Prophylactic LVAD Enabling High-Risk Mitral Repair—Extending Beyond the Guidelines

2019 ◽  
Vol 14 (6) ◽  
pp. 573-576
Author(s):  
Fadi Hage ◽  
Ali Hage ◽  
Stuart Smith ◽  
A. Dave Nagpal ◽  
Michael W. A. Chu
Keyword(s):  
High Risk ◽  
Mitral Valve ◽  
Mitral Regurgitation ◽  
Cardiogenic Shock ◽  
Clinical Symptoms ◽  
Left Ventricular ◽  
Lv Function ◽  
Assist Device ◽  
Mitral Repair ◽  
Lv Dysfunction

Both surgical and percutaneous mitral repair remain contraindicated in patients with severe degenerative mitral regurgitation (DMR) with severe left ventricular (LV) dysfunction because of inadequate LV reserve and increased LV work with a competent mitral valve. We report a 55-year-old gentleman who presented in cardiogenic shock with missed severe DMR and severe LV dysfunction, in whom we performed a high-risk mitral repair and insertion of a prophylactic CentriMag LV assist device. This innovative approach was found to be successful with significant patient improvement in both LV function and clinical symptoms with a competent mitral valve.

scholarly journals Chronic Mitral Regurgitation: When the Optimal Timing of Surgical Intervention?

1970 ◽  
Vol 1 (2) ◽  
pp. 142-147
Author(s):  
H Oemar ◽  
K Yusoff ◽  
HB Abdulgani
Keyword(s):  
Mitral Regurgitation ◽  
Surgical Intervention ◽  
Clinical Symptoms ◽  
Left Ventricular ◽  
Long Term Results ◽  
Lv Function ◽  
Optimal Timing ◽  
Pathophysiological Mechanism ◽  
Lv Dysfunction

Optimal timing of surgery in mitral regurgitation (MR) is a complex problem that has been studied widely. The pathophysiological mechanism and hemodynamic changes whereby MR exerts its deleterious effects on survival is well recognized. Early reports in the literatures and newer prospective studies suggest that severe MR is not a benign state and it has a high morbidity and eventually mortality. Thus, it is obviously rationale in understanding pathophysiological construct and be able to identify disease condition in choosing the golden moment for surgical intervention. Surgical intervention has been exposed to be the only efficient management, but its optimal timing remains a matter of controversy. The ultimate goal of patient care is obviously no longer the relief of limiting symptoms but the achievement of an optimal long-term outcome with regard to mortality and morbidity. Preoperative developments of severe symptoms, left ventricular (LV) dysfunction, LV enlargement, chronic atrial fibrillation, or progressive pulmonary hypertension were found to be associated with an unfavorable outcome. The timing of surgical correction for MR depends chiefly on three factors: clinical symptoms, LV function and the severity of MR. In term of waiting symptoms, the surgery has changed considerably from a relatively passive response to the development of severe symptoms, to an early surgery concept preceding the signs of LV dysfunction. This because clinical symptoms can remain absent or minimal despite severe regurgitation caused by adaptive remodeling of LV and left atrium, or because of patient adaptation of the disease. Thus, in chronic severe MR, there should be no waiting for LV function to decline before intervening, because the long-term results of that approach are not gratifying. Recent data underscored that mitral surgery is associated with a considerably decreased subsequent risk of mortality and heart failure. The reduction in the risk of death associated with surgery is greater among patients with a larger effective regurgitant orifice (ERO) assessed echocardiographically than among those with a smaller ERO and results in normalization of the life expectancy. These data provide a firm basis for considering surgery in patients with asymptomatic chronic mitral regurgitation who have an ERO of at least 40 mm². Key words: Mitral regurgitation; Mitral valve surgery; Echocardiography. DOI: http://dx.doi.org/10.3329/cardio.v1i2.8120 Cardiovasc. j. 2009; 1(2) : 142-147

Mitral Intervention with LVAD: Preparing for Recovery

2018 ◽  
Vol 23 (1) ◽  
pp. 134-139 ◽  
Author(s):  
Cory Maxwell ◽  
George Whitener
Keyword(s):  
Mitral Valve ◽  
Mitral Regurgitation ◽  
Left Ventricular ◽  
Assist Device ◽  
Perioperative Mortality ◽  
Ventricular Assist ◽  
Left Ventricular Assist ◽  
Practice Variability ◽  
Valve Pathology ◽  
New Evidence

Left ventricular assist device (LVAD) insertion is an increasingly common treatment of advanced heart failure. Insertion guidelines suggest regurgitant lesions of the mitral valve should not be addressed. However, recent evidence suggests that mitral regurgitation may not necessarily improve with LVAD insertion, and such patients may have worse outcomes. Thus, practice variability is high given the discrepancy between traditional thinking and new evidence that unrepaired mitral regurgitation may increase perioperative mortality. Additionally, the challenges of LVADs can make transesophageal echocardiography evaluation and assessment of mitral valve pathology difficult.

