Immediate clinical results of the new biological support ring for correction of mitral insufficiency

Aim. To make the first clinical experience evaluation of the new biological closed support ring for mitral valve.Methods. 26 patients (16 men, 10 women, mean age 55 [49; 62] years) with dysplastic mitral insufficiency were implanted “NEORING” biological ring for the first time from March 2020 to June 2021. The etiological factor of the defect formation in all cases was the connective tissue dysplasia. The mean functional class of heart failure before surgery was 2 [2; 3] according to NYHA, the effective regurgitant orifice (ERO) was 0.4 [0.3; 0.5], vena contracta was 0.7 [0.6; 0.8]. Ten patients received rings of 28 mm diameter, ten patients – 30 mm, six patients – 32 mm.Results. No significant adverse events such as death from any causes, strokes, myocardial infarction, cardiac complications, bleeding, and return of regurgitation or failure of plastic surgery requiring reoperation, infective endocarditis after the intervention were observed. In two cases a permanent pacemaker was implanted due to sinus node dysfunction. At discharge all patients had no regurgitation (ERO 0), medium transvalvular gradient was 4.0 [3.0; 5.3] mm Hg. All the patients were assigned to NYHA functional class I heart failure after the surgery.Conclusion. New biological support ring “NEORING” (“NeoKor”, Kemerovo) use in the middle age group of patients showed high hemodynamic efficiency, the absence of specific complications in the early stages after the surgery. It is planned to expand the clinical material on the use of the biological ring, as well as to evaluate the long-term results in the format of a prospective, randomized trial and compare the new device with the existing ones.

Echokardiografische Gradeinteilung der Mitralendokardiose beim Hund

Die myxomatöse Mitralklappenendokardiose (MME) mit resultierender Mitralinsuffizienz (MI) ist beim Hund eine der häufigsten erworbenen kardialen Veränderungen und macht bis zu 75 % der Herzerkrankungen aus. Die echokardiografische Beurteilung der Remodellierung des Herzens stellt eine bedeutsame Methode zur Evaluierung der Erkrankung dar, doch fehlt dafür eine entsprechende allgemeingültige Gradeinteilung. Ziel dieser Studie war daher, einen auf routinemäßig erhobenen echokardiografischen Parametern basierenden „Mitral Insufficiency Echocardiographic Score“ (MINE Score) für den Schweregrad der Erkrankung zu entwickeln und dessen prognostische Aussagekraft zu überprüfen.

Spectrum of cardiovascular diseases at a referral tertiary care hospital in Somalia, Mogadishu: an echocardiographic study

Background To investigate the frequencies and patterns of cardiovascular diseases (CVDs), including rheumatic and congenital heart diseases, among patients with abnormal hearts assessed by echocardiographic examination. Methods This retrospective, descriptive registry reviewed abnormal echocardiographic findings of 1140 patients aged 0–100 years who were admitted to the cardiology outpatient clinic at a tertiary training institution in Mogadishu. Results Hypertensive heart disease (HHD) (n:454, 39.8%), valvular heart disease (VHD) (n:395, 34.6%), and heart failure with reduced ejection fraction (HFrEF) (n:351, 30.8%) were the most frequent comorbidities. Congenital heart diseases (CHDs) were detected in 151 (13.2%) of the patients, with the most common ones including atrial septal defect (ASD) (n:37, 3.2%) and ventricular septal defect (VSD) (n:26, 2.3%). Rheumatic heart disease (RHD) was observed in 84 (7.4%) patients, among whom the most common age range was 16–30 years (40.5%), followed by 31–45 years (31%) and 0–15 years (15.5%). Mitral insufficiency (n:541, 47.5%) was detected as the most frequent VHD, followed by aortic insufficiency (n:437, 38.3%), and tricuspid insufficiency (n:264, 23.2%) and mitral valve stenosis (n:39, 3.4%) was the least common VHD. Conclusion In the present study, we found that HHD was the most common comorbidity, followed by VHD, and HFrEF. Moreover, the most common VHD was mitral insufficiency and the most common CHD was ASD.

