Concomitant Repair For Mild Aortic Insufficiency And Implantation Of Left Ventricle Mechanical Support

Aortic valve regurgitation in patients undergoing LVAD implantation is a significant complication which occurs in up to 10% of patients in the INTERMACS database. Patients who have aortic valve regurgitation at the time of implant have been handled by several methods, including aortic valve leaflets approximation, to aortic valve replacement or even valve closure. We report a case where we used HAART Ring to repair a regurgitant aortic valve during LAVD implant for destination therapy.

Mitral Plasticity: The Way to Prevent the Burden of Ischemic Mitral Regurgitation?

The ischemic impairment of the left ventricular contractility, followed by an adverse remodeling leading to the displacement of the papillary muscles (PMs), increased tethering forces and loss of valve competence has been the long-term accepted definition of ischemic mitral regurgitation (IMR). Over the years, different approaches of management have attempted to address valve regurgitation, nevertheless failing to achieve satisfactory outcomes. Recent studies have observed some structural and molecular changes of the mitral valve (MV), challenging the concept of a bystander passive to the subvalvular involvement. Indeed, the solely mechanical stretch of the PMs, as in the dilated left ventricle because of the aortic valve regurgitation, is not enough in causing relevant MV regurgitation. This setting triggers a series of structural changes called “mitral plasticity,” leaflets increase in their size among others, ensuring an adequate systolic area closure. In contrast, the ischemic injury not only triggers the mechanical stretch on the subvalvular apparatus but is also a powerful promotor of profibrotic processes, with an upregulation of the transforming growth factor (TGF)-β signaling pathway, leading to a MV with exuberant leaflet thickness and impaired mobility. In this article, we revise the concept of IMR, particularly focusing on the new evidence that supports dynamic changes in the MV apparatus, discussing the consequent clinical insights of “mitral plasticity” and the potential therapeutic implications.

Evaluation of Changes in the Cardiac Function before and after Transcatheter Edge-to-Edge Mitral Valve Repair in Healthy Dogs: Conventional and Novel Echocardiography

Mitral valve regurgitation is a common canine heart disease. Transcatheter Edge-to-Edge Repair (TEER) is a transcatheter, edge-to-edge mitral repair device that uses a hybrid approach. No detailed information has been published on the hemodynamic effect of TEER on cardiac function. The aim of this report is to provide a longitudinal observation of the cardiac functional changes observed after TEER implantation in normal dogs using traditional, two-dimensional speckle tracking, and color M-mode echocardiographic methods. In the current report, TEER was implanted into two healthy dogs under general anesthesia. An echocardiographic examination was performed at baseline and weekly postoperative follow-ups were conducted until the fourth week. Successful TEER implantation was achieved with a short operation time (98 and 63 min) in the two dogs. Functional mitral valve regurgitation, elevated E/e’ ratio, elevated radial strain, and stable intraventricular pressure gradients (IVPG) were observed after the operation in the dogs. Mild non progressive mitral valve stenosis was observed in both dogs. TEER is a minimally invasive method for mitral valve surgery that necessitates more clinical trials. With longitudinal observation of heart function using novel approaches, better outcomes will be expected.

Association between Cardiac Auscultation and Echocardiographic Findings in Warmblood Horses

Heart murmurs are detected frequently when auscultating horses and certain murmurs can usually be linked to specific valvular regurgitations. Limited information exists about the accuracy of these broad rules in warmblood horses and the influence of grade of the regurgitation and dimensional changes on murmur intensity. This study aims to clarify the accuracy of cardiac auscultation in warmblood horses and the influence of the grade of regurgitation and dimensional changes on the loudness of the murmur. In this retrospective study, 822 warmblood horses presented for cardiac examination in a large equine referral center in northern Germany underwent a thorough cardiac auscultation. In total, 653 of these revealed one or more heart murmurs. Most common auscultatory findings were left-sided systolic murmurs (68%) or left-sided diastolic murmurs (15%). On 635 of these horses, an echocardiographic examination was performed, revealing regurgitations of the mitral valve as the most common valvular regurgitation (77%) followed by regurgitations of the aortic valve (23%). Thirty-one percent of horses that underwent echocardiographic examination displayed dimensional changes of one or more compartments of the heart, with the left atrium being most affected (21%), followed by the left ventricle (13%). The main goal of this study was to link certain auscultatory findings with results of the echocardiographic examinations, trying to determine whether auscultation and echocardiography agreed on the valve affected, as well as to find out if loudness of the murmur coincided with grade of regurgitation and presence of dimensional changes. Agreement between auscultation and cardiac ultrasound was substantial (Kappa 0.74) if one or more murmurs and regurgitations were present and almost perfect (Kappa 0.94) if only one murmur and one regurgitation were found. Auscultation was particularly well suited for detection of left-sided systolic and diastolic murmurs, with 87% of left-sided systolic murmurs being caused by a mitral valve regurgitation and 81% of left-sided diastolic murmurs originating from an aortic valve regurgitation. We found a fair agreement between the grade of regurgitation and the respective murmur. Association was particularly good between mild regurgitations and low-grade murmurs, while differentiation between moderate to severe regurgitation based upon the loudness of the murmur was less reliable. Dimensional changes were usually linked to more severe regurgitations and higher-grade murmurs. However, a direct correlation between murmur intensity and the presence or severity of dimensional changes, independent of the grade of valvular regurgitation, could not be established in this cohort of horses.

How to remove an embolized TriClip from the femoral vein? Case report

Background and case summary We report a case of a 76-year old female who was admitted to our hospital because of dyspnoea caused by a known high-grade tricuspid valve regurgitation. The patient received an edge-to-edge reparation of the tricuspid valve one month before the current admission using the TriClip XTR (Clip) system. The postinterventional echocardiographic results were satisfying, and the patient was discharged with tricuspid valve regurgitation grade I. At this new admission, the echocardiographic control showed a missing Clip on the tricuspid valve with a recurrent high-grade regurgitation. Fluoroscopy showed the dislocated Clip at the level of the femoral vein. This was also confirmed using Duplex sonography with no signs of thrombosis or embolization. The challenge was how to extract the Clip using endovascular methods as the patient refused any kind of surgical removal. We managed to remove the 20 x 10 mm big clip using transfemoral access and an endovascular snare system. No postinterventional complications were registered. The patient was discharged after the intervention with a new scheduled Clip procedure. Discussion This case shows a possible safe and challenging alternative to removing dislocated Clip from the femoral vein. Experienced operators are required to have the knowledge and skills to manage these possible procedural complications using the appropriate apparatus. A surgical technique would be, in this case, common practice, however as the patient declined surgical intervention, the endovascular approach was the alternative option.