Abstract An 88–year–old woman with a history of atrial fibrillation and amoxicillin allergy presented progressive dyspnea. She had been treated in the previous three months for pneumonia and bronchitis. Physical examination revealed basal crackles and a 4/6 systolic murmur. Echocardiography identified mobile vegetations in the mitral and aortic valves (Figure 1), severe mitral regurgitation and leaflet perforation of the mitral valve (Figure 2-3). Laboratory findings included elevated levels of NT–proBNP and fibrinogen. Blood cultures were negative, but valve tissue culture identified Micrococcus luteus, which plausible entered in the bloodstream through a skin or mucosal injury. Empiric antibiotic therapy with ceftriaxone and vancomycin was started. The patient underwent a successful mitral valve replacement with a bioprosthesis and aortic valve shave through endoscopic right minithoracotomy. The postoperative recovery was uneventful, and the patient completed a 6–week antibiotic course. Follow–up echocardiography showed stable prosthesis function and significant symptomatic improvement. This case highlights the evolving microbiology of infective endocarditis associated with gram–positive catalase–positive cocci, typically considered a skin contaminant. Clinicians should recognize Micrococcus luteus as a potential pathogen in susceptible patients and ensure a timely diagnosis and intervention to optimize results.Figure 1 Figure 2 Figure 3
2Abnormal Echoes in the Left Ventricular Outflow Tract Caused by Ruptured Chordae Tendineae of the Mitral Valve
Abnormal Echoes in the Left Ventricular Outflow Tract Caused by Ruptured Chordae Tendineae of the Mitral Valve
52The effect of the Cox-maze procedure for atrial fibrillation concomitant to mitral and tricuspid valve surgery
The effect of the Cox-maze procedure for atrial fibrillation concomitant to mitral and tricuspid valve surgery
22Intravascular Hemolysis and Acute Renal Failure After Mitral and Aortic Valve Repair
Intravascular Hemolysis and Acute Renal Failure After Mitral and Aortic Valve Repair
49High-Throughput Deep Learning Detection of Mitral Regurgitation
BACKGROUND:Diagnosis of mitral regurgitation (MR) requires careful evaluation by echocardiography with Doppler imaging. This study presents the development and validation of a fully automated deep learning pipeline for identifying apical 4-chamber view videos with color Doppler echocardiography and detecting clinically significant (moderate or severe) MR from transthoracic echocardiograms.METHODS:A total of 58 614 transthoracic echocardiograms (2 587 538 videos) from Cedars-Sinai Medical Center were used to develop and test an automated pipeline to identify apical 4-chamber view videos with color Doppler across the mitral valve and then assess MR severity. The model was tested internally on a test set of 1800 studies (80 833 videos) from Cedars-Sinai Medical Center and externally evaluated in a geographically distinct cohort of 915 studies (46 890 videos) from Stanford Healthcare.RESULTS:In the held-out Cedars-Sinai Medical Center test set, the view classifier demonstrated an area under the curve (AUC) of 0.998 (0.998–0.999) and correctly identified 3452 of 3539 echocardiography videos as having color Doppler information across the mitral valve (sensitivity of 0.975 [0.968–0.982] and specificity of 0.999 [0.999–0.999] compared with manually curated videos). In the external test cohort from Stanford Healthcare, the view classifier correctly identified 1051 of 1055 manually curated videos with color Doppler information across the mitral valve (sensitivity of 0.996 [0.990–1.000] and specificity of 0.999 [0.999–0.999]). In the Cedars-Sinai Medical Center test cohort, MR moderate or greater in severity was detected with an AUC of 0.916 (0.899–0.932) and severe MR was detected with an AUC of 0.934 (0.913–0.953). In the Stanford Healthcare test cohort, the model detected MR moderate or greater in severity with an AUC of 0.951 (0.924–0.973) and severe MR with an AUC of 0.969 (0.946–0.987).CONCLUSIONS:In this study, a novel automated pipeline for identifying clinically significant MR from full transthoracic echocardiography studies demonstrated excellent performance across large numbers of studies and across multiple institutions. Such an approach has the potential for automated screening and surveillance of MR.
Read more80Sizing for Mitral Annuloplasty: Where Does Science Stop and Voodoo Begin?
