B-PO05-128 THE EFFECT OF CATHETER ABLATION FOR VENTRICULAR ARRHYTHMIAS ORIGINATING FROM THE LEFT VENTRICULAR PAPILLARY MUSCLES ON MITRAL VALVE FUNCTION

Background: Malignant mitral valve prolapse (MVP) identifies a subset of patients with MVP associated with ventricular arrhythmias (VAs), including sudden cardiac death (SCD). We hypothesized that papillary muscles, which see significant mechanical stress in MVP, are richly innervated with sensory nerves, which induce severe autonomic imbalance on the heart and may trigger malignant VAs. Methods and Results: Longitudinal sections of the anterior and posterior left ventricular papillary muscles, right ventricular outflow tract (RVOT), ventricular septum, and basolateral left ventricular wall (LV) of Yorkshire pigs (n=8) were excised, formalin-fixed, paraffin-embedded, and sectioned. Immuno-staining for protein gene product 9.5 (PGP9.5), a pan-neuronal marker, and calcitonin-gene related peptide (CGRP), a sensory afferent neuron marker, was performed. Areas of immunoreactivity (IR) for CGRP were verified by direct comparison to PGP9.5 IR. The density of CGRP was then compared across anatomical regions. The mean CGRP IR area was 1229.44 ± 116.65 μm 2 /nucleus in papillary muscles, while in the septum, basolateral LV, and RVOT, the CGRP stained areas were 699.36 ± 88.28 μm 2 /nucleus, 681.51 ± 81.90 μm 2 /nucleus, and 381.98 ± 31.14 μm 2 /nucleus, respectively (p<0.001). There was no significant difference between CGRP IR area in the anterior papillary muscle (1091.36 ± 189.82 μm 2 /nucleus) and the posterior papillary muscle (1347.79 ± 140.50 μm 2 /nucleus) (p>0.3). Conclusions: There is a significantly greater amount of afferent innervation in the papillary muscle compared to the septum, basolateral LV, and RVOT. This enrichment of afferent innervation warrants further study to understand how afferent neurotransmission during abnormal mitral valve function may impact ventricular electrophysiology.

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A Complex Mitral Valve Reconstruction: A Case Report

The Heart Surgery Forum ◽

10.1532/hsf.648 ◽

2005 ◽

Vol 6 (2) ◽

pp. 27

Author(s):

Dimitrios Buklas ◽

Massimo Massetti ◽

Eric Saloux ◽

Eugenio Neri ◽

Olivier LePage ◽

...

Keyword(s):

Mitral Valve ◽

Surgical Techniques ◽

Mitral Valve Insufficiency ◽

Left Ventricular ◽

Mitral Valve Reconstruction ◽

Mitral Repair ◽

Valve Reconstruction ◽

Valve Insufficiency ◽

Valve Function ◽

Valvular Function

Several techniques are currently in use for mitral valve reconstruction. We report a mitral repair case in which the use of a combination of different surgical techniques resulted in the necessary correction. A 47-year-old woman underwent surgical intervention to treat severe mitral valve insufficiency due to A1/A2/A3 and P2 prolapsed valve tissue. A combination of quadrangular resection, sliding leaflet, single chordal transposition, "flip-over" leaflet, and ring annuloplasty techniques were applied, and postsurgical correct valve function was documented by results of a left ventricular saline filling test and transesophageal echocardiography control. Complex mitral valve repairing techniques can be combined to reestablish valvular function.

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Minimising radiation exposure in catheter ablation of ventricular arrhythmias

BMC Cardiovascular Disorders ◽

10.1186/s12872-021-02120-4 ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Matevž Jan ◽

David Žižek ◽

Tine Prolič Kalinšek ◽

Dimitrij Kuhelj ◽

Primož Trunk ◽

...

