453 An unexpected finding in an asymptomatic patient planned for non-cardiac surgery

Aims Left ventricular (LV) aneurysms and pseudoaneurysms are two complications of myocardial infarction, either symptomatic or silent, leading to death or serious morbidity in several cases and often precluding non-cardiac surgery. Here the differential diagnosis is challenging and multimodality imaging is often needed to assess the risk of heart rupture. Methods and results A 71 years-old woman was referred to our Cardiology Department for a preoperative evaluation before lung lobectomy. Her past medical history included multiple cardiovascular risk factors and abdominal aorta aneurysm. She also had severe peripheral arterial disease treated with femoral popliteal bypass surgery in June 2021. In August 2021 she suffered from vascular graft thrombosis requiring a redo surgery. During hospitalization, she was found to have a lung adenocarcinoma. The patient had an unremarkable cardiological history and was asymptomatic. EKG was unremarkable. Transthoracic echocardiography revealed a mildly impaired LV systolic function (EF = 40%), an inferolateral basal wall akinesia and a huge aneurysm with intracavitary thrombus and a wide neck arising right below the posterior mitral annulus. The annular distortion caused by the expanding aneurysm contributed to the development of mitral regurgitation (MR) by displacing the annulus and subvalvular apparatus, resulting in restriction of the posterior mitral valve leaflet, coaptation failure, and moderate MR. Coronary angiography demonstrated a severe 3-vessel coronary artery disease. To further characterize the aneurysm, a cardiac magnetic resonance was carried out. T1 weighted inversion recovery LGE 2-chamber and short axis views showed transmural LGE of the inferior wall and confirmed the presence of a saccular dilatation with thin wall, wide neck (5 × 6 cm) and large intracavitary thrombus at high risk of rupture. Since the presence of metastatic lesions was excluded, the patient underwent cardiac surgery followed by elective lobectomy. Intraoperative findings were consistent with LV aneurysm with a thin myocardial wall. Aneurysm and related thrombus were removed and the orifice was closed with a Dacron patch. In the same setting a myocardial revascularization with two coronary artery bypass grafts was also performed. Surgery was successfully performed without any complication. Intraoperative transesophageal echocardiography clearly revealed the aneurysm and witnessed the reduction of MR after the restoration of LV inferolateral wall geometry. Conclusions Our case highlights the importance of thorough evaluation prior to non-cardiac surgery using multimodality imaging, especially when incidental echocardiographic findings in asymptomatic patients occur. A careful pre-operative assessment of patients planned for non-cardiac surgery is the key to favourable postoperative outcome.

Screening for subclinical rheumatic heart disease: Addressing borderline disease in a real-world setting

Introduction The World Heart Federation (WHF) criteria identify a large borderline rheumatic heart disease (RHD) category that has hampered the implementation of population-based screening. Inter-scallop separations (ISS) of the posterior mitral valve leaflet (PMVL), a recently described normal variant of the mitral valve, appears to be an important cause of mild mitral regurgitation (MR) leading to misclassification of cases as WHF ‘borderline RHD’. This study aims to report the findings of the Echo in Africa project (EIA), a large-scale RHD screening project in South Africa and determine what proportion of borderline cases would be re-classified as normal if there were a systematic identification of ISS-related MR. Methods A prospective cross-sectional study of underserved secondary schools in the Western Cape was conducted. Participants underwent a screening study with a handheld (HH) ultrasound device. Children with an abnormal HH study were re-evaluated with a portable laptop echocardiography machine. A mechanistic evaluation was applied in cases with isolated WHF ‘pathological’ MR (WHF ‘borderline RHD’). Results 5255 participants (mean age 15± years) were screened. 3439 (65.8%) were female. 49 cases of WHF ‘definite RHD’ (9.1 cases/1000 [95% CI, 6.8-12.1 cases/1000]) and 104 cases of WHF ‘borderline RHD’ (19.5 cases/1000[95% CI,16.0-23.7 cases/1000]) were identified. ISS-related MR was the underlying mechanism of MR in 48/68 cases classified as WHF ‘borderline RHD’ with isolated WHF ‘pathological’ MR (70.5%). Conclusion In a real-world, large-scale screening project, the adoption of a mechanistic evaluation based on the systematic identification of ISS-related MR markedly reduced the number of WHF ‘screen-positive’ cases misclassified as WHF ‘borderline RHD’. Implementing strategies that reduce this misclassification could reduce the cost- and labour-burden on large scale RHD screening programs.

Mitral degenerative valve leaflets suspected as primary valvular tumor: a case report

Introduction: Echocardiography plays an important role in the diagnosis of heart disease. However, sometimes misdiagnosis information is also provided. Methods and Results: We report a rare case of preoperative echocardiography misdiagnosed as a primary mitral valvular tumor with severe regurgitation. During the surgery procedure, the true lesion was found to be mitral valve leaflet prolapse due to degenerative mitral valve disease. Conclusions: For individual patient, it may need to combine clinical symptoms and wide use of echocardiography and CT or MRI to make the optimal clinical decision.

Patch repair in infective native mitral valve endocarditis

Infective native mitral valve endocarditis occurs rarely. Mitral valve repair, although surgically challenging, is favored over replacement in the latest European and American guidelines. In this video tutorial, patch repair of the posterior mitral valve leaflet is performed in a 61-year-old patient with endocarditis caused by Streptococcus agalactiae.

Valve-in-Valve for Failing Mitral Bioprosthesis With Tip-to-Base LAMPOON to Prevent Left Ventricular Outflow Tract Obstruction

Transcatheter mitral valve replacement (TMVR) is a new approach for treating failed bioprosthetic valves, annuloplasty repairs, and mitral annular calcification. Computed tomography is the key in procedure planning and guiding to identify patients at high risk of anatomic complications, in particular, for left ventricular outflow tract (LVOT) obstruction. There are several methods to reduce the risk of LVOT obstruction. A simple option is preemptive alcohol septal ablation, but this needs to be done prior to the TMVR procedure. Intentional laceration of the anterior mitral leaflet to prevent LVOT obstruction (LAMPOON), a transcatheter electrosurgical technique to split the anterior mitral valve leaflet immediately prior to TMVR, can be done anterograde or retrograde but requires leaflet traversal, which is technically challenging. In this article, we describe a case of valve-in-valve TMVR in a patient with high risk for LVOT obstruction and a novel simple technique—tip-to-base LAMPOON.