717 A case of takotsubo cardiomyopathy due to… fear of COVID

Takotsubo syndrome (TTS), also known as ‘stress cardiomyopathy’ or ‘broken heart syndrome’, is a frequent cause of transient ST-segment elevation, characterized by typically reversible abnormalities of segmental kinetics of the left ventricle, triggered by emotional or physical stress, with not critical stenosis at coronarography. This cardiomyopathy mainly affects women (about 90% of cases), especially in the post-menopausal age, and owes its names to the typical shape of the left ventricle in telesystole to ventriculography (‘takotsubo’ is a Japanese term for a vessel used as an octopus trap, with a thin neck and rounded tip). The incidence of Takotsubo cardiomyopathy showed a marked increase during the COVID-19 pandemic. On the other hand, a marked worsening of anxiety and depressive symptoms in the general population was recorded during the lockdown. In April 2020, an 86-year-old woman was admitted to the Coronary Intensive Care Unit of our hospital. Her remote medical history shows: arterial hypertension, previous breast cancer, operated and treated with adjuvant radiotherapy and hormone therapy, and cervical cancer, subjected to radical hysterectomy and subsequent pelvic radiotherapy. Upon entering the ward, the patient was in a state of shock (BP 75/50 mmHg, HR 105/m') and there was marked hypothermia (34 °C). The relatives reported that the patient did not leave home since the beginning of the Sars-CoV-2 pandemic due to the high fear of contracting the infection and in the day before admission she had a feverish rise (39 °C), which regressed spontaneously. ECG showed sinus tachycardia with ST-segment elevation V2–V6, in I and aVL and under level in III and aVR (Figure 1) with elongated QT interval. Echocardiogram revealed akinesia of the mid-apical segments, with kinetics preserved in the basal segments, severe left ventricular systolic dysfunction (ejection fraction: 25%), moderate dual-jet mitral insufficiency due to symmetrical tethering of the flaps and a mild infero-lateral pericardial effusion. The indices of myocardionecrosis and inflammation were high. The patient was asymptomatic for chest pain and equivalents and expressed an excessive fear of having contracted COVID-19. Nasal swab for SARS-CoV-2 was performed, which was negative. The interTAK score was 68 (Takotsubo probability: 82.4%). Emergency coronary angiography was performed, which showed no critical coronary stenosis. Ventriculography revealed apical dyskinesia with hyperkinesis of the basal segments (Figure 2). At the end of the procedure due to hemodynamic instability an intra-aortic balloon pump (IABP) was placed and inotropic and vasopressor therapy was undertaken. Over the next 48 h there were numerous episodes of non-sustained ventricular tachycardia and amiodarone was applied for the onset of atrial fibrillation, with prompt restoration of the sinus rhythm. The patient was progressively weaned from the mechanical and pharmacological support of the circulation and she was discharged in optimal medical therapy, with indication for echocardiographic follow-up, still in progress.

The Effectiveness of Training on Auscultation of Heart with a Simulator of Cardiology in Medical Students

The purpose of this study was to determine whether the training module with a simulator of cardiology improves auscultation skills in medical students. Methods. Medical students of the third year after completing the module of the cardiovascular system of the discipline “Propaedeutics of internal diseases, passed a two-hour or four-hour training module in clinical auscultation with retesting immediately after the intervention and in the fourth year. The control group consisted of fourth-year medical students who had no intervention. Results. The diagnostic accuracy in two-hour training was 45.9% vs 35.3% in four-hour training p <.001. The use of a cardio simulator significantly increased the accurate detection of mitral regurgitation immediately after training on a simulator (more than 73%) p <.001. The next academic year, regression was observed in the diagnostic accuracy of mitral insufficiency in the intervention group after six months of observation by 4%. The auscultation skills of students at the bedside of real patients did not increase after training on a simulator: the accuracy of diagnosis of the auscultatory picture of the defect was equally low in the intervention group and the control group (35.0% vs 30.8%, p = 0.651). Conclusions. Two-hour training was more effective than four-hour training. After training on cardiac auscultation using a patient’s cardiological simulator, the accuracy rate was low in a situation close to the clinical conditions and a clinic on a real patient.