Keyword(s):

Catheter Ablation ◽

Radiation Exposure ◽

Ventricular Arrhythmias ◽

Major Complication ◽

Structural Heart Disease ◽

Left Ventricular ◽

Complex Nature ◽

Group 2 ◽

Procedural Outcomes ◽

Group 1

Abstract Background Conventional fluoroscopy guided catheter ablation (CA) is an established treatment option for ventricular arrhythmias (VAs). However, with the complex nature of most procedures, patients and staff bare an increased radiation exposure. Near-zero or zero-fluoroscopy CA is an alternative method which could substantially reduce or even eliminate the radiation dose. Our aim was to analyse procedural outcomes with fluoroscopy minimising approach for treatment of VAs in patients with structurally normal hearts (SNH) and structural heart disease (SHD). Methods Fifty-two (age 53.4 ± 17.8 years, 38 male, 14 female) consecutive patients who underwent CA of VAs in our institution between May 2018 and December 2019 were included. Procedures were performed primarily with the aid of the three-dimensional electro-anatomical mapping system and intra-cardiac echocardiography. Fluoroscopy was considered only in left ventricular (LV) summit mapping for coronary angiography and when epicardial approach was planned. Acute and long-term procedural outcomes were analysed. Results Sixty CA procedures were performed. Twenty-five patients had SHD-related VAs (Group 1) and 27 patients had SNH (Group 2). While Group 1 had significantly higher total procedural time (256.9 ± 71.7 vs 123.6 ± 42.2 min; p < 0.001) compared to Group 2, overall procedural success rate [77.4% (24/31) vs 89.7% (26/29); p = 0.20)] and recurrence rate after the first procedure [8/25, (32%) vs 8/27, (29.6%); p = 0.85] were similar in both groups. Fluoroscopy was used in 3 procedures in Group 1 where epicardial approach was needed and in 4 procedures in Group 2 where LV summit VAs were ablated. Overall procedure-related major complication rate was 5%. Conclusions Fluoroscopy minimising approach for CA of VAs is feasible and safe in patients with SHD and SNH. Fluoroscopy could not be completely abolished in VAs with epicardial and LV summit substrate location.

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Use of a Sandwich Technique to Repair a Left Ventricular Rupture after Mitral Valve Replacement

Texas Heart Institute Journal ◽

10.14503/thij-12-2931 ◽

2014 ◽

Vol 41 (2) ◽

pp. 195-197 ◽

Cited By ~ 2

Author(s):

Myles E. Lee ◽

Mallika Tamboli ◽

Anthony W. Lee

Keyword(s):

Mitral Valve ◽

Valve Replacement ◽

Mitral Valve Replacement ◽

Left Ventricular ◽

Left Ventricular Aneurysm ◽

Sandwich Technique ◽

Ventricular Rupture ◽

Left Ventricular Rupture ◽

Valve Function ◽

Normal Mitral Valve

One difficulty with external repair of left ventricular rupture after mitral valve replacement is collateral bleeding in friable myocardium adjacent to the rupture. The bleeding is caused by tension on the closing sutures, whether or not pledgets have been used. We report the case of a 69-year-old woman who underwent an uneventful mitral valve replacement. After cardiopulmonary bypass was terminated, brisk bleeding started from high in the posterior left ventricular wall, typical of a type III defect. We undertook external repair, placing a plug of Teflon felt into the cavity of the rupture and sandwiching it into place with pledgeted mattress and figure-of-8 sutures. The space occupied by the plug decreased the distance needed to obliterate the defect and thereby reduced the tension on the sutures necessary to achieve hemostasis. This simple technique enabled closure of the defect and avoided collateral tears that would have compromised an otherwise successful repair. Two years postoperatively, the patient had normal mitral valve function and no left ventricular aneurysm. In addition to reporting the patient's case, we review the types of left ventricular rupture that can occur during mitral valve replacement and discuss the various repair options.

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Coordinate-Free Analysis of Mitral Valve Dynamics in Normal and Ischemic Hearts

Circulation ◽

10.1161/circ.102.suppl_3.iii-62 ◽

2000 ◽

Vol 102 (suppl_3) ◽

Author(s):

Paul Dagum ◽

Tomasz A. Timek ◽

G. Randall Green ◽

David Lai ◽

George T. Daughters ◽

...

