Papillary muscle rupture without severe mitral regurgitation following percutaneous balloon mitral commissurotomy: a case report.

Background: Percutaneous transvenous mitral commissurotomy (PTMC) is the first-line therapy of clinically significant rheumatic mitral stenosis. While the procedure is generally safe, new onset or aggravation of mitral regurgitation (MR) may occur, mainly due to commissural splitting and, less frequently, to leaflet tear and chordal rupture. Papillary muscle rupture (PMR) is exceedingly rare in this setting. Case summary: A 74-year-old woman with a history of aortic valve replacement and prior rheumatic mitral commissurotomy presented for worsening exercise intolerance and exertional dyspnoea. Transthoracic echocardiography showed a mean pressure gradient of 10 mmHg and a mitral valve area of 1.0 cm², consistent with clinically significant mitral stenosis. Subsequent PTMC was complicated by anterolateral PMR. However, the resulting MR was unexpectedly only of mild-to-moderate severity. Because of residual mitral stenosis and persisting symptoms, surgical mechanical mitral valve replacement and tricuspid annuloplasty were performed 6 weeks after PTMC. Papillary muscle rupture was confirmed during surgery. Discussion: We herein describe the occurrence of PMR induced by PTMC; the resulting MR was unexpectedly of mild-to-moderate severity, as a result of extensive rheumatic lesions limiting valve mobility. This case challenges the dogma according to which PMR invariably leads to severe MR. This might not be necessarily the case when it occurs following PTMC.

Role of imaging for diagnosis and management of aortic valve papillary fibroelastoma and cardiac amyloid light chain amyloidosis: a case report.

BACKGROUND: We report the case of a patient who presented with concomitant aortic valve papillary fibroelastoma (PFE) and cardiac amyloidosis. Although histologically benign, PFE confers an increased thromboembolic risk, and surgical excision is often indicated. However, outcomes of cardiac surgery are poor in patients with cardiac amyloidosis. CASE SUMMARY: A 61-year-old man with complaints of dyspnoea and weight loss of 10 kg developing over the past 5 months was evaluated in the cardiology clinic. Echocardiography revealed sessile aortic valve PFE and was also highly suggestive of cardiac amyloidosis. The diagnosis of amyloid light chain amyloidosis secondary to indolent multiple myeloma was eventually confirmed. Therapy with daratumumab, bortezomib, cyclophosphamide, and dexamethasone allowed full remission over a 6-month period and resulted in marked improvement in symptoms and cardiac function as evaluated by global longitudinal strain. Further workup with cerebral magnetic resonance revealed multiple vascular sequelae. Surgical removal of the aortic fibroelastoma with bioprosthetic aortic valve replacement was performed successfully and the patient had an uneventful recovery. DISCUSSION: Papillary fibroelastoma and cardiac amyloidosis are rare and most likely unrelated entities. Concomitant presentation of both conditions in the same patient presents a unique therapeutic challenge. By allowing cardiac function to be monitored during chemotherapy, speckle-tracking echocardiography can prove instrumental in determining the optimal timing of surgical intervention.

Pathophysiology and management of combined aortic and mitral regurgitation.

The combination of aortic and mitral regurgitation is a typical example of a frequent yet understudied multiple valve disease scenario. The aetiology is often rheumatic or degenerative; less frequently it can be induced by drugs or radiation, or caused by infective endocarditis or congenital valvular lesions. Aortic regurgitation resulting in secondary mitral regurgitation is also not uncommon. There are limited data to guide the management of combined aortic and mitral regurgitation. Left ventricular dysfunction is frequent at initial presentation, and even more so postoperatively, suggesting that surgical management should not be delayed, particularly when symptoms occur or when there is evidence of even subtle left ventricular dysfunction. The decision to operate on one or both valves not only depends on the severity of each lesion, but also on several other factors, including age, co-morbidities and frailty, the increased operative risk of double valve surgery, the increased risk of long-term thrombotic and bleeding complications with multiple mechanical valves, the risk of leaving one valve unoperated and the probability of requiring redo surgery. The role of a multidisciplinary heart valve team is critical in this setting to optimize management and outcomes. The role of transcatheter approaches is currently limited, but technological advances will probably soon change the management paradigm.

