Diagnostic Accuracy of Transesophageal Echocardiographic Commissural-Biplane Approach in Identifying Mitral Valve Anatomy.

BACKGROUND: Transesophageal echocardiography (TEE) conventional multiplane approach (MPA) and the newly proposed commissural-biplane approach (CBA) are the recommended algorithms for identifying the affected mitral valve (MV) segments in the setting of mitral regurgitation. To date, there are no reports to address the diagnostic performance of CBA. In this study we aim to analyze the diagnostic accuracy of CBA and MPA in comparison with three-dimensional echocardiographic findings in patients with severe mitral regurgitation. METHODS: We prospectively enrolled 102 patients with severe mitral regurgitation. All patients underwent systematic TEE assessment of MV before surgical intervention to define the affected MV segments/scallops. The standard MPA includes 4-chamber, 2-chamber, long-axis, and commissural views; CBA was performed by obtaining the bicommissural view and simultaneous biplane imaging of the medial, middle, and lateral MV aspects. The findings of both TEE approaches were compared with three-dimensional TEE data to assess the diagnostic accuracy of MPA and CBA. RESULTS: The mean patient age was (65 ± 11) years, and 37 (36.3%) were female. We found that CBA had an overall diagnostic accuracy between 88% and 97% in identifying the abnormal MV scallops; in contrast, MPA accuracy ranged between 82% and 95%. The CBA and MPA were the least accurate in identifying the P3 scallop-88% and 82% respectively; however, both were the most accurate in assessing the A2 segment-95% and 97%, respectively. The sensitivity of identifying commissural abnormalities was 80% with CBA and 30% with MPA. Three-dimensional TEE was found to have a strong agreement with CBA (averaged kappa of 0.81, P < .0001) and a modest agreement with MPA (averaged kappa of 0.61, P < .0001) in identifying abnormal anterior or posterior segments. On the other hand, three-dimensional TEE had a weak agreement with CBA (kappa of 0.43, P < .0001) and no agreement with MPA (kappa of 0.14, P = .153) in the assessment of commissural involvements. CONCLUSION: The CBA is more accurate than the MPA in the assessment of MV commissural involvement. Given the accuracy differences of the 2 approaches for specific leaflet/scallops, a comprehensive evaluation using both approaches is recommended for all MV scallop assessments.

Echocardiographic Method to Determine the Length of Neochordae Reconstruction for Mitral Repair.

BACKGROUND: We evaluated a novel formula using preoperative transesophageal echocardiographic measurements to determine neochordae length for repair of degenerative mitral regurgitation (MR). METHODS: The formula is based on measuring the distance from the adjacent papillary head to the intended coaptation zone of the flail/prolapsing leaflet segment and subtracting the redundant leaflet length. Between 2008 and 2017, 264 consecutive patients underwent mitral valve repair (82.2% endoscopic, minimally invasive approach and 17.8% sternotomy) with neochordae loop reconstruction (68.6% posterior, 6.4% anterior, and 25% bileaflet repair). Mean patient age was 63 ± 13.6 years, 73.5% were men, and mean left ventricular ejection fraction was 63.1% ± 6.7%. RESULTS: Mitral valve repair was successful in 100% of patients, with no patient requiring conversion to replacement. Neochordae length measurement was accurate in 259 patients (98%), with 4 patients requiring conversion to resection and 1 patient requiring longer anterior leaflet neochordae. Median anterior and posterior neochordae lengths were 27 mm (range, 18-32) and 17 mm (range, 9-27), respectively. Intraoperative transesophageal echocardiography demonstrated no or trace residual MR in 254 patients and mild residual MR in 10 patients. In-hospital mortality occurred in 1 patient, and complications included respiratory failure (2.7%) and renal failure (1.8%). At the median follow-up of 12.6 months (interquartile range, 11.1), 98.9% of patients remained free from ≥2+ MR, whereas freedom from reoperation was 100%. CONCLUSIONS: Preoperative transesophageal echocardiographic measurements can accurately and reproducibly predict the required length of neochordae loop reconstruction for degenerative mitral valve repair with good results. Longer-term follow-up is necessary.

Endoscopic Mitral Repair for Degenerative Mitral Regurgitation: Effect of Disease Complexity on Short- and Mid-term Outcomes.

