uma situação em que o seu uso no intraoperatório influenciou de maneira positiva o seu desfecho.