Sizing for Mitral Annuloplasty: Where Does Science Stop and Voodoo Begin?
1Splenic rupture as the presenting symptom in infective endocarditis: a rare and dangerous complication
Infective endocarditis remains a dangerous condition and carries a mortality risk of approximately 20%. Splenic rupture is a rare complication of endocarditis. A 60-year-old woman with a history of atrial...
Read more92019 AATS/ACC/ASE/SCAI/STS expert consensus systems of care document: A proposal to optimize care for patients with valvular heart disease: A joint report of the American Association for Thoracic Surgery, American College of Cardiology, American Society of Echocardiography, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons
2019 AATS/ACC/ASE/SCAI/STS expert consensus systems of care document: A proposal to optimize care for patients with valvular heart disease: A joint report of the American Association for Thoracic Surgery, American College of Cardiology, American Society of Echocardiography, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons
Read moreVegetation Stalagmite in Left Atrium
Mitral valve prolapse (MVP) is a common disorder, occurring in 4% of the general population.1 It is associated with increased risk of infective endocarditis, and antibiotic prophylaxis is suggested in those high-risk patients who have systolic murmurs.2 The vast majority of cases involve the valve and its accessory apparatus. Herein, we present an unusual location of vegetation in a patient with MVP. A 45-year-old woman had been diagnosed with MVP 1 month before admission at our institution, after a grade III/VI pansystolic murmur with late systolic click was heard during a regular health checkup. Echocardiography illustrated myxomatous change and prolapse of the anterior mitral leaflet, with severe eccentric mitral regurgitation. Because of intermittent fever, left flank pain, and tender skin erythema of both feet, the patient visited our emergency department, where blood pressure 113/76 mm Hg, heart rate 126 bpm, and body temperature 39.5°C were noted. Blood analysis showed white blood cell count of 11 400/mm3, hemoglobin level of 9.7 g/dL, C-reactive …
Read more31Mitral valve replacement combined with coronary artery operation: Determinants of early and late results
Mitral valve replacement combined with coronary artery operation: Determinants of early and late results
Long-Term Surgical Outcome for Idiopathic Acute Rupture of Mitral Chordae Tendineae in Infants
ObjectivesAcute rupture of mitral valve chordae tendineae in infants is rare and rapidly leads to cardiorespiratory failure. Acute progression with slight mitral valve annulus dilatation and valve degeneration limits the surgical treatment options. This study investigated the long-term surgical outcomes and factors influencing prognosis.MethodsWe assessed 20 infants who underwent surgical treatment for acute mitral valve chordal rupture between 2001 and 2015. The median age was 5.5 months (IQR: 4.5-7.2). Seventeen experienced cardiogenic shock. Twenty had severe mitral regurgitation with a mitral valve diameter z-score of 1.1 (0.06-2.5). The infants underwent mitral valve repair primarily with artificial chordae reconstruction. Mitral valve replacement was performed when regurgitation control was unsuccessful.ResultsThe follow-up period was 12.9 (10.6-14.4) years, with no mortality. The number of prolapsed leaflet segments was 3 (1-3). Twelve patients (60%) exhibited intraoperatively yellowish oedematous degeneration of the mitral valve. Although 13 underwent mitral valve repair at initial surgery, 3 were converted to mitral valve replacement before discharge. Consequently, 10 required mitral valve replacement because of uncontrollable mitral regurgitation before discharge. Univariable logistic regression revealed that mitral valve degeneration (odds ratio: 21, P = .015) and the number of prolapsed leaflet segments (odds ratio: 4.6, P = .025) were significantly associated with mitral valve replacement before discharge.ConclusionsPrompt valve surgery yields good long-term outcomes. Mitral valve repair using artificial chordae reconstruction is a reasonable option for infants. Mitral valve degeneration and numerous prolapsed segments are associated with uncontrollable mitral regurgitation.
Read more1Update of Patient Selection and Therapeutic Strategy Using MitraClip.