Impact of Valve Surgery on Serum Osteopontin Levels in Patients with Mitral Regurgitation

Cardiology ◽  
2015 ◽  
Vol 130 (2) ◽  
pp. 82-86
Author(s):  
H.M. Gunes ◽  
G.B. Guler ◽  
E. Guler ◽  
G.G. Demir ◽  
S. Hatipoglu ◽  
...  
Keyword(s):  
Mitral Regurgitation ◽  
Left Ventricular ◽  
Valve Surgery ◽  
Lv Function ◽  
Vena Contracta ◽  
Atherosclerotic Lesions ◽  
Lv Dysfunction ◽  
Echocardiographic Parameters ◽  
Artery Disease ◽  
The Impact

Objective: Osteopontin (OPN), a sialoprotein present within atherosclerotic lesions, especially in calcified plaques, is linked to the progression of coronary artery disease and heart failure. We assessed the impact of valve surgery on serum OPN and left ventricular (LV) function in patients with mitral regurgitation (MR). Methods: Thirty-two patients with severe MR scheduled for surgery were included in the study. Echocardiography markers were assessed preoperatively and at 3 months following the surgery and matched with the serum OPN levels. Results: Valve surgery was associated with a reduction of the ejection fraction (EF) from 55.2 ± 6.3 to 48.8 ± 7.1% after surgery, p < 0.001. Following surgery, the OPN level was significantly higher than preoperatively (mean 245, range 36-2,284 ng/ml vs. 76, 6-486 ng/ml, p = 0.007). Preoperative OPN exhibited a slight negative correlation with the EF (r = -0.35, p = 0.04), and a moderate correlation with vena contracta (r = -0.38, p = 0.02). There were no other meaningful correlations between conventional echocardiographic parameters and OPN. Conclusion: Following valve surgery due to severe MR, patients exhibited a decrease in EF and an increase in OPN levels. The assessment of preoperative OPN failed to strongly predict probable LV dysfunction.

Abstract 15934: Refractory Cardiogenic Shock in a Patient With Hypertrophic Obstructive Cardiomyopathy and Mitral Regurgitation Necessitating Intra-Aortic Balloon Pump Use

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
Indrajeet Mahata ◽  
Michael Faulx ◽  
Snigdha kola ◽  
Sweta Singh
Keyword(s):  
Mitral Valve ◽  
Mitral Regurgitation ◽  
Cardiogenic Shock ◽  
Pulmonary Edema ◽  
Muscle Protein ◽  
Hypertrophic Obstructive Cardiomyopathy ◽  
Left Ventricular ◽  
Afterload Reduction ◽  
Intra Aortic Balloon Pump ◽  
Refractory Cardiogenic Shock

Introduction: Hypertrophic obstructive cardiomyopathy (HOCM) is a genetic disease due to a mutation in cardiac muscle protein resulting in left ventricular wall and septal hypertrophy. The presence of systolic anterior motion (SAM) of the mitral valve leads to dynamic left ventricular outflow tract (LVOT) obstruction. With increasing SAM of the anterior mitral leaflet there is resultant loss of coaptation leading to mitral regurgitation (MR). MR has been associated with HOCM but severe MR physiology causing refractory cardiogenic shock and requiring the use of afterload reduction through intra-aortic balloon pump (IABP) is rare and seems paradoxical to the conventional therapy for HOCM. Case summary: This is a case of 71year old female with HOCM, presenting with worsening shortness of breath. She had pulmonary vascular congestion on Chest X-ray and her Transthoracic Echocardiography demonstrated significant LVOT obstruction with moderate MR. She was being evaluated for myomectomy while being treated medically with beta blocker therapy for HOCM. She decompensated with acute respiratory failure from pulmonary edema, her blood pressure and oxygen saturation dropped. She was intubated. Swan- ganz catheter reading suggested wedge pressures of 22 and elevated pulmonary pressures. MvO2 was 32% and this was suggestive of cardiogenic shock. The Trans-esophageal echocardiogram (TEE) showed normal EF with severe concentric LVH and a moderate to severe (3+) MR due to restricted leaflet motion with regurgitant orifice area being 2.5cm2. At that point her MR was the dominant physiology behind her acute decompensation and cardiogenic shock and hence an IABP was placed for reducing afterload that helped in stabilizing her. Subsequently her wedge pressure and MvO2 improved, she was weaned off the IABP and extubated. The patient is being evaluated for myomectomy and mitral valve repair. Conclusion: This case illustrates complex hemodynamics and a challenging management due to competing MR and HOCM physiologies, too much central volume to offset HOCM may worsen MR and pulmonary edema while too much afterload reduction might worsen the HOCM. The use of IABP in a HOCM patient though seems paradoxical but was necessary in this setting to deal with complex physiologies.

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