Late mortality after cardiac interventions over 10-year period in two Cameroonian government-owned hospitals.

BACKGROUND: Cardiac surgery is a growing activity in Sub-Saharan Africa, however, data related to long-term mortality are scarce. We aimed to analyze outcome data of cardiac interventions in two hospitals in Cameroon over 10 years' period. METHODS: we conducted a retrospective analytical and descriptive study at the Douala General Hospital and Yaoundé General Hospital. All patients operated between January 2007 and December 2017, or their families were contacted by phone between January and April 2018 for a free of charges medical examination. RESULTS: Of a total of 98 patients operated during the study period, 8 (8.2%) were lost to follow-up. Finally, 90 patients [49 (54.4%) women and 41 (45.6%)] men were included. The mean age was 49±22 years (range, 13-89 years). The surgical indications were valvular heart diseases in 37 (41.1%) cases, congenital heart diseases in 11 (12.2%) cases, chronic constrictive pericarditis in 4 (4.4%) cases, and intra cardiac tumor in 1 (1.1%) case. Valve replacement was the most common type of surgery carried out in 37 (41.1%) cases-mostly with mechanical prosthesis. Pacemaker-mostly dual-chambers were implanted in 36 (40.0%) patients. The median follow-up was 26 months. The overall late mortality was 5.7%, and the overall survival rates at 5 and 10 years were 95.5% and 94.4% respectively. The overall survival rates at 5 and 10 years for mechanical valve prosthesis were 93.3% and 90% respectively. The survival at 10 years was 100% for patients with bioprosthesis. The survival rates at 10 years were 94.1% and 100% respectively for dual and single chamber pacemaker. CONCLUSIONS: Long-term outcome of cardiac surgery in hospitals in Cameroon are acceptable with low mortality rate. However, outcome metrics beyond mortality should be implemented for a prospective data collection.

Anesthetic Management of a Voluminous Left Atrial Myxoma Resection in a 19 Weeks Pregnant with Atypical Clinical Presentation.

We report the case of a semi-urgent cardiac surgery, in a 19 gestation age pregnant. Despite the fact that the patient was asymptomatic, except for some palpitations, a large left auricle (LA) myxoma was fortuitously diagnosed with transthoracic echocardiography (TEE). Considering the important embolic risk, the tumor was successfully removed during cardiac surgery under cardiopulmonary bypass (CPB). Fetal bradycardia following defibrillation under stable maternal and CPB conditions was successfully managed. The postoperative period and remainder of the pregnancy was smooth and the delivery uneventful.

Left superior pulmonary vein connected to superior vena cava vein in a patient with situs inversus totalis: A challenging diagnosis.

We herein describe the previously unreported combination of partial anomalous venous connection to the superior vena cava combined with situs inversus totalis. Following peripheral contrast injection, bubbles appeared initially in the left atrium allowing the diagnosis of a supra-atrial connection to be made using transthoracic echocardiography, but this timing was not anymore reproduced during transesophageal echocardiography performed minutes later. Cardiac computed tomography allowed the final diagnosis to be made. This case emphasizes the importance of performing bubble studies both during transesophageal and transthoracic echocardiography.

Clinical Implications of Preserving Subvalvular Apparatus During Mitral Valve Replacement for Acute Ischemic Papillary Muscle Rupture.

We report the case of a patient who presented with sequential rupture of two papillary muscle bellies after emergent mitral valve replacement with subvalvular apparatus preservation for acute severe mitral regurgitation and cardiogenic shock during acute myocardial infarction. We discuss the possibility that the remaining chordae may have meanwhile contributed to muscle avulsion by exerting traction on ischemic myocardium and prevented embolization of the secondarily detached papillary muscle heads.

The clinical challenge of concomitant aortic and mitral valve stenosis.