Patients with advanced heart failure often accompany severe function mitral regurgitation refractory to optimal medical therapy. Degenerative mitral regurgitation also develops due to various degeneration of mitral valve. Surgical intervention to the mitral valve might be effective in some cases, but it is challenging for the high-risk cases. Recently, percutaneous edge-to-edge mitral valve repair using the MitraClip system, which enables us to approach the mitral valve at relatively low risk, has developed. Two major prospective randomized control trials have been conducted to investigate the clinical advantage of MitraClip system over optimal medical therapy in patients with severe mitral regurgitation; both showed controversial conclusions. Now is a time to consider optimal patient selection and therapeutic strategy using MitraClip system.
Read more27 MYXOMATOUS MITRAL VALVE DEGENERATION PRESENTING AS ACUTE PULMONARY EDEMA.
A 69-year-old Hispanic male came to the Coney Island Hospital emergency room with complaints of dyspnea for 2 days, reduced exercise tolerance, orthopnea, and paroxysmal nocturnal dyspnea. The patient denied...
Read more52Mitral valve interventions in heart failure.
Secondary mitral regurgitation (MR) results from left ventricular dilatation and dysfunction. Quantification of secondary MR is challenging because of the underlying myocardial disease. Clinical and echocardiographic evaluation requires a multi‐parametric approach. Severe secondary MR occurs in up to one‐fourth of patients with heart failure with reduced ejection fraction, which is associated with a mortality rate of 40% to 50% in 3 years. Percutaneous edge‐to‐edge mitral valve repair (MitraClip) has emerged as an alternative to surgical valve repair to improve symptoms, functional capacity, heart failure hospitalizations, and cardiac haemodynamics. Further new transcatheter strategies addressing MR are evolving. The Carillion, Cardioband, and Mitralign devices were designed to reduce the annulus dilatation, which is a frequent and important determinant of secondary MR. Several transcatheter mitral valve replacement systems (Tendyne, CardiAQ‐Edwards, Neovasc, Tiara, Intrepid, Caisson, HighLife, MValve System, and NCSI NaviGate Mitral) are emerging because valve replacement might be more durable compared with valve repair. In small studies, these interventional therapies demonstrated feasibility and efficiency to reduce MR and to improve heart failure symptoms. However, neither transcatheter nor surgical mitral valve repair or replacement has been proven to impact on the prognosis of heart failure patients with severe MR, which remains high with a mortality rate of 14–20% at 1 year. To date, the primary indication for treatment of secondary severe MR is the amelioration of symptoms, reinforcing the value of a Heart Team discussion. Randomized studies to investigate the treatment effect and long‐term outcome for any transcatheter or surgical mitral valve intervention compared with optimized medical treatment are urgently needed and underway.
Read more15Novel mitral valve technologies-transcatheter mitral valve implantation: a systematic review.
Valvular heart disease is an important cause of morbidity and mortality throughout the world; in industrialized nations, mitral regurgitation (MR) is the most common valvular lesion. Untreated, severe MR has a poor prognosis, with a 5-year mortality rate of up to 50%. Surgical repair of symptomatic, severe primary MR has been demonstrated to improve survival. The aim of this review is to assess the early outcomes of newly developed transcatheter mitral valve implantation technologies for the treatment of secondary native valve disease. Furthermore, the outcomes of patients receiving transcatheter treatment of regurgitant failure of surgically repaired or replaced mitral valve has also been addressed. A systematic review of twenty-five studies assessing the outcomes of patients undergoing transcatheter mitral valve implantation for native mitral regurgitation or failed prior surgical repair or bioprosthetic replacement was carried out. The outcomes of 112 patients undergoing transcatheter mitral valve replacement for secondary mitral regurgitation using six different valve systems were assessed. There were 15 early deaths and 24 deaths over the follow-up period. The outcomes of 44 patients undergoing transcatheter valve-in-valve replacement were assessed with an overall mortality of ten patients. There were 20 patients included who had valve-in-ring transcatheter mitral replacement for previous failed repair. The total mortality was five patients during the follow-up period. Transcatheter mitral valve implantation represents a new evolution in management of valvular disease and affords management options to patients who historically may not have been offered treatment. Early results have demonstrated some promise and improvements in technology, imaging modalities and patient selection will surely result in a reliable and durable valve.
Read more39Mechanism and Severity of Mitral Regurgitation by Transesophageal Echocardiography in Patients Referred for Percutaneous Valve Repair
Mechanism and Severity of Mitral Regurgitation by Transesophageal Echocardiography in Patients Referred for Percutaneous Valve Repair
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