BACKGROUND: We set out to compare in a prospective cohort study the mid-term clinical and echocardiographic outcomes of mini-mitral repair for simple (posterior prolapse) vs complex regurgitation (anterior/bileaflet prolapse). METHODS: A total of 245 consecutive patients underwent mini-mitral repair for severe degenerative mitral regurgitation through a right, endoscopic approach (n = 145 simple, n = 100 complex). The most common repair technique was annuloplasty + artificial chordae (84%, n = 121 for simple vs 88%, n = 88 for complex, P = 0.3). Patients were prospectively followed for a maximal duration of 9 years. Patients' characteristics were well balanced between groups. RESULTS: The 30-day/in-hospital mortality was similar (0%, n = 0 simple vs 1%, n = 1 complex, P = 0.2). Both groups had similar rates of early postoperative complications: myocardial infarction (1.4%, n = 2 vs 0%, n = 0, P = 0.2), neurologic complications (1.4%, n = 2 vs 0%, n = 0, P = 0.2), reoperation for bleeding (0.7%, n = 1 vs 3%, n = 3, P = 0.2), intensive care unit length of stay (1 interquartile range, 1-1 days vs 1 interquartile range, 1-1 days, P = 0.7). Late survival (88% for simple vs 92% for complex, P = 0.4) was similar between groups. Cumulative incidence of late reoperation at 6 years is 0% for both groups (subdistribution hazard ratio = 1, P = 1). There was no difference in recurrent mitral regurgitation greater than 2+ at each year after surgery up to 6 years postoperatively. CONCLUSION: Mitral repair using an endoscopic, minimally invasive approach yields excellent mid-term outcomes regardless of disease complexity.

CONTEXTE: Dans le cadre d'une étude de cohorte prospective, on a comparé les résultats cliniques et échocardiographiques que la réparation mitrale mini-invasive procurait à moyen terme selon que cette dernière était pratiquée dans un contexte de régurgitation simple (prolapsus postérieur) ou de régurgitation complexe (prolapsus antérieur/bivalvulaire). MÉTHODOLOGIE: Au total, 245 patients consécutifs qui présentaient une régurgitation mitrale dégénérative sévère ont subi une réparation mitrale mini-invasive par abord endoscopique droit (n = 145 cas de régurgitation simple et n = 100 cas de régurgitation complexe). La technique de réparation la plus courante était l'annuloplastie avec implantation de cordages artificiels (84 %, n = 121 cas de régurgitation simple vs 88 %, n = 88 cas de régurgitation complexe, p = 0,3). Les patients ont été l'objet d'un suivi prospectif d'une durée maximale de 9 ans. Il y avait une répartition équilibrée des caractéristiques des patients entre les groupes. RÉSULTATS: Les taux de mortalité à 30 jours et de mortalité hospitalière se sont avérés semblables (0 %, n = 0 cas chez les patients qui présentaient une régurgitation simple vs 1 %, n = 1 cas chez les patients qui présentaient une régurgitation complexe, p = 0,2). Les taux de complications postopératoires précoces se sont également révélés semblables chez les patients des deux groupes, notamment en ce qui concerne l'infarctus du myocarde (1,4 %, n = 2 vs 0 %, n = 0, p = 0,2), les complications neurologiques (1,4 %, n = 2 vs 0 %, n = 0, p = 0,2), les nouvelles interventions chirurgicales en raison d'une hémorragie (0,7 %, n = 1 vs 3 %, n = 3, p = 0,2) et la durée de l'hospitalisation à l'unité de soins intensifs (1 intervalle interquartile, 1-1 jour vs 1 intervalle interquartile, 1-1 jour, p = 0,7). De même, des taux de survie tardive similaires ont été notés chez les patients des deux groupes (88 % chez les patients qui présentaient une régurgitation simple vs 92 % chez les patients qui présentaient une régurgitation complexe, p = 0,4). L'incidence cumulative de nouvelles interventions chirurgicales tardives à 6 ans s'est établie à 0 % dans les deux groupes (rapport des risques instantanés de sous-distribution = 1, p = 1). Aucune différence quant à la récidive de régurgitation mitrale de grade supérieur à 2 n'a été relevée au cours de chacune des 6 années suivant l'intervention chirurgicale. CONCLUSIONS: La réparation mitrale minimalement invasive par abord endoscopique permet d'obtenir d'excellents résultats à moyen terme, indépendamment de la complexité de la maladie.

Stroke risk and atrial mechanical dysfunction in cardiac amyloidosis.

Amyloidosis is associated with poor prognosis, and patients with cardiac involvement have especially poor outcomes. Cardiac amyloidosis leads to higher rates of atrial arrhythmia and an increased risk of intracardiac thrombus formation. However, atrial mechanical dysfunction due to protein deposition in amyloidosis may lead to thrombus formation in the absence of atrial arrhythmia. We present a 42-year-old male patient with familial transthyretin amyloidosis who suffered an embolic stroke that originated from a left atrial appendage thrombus in the absence of any documented atrial fibrillation. This case highlights atrial mechanical dysfunction in patients with cardiac amyloidosis and the need to better stratify thrombotic risk in this population with integration of echocardiographic parameters and transesophageal echocardiography.

Evolution of Tricuspid Regurgitation After Repair of Degenerative Mitral Regurgitation.