The coexistence of mitral and aortic stenosis is not exceptional. Whereas rheumatic fever is currently plummeting in the Western countries, the incidence of degenerative disease is inversely increasing. The haemodynamic interactions which may interfere both with the usual echocardiographic parameters and with the invasive assessment may render the diagnosis difficult. The therapeutic challenges raised by this entity should not be underestimated. The increased morbidity and mortality of multivalvular surgery has to be balanced with the risk of a second operation down the line if one valvular involvement, deemed of a lesser importance, is neglected. This complex situation requires the multidisciplinary approach of a heart team involving surgeons, cardiologists, geriatrists if need be and imaging specialists.

Swinging cardiac calcified amorphous tumour arising from a calcified mitral annulus in a patient with normal renal function.

A 67-year-old man was referred to our institution for the management of a left-sided intracardiac mass discovered following two cardioembolic events. Imaging studies revealed a highly mobile mass attached to the ventricular side of a calcified mitral annulus. The mass had not been present on echocardiography 1 year earlier. Surgical resection was performed. Microscopic examination confirmed the diagnosis of a calcified amorphous tumour. The postoperative course was unremarkable, and the patient remains asymptomatic and without recurrence of a mass or neurological event after a 12-month follow-up.

Cardiac calcified amorphous tumor: A systematic review of the literature.

BACKGROUND: Calcified amorphous tumor (CAT) of the heart is a rare non-neoplastic intracavitary cardiac mass. Several case reports have been published but large series are lacking. OBJECTIVE: To determine clinical features, current management and outcomes of this rare disease. DESIGN: A systematic review of all articles reporting cases of CAT in order to perform a pooled analysis of its clinical features, management and outcomes. DATA SOURCES: An electronic search of all English articles using PUBMED was performed. Further studies were identified by cross-referencing from relevant papers. INCLUSION CRITERIA: We restricted inclusion to articles reporting cases of CAT in the English language literature published up to July 2014. DATA EXTRACTION: One author performed data extraction using predefined data fields. RESULTS: A total of 27 articles, reporting 42 cases of CAT were found and included in this review. CONCLUSION: In this review, the most frequent presenting symptoms were dyspnea and embolic events. Mitral valve and annulus were the most frequent location of CAT. Surgery was most of the time required to confirm diagnosis, and was relatively safe. Overall outcome after surgical resection was good.

The role of biventricular assistance in primary graft failure after heart transplantation.

A 37-year-old man suffered from systolic heart failure as a result of idiopathic dilated cardiomyopathy since 1995 and was followed up in our cardiology department. In June 2006, the patient arrived at our outpatient clinic with an acute renal impairment and all manifestations of acute heart failure. He was already registered on the waiting list for heart transplantation (Eurotransplant) as a highly urgent request. The patient underwent heart transplantation but the reperfused allograft was totally akinetic and we decided to place a biventricular assist device immediately. The patient fully recovered after seven days of biventricular circulatory support and was discharged on the 38th day after the transplantation. Three years later, he is in good general condition without any manifestation of rejection. We conclude that biventricular assist device implantation is a good indication after post-cardiotomy failure and it should be started as early as possible before shock and possible irreversible organ damage.

Respective prevalence of the different carpentier classes of mitral regurgitation: a stepping stone for future therapeutic research and development.

OBJECTIVES: To determine the prevalence of mitral regurgitation (MR) in the U.S. adult population by classifying its mechanisms according to Carpentier's functional class. BACKGROUND: MR is the most common clinically recognizable valvular heart condition in the U.S. affecting 2 to 2.5 million people in 2000. A true estimate of the prevalence of MR in accordance to the functional class and etiology is unavailable. METHODS: We conducted a Medline search regarding prevalence and etiologies of MR. Etiologies were grouped by Carpentier's functional classification, and estimated prevalence numbers were projected to U.S. adult population of 200 million. Moderate-to-severe grades of MR were included. RESULTS: Carpentier type I, including congenital MR and endocarditis, has a prevalence of less than 20 per million. Myxomatous infiltration leading to mitral valve prolapse is the largest group associated with a type II mechanism with 15,000 per million prevalence. Type IIIa includes rheumatic heart disease, systemic lupus erythematosus (SLE), antiphospholipid syndrome (APS), and rare infiltrative and tropical disorders. SLE and APS have a mean prevalence of 10,520 per million. Carpentier IIIb is the largest group leading to MR, which is mostly functional, and includes ischemic cardiomyopathy, left ventricular (LV) dysfunction, and dilated cardiomyopathies. The estimated prevalence of MR in ischemic cardiomyopathy is 7500 to 9000 per million, and in LV dysfunction, 16,250 per million. CONCLUSIONS: The largest number of people with MR is in type IIIb. Certain etiologies show overlap within functional classes due to multiple mechanisms of MR. We attempted to classify etiologies of MR by a functional class to determine the disease burden.