P056 Acute rheumatic fever: still a hot topic

Background Acute rheumatic fever (ARF) still a very common condition and constitutes a real public health problem in the developing countries including Algeria. The objective is to assess the epidemiological and clinical profile and the disease course of ARF in our region and estimate the incidence of cardiac complications. Method The authors report the results of a retrospective study of 52 cases of ARF in children, hospitalized and treated at the Sainte Therese Clinic of the CHU Annaba for a period of 6 years. The diagnosis was made according to Jones criteria. Information was obtained from hospital records. Results The disease mainly concerned the age group of 4–10 years (52%), the sex ratio was 0.86 (28 girls, and 24 boys). The maximum number of hospitalizations is observed during the rainfall period (October-March). 54% of patients had untreated angina. Clinically, fever was noted in 23 patients, polyarthritis in third of cases and a heart murmur in half of patients. Doppler-coupled echocardiography founded carditis in 73% of patients: Endocarditis was noted in all of these cases and the mitral insufficiency was the dominant anatomo-clinical form. The number of infra-clinical carditis was considerable (10/38 cases of carditis). Biologically, accelerated ESR (&gt; 50 mm/H1) was observed in 65% of cases, high CRP level and hyper leucocytosis were noted in 38 and 31 patients, respectively. ASLOs were high in 85% of cases. The outcomes were favorable in the majority of cases. Nevertheless 5 relapses were recorded, including 3 complicated by severe carditis. Conclusion ARF still frequent in our region. Cardiac complications are always frequent and constitute a major factor of morbidity. Our results illustrate the absolute need for a rigorous application of the national prevention program, the main objective of which is to reduce the prevalence of rheumatic heart disease.

Dynamic obstruction of the left ventricular outflow tract as a possible complication of takotsubo cardiomyopathy

Takotsubo cardiomyopathy is a relatively benign condition characterized by stress-induced hypo- and akinesis of the apical segments of the myocardium against the background of intact function of the basal segments. With the addition of obstruction of the left ventricular outflow tract (LVOT) due to hyperkinesis of the basal segments, the patient’s condition and prognosis significantly worsens. In terms of hemodynamic parameters, this situation is similar to obstruction of LVOT in patients with hypertrophic cardiomyopathy, however, due to its rapid development, it can lead to the formation of acute heart failure against the background of low ejection syndrome and acute mitral insufficiency. This article presents a literature review, information on the epidemiology, pathophysiology and diagnosis of this disease, as well as a clinical case of the development of acute heart failure with obstruction of the left ventricular outflow tract and progression of takotsubo syndrome.

The Effect of Depth of Anaesthesia on the Severity of Mitral Insufficiency by Transesophageal Echocardiography

Background The assessment of mitral regurgitation (MR) is complex and complicated by the dynamic nature of this valvular abnormality. Intraoperative transesophageal echocardiography (TEE) is a well-established tool that is used to assess the mitral regurgitation (MR) before and after mitral valve reconstruction. Objectives This study conducted in the National Heart Institute in Cairo aimed at assessing the effect of depth of anaesthesia guided by bispectral index on the severity of mitral insufficiency as measured by transesophageal echocardiography. Patients and Methods This study was conducted in the National Heart Institute in Cairo. The study was conducted for a period of about six months after the approval from Ethical committee. Informed oral consent for every patient was obtained. Prospective observational cross-sectional study with a random sample of 20 patients at National Heart Institute. A sample size of at least 15 data pairs achieves 80% power to reject the null hypothesis of zero effect size when the population effect size is 0.80 and the significance level (alpha) is 0.05 using a two-sided paired ttest. Adult patients undergoing elective cardiac surgery in National Heart Institute. Results The MR severity decreased at a deeper anaesthesia at low BIS than at a shallower anaesthesia at high BIS in patients with organic MR. Eight patients out of twenty patients (40% with organic MR) showed a + 1 grade of improvement in MR grade, by semi-quantitively measuring maximal JA and VC width. Improvement in mitral regurge severity thought to be secondary to unloading effect of general anaesthesia on left ventricle causing a decrease in afterload, preload, and left ventricular dimensions. This study demonstrated that, a comparison between deep anaesthesia and shallow anaesthesia using BIS showed there is a significant reduction in multiple parameters of MR severity assessment secondary to unloading effect of general anaesthesia on left ventricle caused by a decrease in both afterload and preload. Conclusion This reduction in MR severity appeared to be significant enough to modify intraoperative decisions regarding valve surgery by underestimation of valve severity. Thus, strong consideration should be given to thorough preoperative assessment of MR severity, rather than relying on intraoperative findings.