Keyword(s):

Mitral Valve ◽

Color Doppler ◽

Mitral Annulus ◽

Left Ventricular ◽

Free System ◽

Ring Annuloplasty ◽

3D Geometry ◽

Valve Function ◽

Valve Dynamics ◽

Radiopaque Markers

Background —The purpose of this investigation was to study mitral valve 3D geometry and dynamics by using a coordinate-free system in normal and ischemic hearts to gain mechanistic insight into normal valve function, valve dysfunction during ischemic mitral regurgitation (IMR), and the treatment effects of ring annuloplasty. Methods and Results —Radiopaque markers were implanted in sheep: 9 in the ventricle, 1 on each papillary tip, 8 around the mitral annulus, and 1 on each leaflet edge midpoint. One group served as a control (n=7); all others underwent flexible Tailor partial (n=5) or Duran complete (n=6) ring annuloplasty. After an 8±2-day recovery, 3D marker coordinates were measured with biplane videofluoroscopy before and during posterolateral left ventricular ischemia, and MR was assessed by color Doppler echocardiography. Papillary to annular distances remained constant throughout the cardiac cycle in normal hearts, during ischemia, and after ring annuloplasty with either type of ring. Papillary to leaflet edge distances similarly remained constant throughout ejection. During ischemia, however, the absolute distances from the papillary tips to the annulus changed in a manner consistent with leaflet tethering, and IMR was observed. In contrast, during ischemia in either ring group, those distances did not change from preischemia, and no IMR was observed. Conclusions —This analysis uncovered a simple pattern of relatively constant intracardiac distances that describes the 3D geometry and dynamics of the papillary tips and leaflet edges from the dynamic mitral annulus. Ischemia perturbed the papillary-annular distances, and IMR occurred. Either type of ring annuloplasty prevented such changes, preserved papillary-annular distances, and prevented IMR.

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Early Clinical Results After Stentless Mitral Valve Implantation and Comparison With Conventional Valve Repair or Replacement

Circulation ◽

10.1161/circ.100.suppl_2.ii-78 ◽

1999 ◽

Vol 100 (suppl_2) ◽

Author(s):

Thomas Walther ◽

Claudia Walther ◽

Volkmar Falk ◽

Anno Diegeler ◽

Ralf Krakor ◽

...

Keyword(s):

Mitral Valve ◽

Valve Replacement ◽

Mitral Valve Replacement ◽

Maximum Flow ◽

Left Ventricular ◽

Left Ventricular Ejection ◽

Papillary Muscles ◽

Valve Repair ◽

Promising Alternative ◽

Ventricular Ejection Fraction

Background —A new quadricusp stentless mitral bioprosthetic valve (QMV) is evaluated and compared with current standards. Methods and Results —Since August 1997, 67 patients were prospectively evaluated: 23 patients received a QMV, 23 had mitral valve repair (MVR), and 21 received conventional mitral valve replacement (MVP). Patient age was 69±8, 64±10, and 62±9 years for QMV, MVR, and MVP treatment, respectively. The underlying pathology was mitral stenosis, incompetence, and mixed disease in a corresponding 8, 9, and 6 patients for QMV, 1, 22, and 0 patients for MVR, and 2, 12, and 7 patients for MVP. The papillary muscles were sufficient in all QMV cases to suspend the valve. Cross-clamp time was 59±19 minutes for QMV implantation. In-hospital mortality for QMV, MVR, and MVP was 1, 0, and 0 patients, respectively, and thoracotomy had to be performed again in 1, 1, and 2 patients, respectively (these outcomes were not valve related). At baseline transthoracic echocardiography, respective maximum flow velocities were 1.6, 1.4, and 1.7 m/s, and valve orifice area was 2.6, 3.5, and 3.4 cm 2 . Mild transvalvular reflux was seen in 8, 7, and 2 patients; moderate reflux, in 1, 1, and 1 patients. Left ventricular ejection fraction was 52%, 54%, and 51% in the respective treatment groups. At follow-up, hemodynamic parameters had further improved in all groups. Conclusions —One year after clinical implantation, the QMV appears to function well and has no additional risks compared with MVR or MVP. The subvalvular apparatus is preserved by suspending the QMV at the papillary muscles; this arrangement is hemodynamically advantageous. Echocardiography reveals an excellent valve performance that resembles native mitral valve morphology and hemodynamic function. The QMV is a promising alternative for biological mitral valve replacement.

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