Five years follow-up after Y-graft arterial revascularization: on pump versus off pump; prospective clinical trial.

OBJECTIVES: We report our comparative experience of on-pump and off-pump full arterial coronary artery bypass grafting (CABG) using both internal mammary arteries (IMAs) anastomosed as a Y-graft. METHODS: A single-center clinical study was conducted prospectively between January 2003 and May 2008. It compared the short- and mid-term clinical outcomes of on- and off-pump arterial revascularization where the left internal mammary artery (LIMA) was anastomosed to the left anterior descending (LAD) artery while the free right internal mammary artery (RIMA) graft taking off from the LIMA was used to bypass different coronary targets. RESULTS: One hundred and ninety-two patients were divided into 77 on-pump and 115 off-pump procedures based on the intention to treat. The mean age in both groups was 60.2+/-11.7 and 68.1+/-10.6 years, respectively (P<0.05). Mean predictive logistic EuroSCORE was 3.5+/-6.7% for the on-pump group and 7.3+/-8.6% for the off-pump group (P<0.0001). Mean number of distal anastomoses were 2.7+/-0.6 (group ON) and 2.5+/-0.6 (group OFF) (P=NS). Postoperative mortality was two patients (2.6%) in the on-pump group and four patients (3.4%) in the off-pump group (P=0.63). No major adverse cardiac event, no stroke and no late death were reported during the follow-up that averaged 36.5+/-18.6 months. Angina recurrence was three patients (2.6%) in off-pump and two patients (3.5%) in on-pump group (P=NS). CONCLUSIONS: The use of a free RIMA as Y-graft from the LIMA performed off pump eradicates aortic manipulations and provides complete revascularization to high-risk patients with mortality similar to the one of a lower risk population operated on pump. The morbidity and cost was lower in the off-pump group. This advocates for the widespread usage of the technique in high-risk patients.

Robotic hybrid procedure and triple-vessel disease.

A 56-year old man presented with increasing angina pectoris. Coronary angiogram showed a triple-vessel disease, with significant lesions on the main stem, on an obtuse marginal branch of the circumflex coronary artery (Cx), on the right coronary artery (RCA), and a proximal occlusion of the left anterior descending artery (LAD). A hybrid procedure was decided, with a beating heart totally endoscopic double vessel coronary artery bypass grafting (Double BHTECAB) on the LAD and the Cx, with the use of a four-arm robotic device, and a stent placement into the RCA in a second step. Both procedures went uneventfully, and the patient is fully asymptomatic 15 months after the procedure.

Oxidative stress produced by circulating microparticles in on-pump but not in off-pump coronary surgery.