MODERN PRINCIPLES OF DIAGNOSIS AND SURGICAL TREATMENT OF ISCHEMIC MITRAL INSUFFICIENCY

The purpose of the study is to evaluate and analyze the results of surgical treatment of patients with ischemic mitral insufficiency. Material and methods. The results of the examination and surgical treatment of 35 patients with ischemic mitral insufficiency are analyzed. In the operative period, in order to identify the degree of mitral insufficiency and the valvular apparatus, an echocardiography was performed, where the diameter of the fibrous ring, the interpapillary distance, the annulopapillary distance, the area of the cusp tension, and the depth of the coaptation of the valves were determined. Results. A preoperative examination proved the presence of mitral valve insufficiency with regurgitation of varying degrees. 15 patients underwent myocardial revascularization, 20 patients underwent myocardial revascularization + various options for correction of ischemic mitral insufficiency. After the operation, a significant improvement in the spatial-geometric correlation of the LV and mitral valve by reducing the tension forces acting on the valves and in the group of patients undergoing myocardial revascularization + various options for the correction of ischemic mitral insufficiency as the elimination of regurgitation. Conclusion. In patients with ischemic heart disease after echocardiographic studies, having determined the degree of mitral insufficiency with its moderate and severe degree, it is necessary to have a surgical correction of the mitral valve in its apparatus; the use of myocardial revascularization + various options for the correction of ischemic mitral insufficiency gives more tantalizing results than isolated myocardial revascularization.

Earlysurgical treatment of acu te coronary syndrome in patients with ST -segm ent elevation (at < h24), arrhy thm iccomp lications and severe mitral regu rgitation

Treatment outcomes of acute coronary syndrome in 108 patients with ST-segment elevation (after more than 24 hours) complicated by arrhythmias (atrial fibrillation and atrial flutter) and subsequently developed severe (degrees 2 and 3) mitral insufficiency were analyzed. We elaborated an algorithm for the sequence of interventions. All the patients had coronary angiography and stenting of the symptom-dependent artery during the first 2 days after the admission. Depending on the localization of the left ventricular myocardial infarction zone, the patients were divided into 3 groups: 68 (63%) patients with anterior wall and apex infarction; 23 (21.3%) patients with posterior wall infarction; 17 (15.7%) patients with lower wall infarction. It was revealed that patients, who had undergone revascularization in the early stages, had a statistically significant increase in the main indicators of myocardial contractility, in contrast to patients receiving only conservative therapy. In the observation group, sinus rhythm was restored in all patients 1–4 days after hospitalization. 12 patients underwent emergency electrical cardioversion on the day of admission. In 31 patients, sinus rhythm was restored within the first 24 hours during therapy prior to revascularization. In 39 patients, sinus rhythm was restored during therapy on days 3–5 after primary revascularization. In 26 patients, sinus rhythm was restored 2–4 days after complete revascularization. Based on the study, several conclusions can be drawn: in conditions of heart failure, revascularization is best to perform at the earliest possible stage. The optimal values of vital functions for performing revascularization can be considered: systolic blood pressure ≥ 80 mm Hg; heart rate ≤ 110 beats per minute. In primary surgical treatment, it is most optimal to revascularize only the symptom-dependent artery. Reintervention for complete revascularization is most effective and safe 10–14 days after the initial intervention. The use of emergency electrical cardioversion in those patients in the preoperative period is fully justified, despite the existing risks. Application of our algorithm helps to restore sinus rhythm, reduce the degree of mitral regurgitation and reduce mortality.