BACKGROUND: The fate of unrepaired tricuspid regurgitation (TR) after mitral valve repair for degenerative mitral regurgitation remains highly debated. The objective of this study was to examine the progress of unrepaired TR after mitral valve repair for degenerative mitral regurgitation, with a particular focus on comparing patients with moderate preoperative TR with those having none or mild preoperative TR. METHODS: Between 2008 and 2018, 183 consecutive patients (mean age, 61 years [SD, 14]) with severe degenerative mitral regurgitation and less-than-severe TR underwent mitral valve repair alone without concomitant TR repair. They were prospectively followed for a median duration of 3.1 years (interquartile range, 1.6-5.5; maximal duration of 9.4 years). RESULTS: At baseline 146 patients (80%) had none or mild TR; 37 patients (20%) had moderate TR. At follow-up 51 patients (30%) had improved TR compared with 28 patients (17%) who had worse TR. At 3 years postoperatively echocardiographic data were available for 82 of 183 patients: 70 (85%) had none or mild TR, 11 (13%) had moderate TR, and 1 (1.2%) had moderate to severe TR. In an exploratory multivariable analysis with limited statistical power, patients with moderate preoperative TR (vs those with none or mild TR) had an association with higher mortality (hazard ratio, 2.8; 95% confidence interval, 0.81-9.4; P = .11). CONCLUSIONS: After mitral valve repair but without concomitant tricuspid valve repair, a number of patients had progression in their TR. There was a signal of harm in patients having moderate preoperative TR in terms of mortality, but this finding is exploratory and requires investigation.

Left ventricular remodeling after mini-mitral repair-does the complexity of mitral disease matter?

OBJECTIVES: Degenerative mitral valve (MV) regurgitation (MR) is associated with left ventricular (LV) dilatation. Surgical treatment of MR has been shown to favorably affect LV remodeling. We prospectively compared the long-term echocardiographic outcomes of LV remodeling following mini-mitral repair for simple versus complex MV disease. METHODS: We prospectively followed up 203 consecutive patients who underwent mini-MV repair for severe degenerative MR over a 9-year period. Simple disease (n = 122 patients: posterior leaflet prolapse) was compared to complex disease (n = 81 patients: anterior, bilateral or commissural prolapse). Baseline demographics were similar between simple and complex groups (age: 63 ± 13 years vs 60 ± 15 years; p = .2; sex: 71% male vs 72% male, p = 1; preoperative MR grade ≥ 3+: 100%; n = 122; vs 100%; n = 81; p = 1), respectively. RESULTS: Preoperative left ventricular ejection fraction (LVEF) was significantly lower in the complex group as compared to the simple group (57.2% simple vs 56.0% complex; p = .04). Preoperative LV end-systolic diameter (LVESD: 35 mm simple vs 36 mm complex, p < .05) and LV end-diastolic diameter (LVEDD: 50 mm simple vs 51 mm complex; p < .05), as well as LV mass index (99.5 g/m2 vs 102.4 g/m2 ; p = .06) were larger in the complex group. Despite different baseline characteristics of LV function and geometry, both groups had similar remodeling of LV after MV repair. CONCLUSIONS: Patients with complex MV disease are referred late for surgical repair, causing LV function and dimensions to never fully recover. This suggests that earlier referral (before LV changes and potentially before symptoms) may be the preferred approach in those with complex disease.

Diagnosis and follow-up of idiopathic dilatation of inferior vena cava.

In the absence of cardiac pathology, the presence of a dilated inferior vena cava (IVC) is considered idiopathic. To date, this phenomenon has only been described in athletic individuals as an adaptation to chronically augmented venous return. This is the largest prospective cohort study, following ten individuals with idiopathic dilated IVC against an age-matched control group with annual echocardiograms and cardiac magnetic resonance (CMR) imaging for a median of 55 months. No significant difference was found between echocardiography and CMR measurements in IVC diameter assessment both at baseline and at follow-up. Over the study period, there was no significant progression of the IVC in diameter as measured either by echocardiography or CMR. None of the patients suffered any cardiovascular events, and there were no hospitalizations. Our findings indicate the benign nature of this condition and provide reassurance with regard to future clinical implications.

Arrhythmia Management in the Elderly-Implanted Cardioverter Defibrillators and Prevention of Sudden Death.

We present an overview of arrhythmia management in elderly patients as it pertains to implantable cardioverter defibrillator (ICD) therapy and prevention of sudden death. Treatment of arrhythmia in elderly patients is fraught with challenges pertaining to goals of care and patient frailty. With an ever increasing amount of technology available, realistic expectations of therapy need to balance quality and quantity of life. The ICD is an important treatment option for selected patients at risk of ventricular arrhythmia and sudden cardiac death. However, the incidence of sudden death as a percentage of all-cause mortality decreases with age. Studies have reported that 20% of elderly patients might die within 1 year of an episode of life-threatening ventricular arrhythmia, but most because of nonarrhythmic causes. This illustrates the 'sudden cardiac death paradox,' with a great proportion of death in elderly patients, even those at risk for ventricular arrhythmias, attributable to medical conditions that cannot be addressed by an ICD. We discuss current practices in ICD therapy in elderly patients, existing evidence from registries and clinical trials, approaches to risk stratification, and important ethical considerations. Although the decision on whether ICD insertion is appropriate in the elderly population remains an area of uncertainty from an evidence-based and ethical perspective, we offer insight on potential clinical and research strategies for this growing population.