OBJECTIVE: This study was undertaken to assess whether plasmas isolated during off-pump coronary surgery trigger less oxidative stress than those isolated during on-pump surgery. METHODS AND RESULTS: Plasmas were sampled from patients before (TO), just after (TI) and 24 hours after (T2) cardiac surgery (n=24 on-pump and n=10 off-pump). Rings of rat thoracic aortas were incubated for 20 hours with these different plasmas (100 microl + 4 ml medium) or saline (control). Thereafter, superoxide anion production was assessed by chemiluminescence and the mean signal was expressed as percent of that in the control ring. In rat aorta exposed to plasmas from on-pump CABG patients (n=6), the signal was enhanced by 210 +/- 29% at T1 (P < 0.05) and by 174 +/- 29% at T2 (P < 0.05) versus 53 +/- 12% at T0. Moreover, at T1 and T2, there was an upregulation of p22(phox), the key subunit of NADPH oxidase, the main enzyme involved in oxidative stress of the vascular wall. In contrast, off-pump plasmas did not induce this superoxide production. Incubation with microparticles obtained by ultracentrifugation also markedly enhanced the signal at T1 and T2 (vs. T0) in the on-pump group (but not in the off-pump group). Selective removal of CD34, CD105, CD59, CD146, CD42 microparticles using flow cytometry did not abolish the signal. CRP and SAA plasma levels were enhanced only at T2 in both groups. CONCLUSIONS: Plasmas isolated after on-pump but not off-pump coronary bypass surgery can induce superoxide generation by the vascular wall which seems related to circulating microparticles remaining present at least 24 hours after the procedure that might be of endothelial origin.

Effects of valve replacement for aortic stenosis on mitral regurgitation.

We aimed to prospectively and quantitatively assess the effects of aortic valve replacement (AVR) for aortic stenosis (AS) on mitral regurgitation (MR) and to examine the determinants of the changes in MR. Fifty-two patients with AS scheduled for AVR were included if holosystolic MR not being considered for replacement or repair was detected. MR was quantified using the proximal isovelocity surface area method before and 8 +/- 4 days after surgery. Mitral valvular deformation parameters did not change significantly, but the mitral effective regurgitant orifice (ERO) and regurgitant volume decreased from 11 +/- 6 mm(2) to 8 +/- 6 mm(2) and from 20 +/- 10 ml to 11 +/- 9 ml, respectively (both p <0.0001). Using multiple linear regression analysis, preoperative severity of MR, mitral leaflet coaptation height, and end-diastolic volume decrease were independently associated with postoperative reduction in MR, whereas changes in mitral valve morphology after surgery were not. MR etiology did not predict the reduction in MR. In conclusion, the decrease in MR observed in most patients after AVR is associated with the magnitude of acute left ventricular reverse remodeling. As the reduction in left ventricular systolic pressure contributes to the decrease in regurgitant volume, the preoperative quantitative assessment of MR should best be performed by measurement of the ERO.

Acquired coronary fistula after left ventricular de-airing by apical needle aspiration.

Acquired coronary fistula is uncommon, but has been reported to occur after several surgical procedures, acute myocardial infarction, endomyocardial biopsy, coronary angioplasty, and thoracic trauma. We describe the occurrence of a left coronary to left ventricular cavity fistula following resection of a left atrial myxoma, with spontaneous closure in the following weeks. The fistula was likely caused by a needle inserted into the left ventricular apex, a procedure routinely used to ensure left ventricular de-airing.

Long-term follow-up after endocardial radiofrequency modified Nitta procedure for concomitant atrial fibrillation treatment.

In atrial fibrillation (AF) patients, the surgical restoration of sinus rhythm aims at restoring atrial contraction, hence to decrease thromboembolic events. We investigated the long-term outcome of radiofrequency (RF) ablation by a modified Nitta procedure, in patients with AF associated with operative structural heart diseases. Between September 2000 and April 2004, a total of 20 patients (63.7+/-13.34 years) with structural heart diseases due to surgery and chronic AF underwent endocardial RF ablation. Evaluation was achieved at discharge, at 6 months, 12 months and in November 2005. Echocardiography, 12-derivations electrocardiogram and 24-h electrocardiogram were obtained. At the mean follow-up of 43.25+/-13.4 months, 14 out of 20 patients (70%) were in sinus rhythm. Actuarial freedom from AF recurrence was 85% after 6 months, 75% after 12 months and 70% at the follow-up completion. Effective atrial contraction was present in 78.5% of patients with sinus rhythm. No hemodynamic pulmonary edema has been reported during the hospital stay, and no thromboembolic event has been reported during the follow-up period. The Nitta procedure, modified for RF ablation, is an easy procedure when performed in the setting of structural heart disease surgery. Further studies are warranted to evaluate this technique on a larger scale basis.