Transcatheter closure of multiple paravalvular leaks by a transapical approach under echocardiographic guidance: A case report

Case summary A patient who underwent mechanical aortic and mitral valve replacement developed three paravalvular leaks 10 months later. We located the tracks by puncturing the apex cordis under transoesophageal echocardiography guidance alone and puncturing the femoral artery guided by fluoroscopy. Three paravalvular leaks were occluded with a hybridization method simultaneously. The patient was followed up for 24 months and maintained a good condition. Conclusion Multiple paravalvular leaks after double valve replacement can be occluded in patients by the use of different approaches under echocardiographic guidance alone.

Double-valve Replacement for Aortic and Tricuspid Autoimmune Endocarditis

Libman–Sacks endocarditis (LSE) is a cardiac manifestation of systemic lupus erythematosus and antiphospholipid syndrome and is characterized by non-bacterial verrucous vegetations with thrombogenic potential, causing stenosis and/or regurgitation in left heart predominantly, which can be asymptomatic in most of the cases but in the acute form it may present an infective form (pseudoinfective endocarditis) and complicate diagnosis and treatment. We present a case of aortic and tricuspid valve destruction due to Libman-Sacks endocarditis in a patient with antiphospholipid syndrome requiring surgical treatment by aortic and tricuspid valve replacement.

Case report of Double Valve Replacement with Coronary Artery Bypass Grafting with Supracoronary Ascending Aortic Replacement in a Single Patient - A Chimera

Double valve replacement is now-a-days a common procedure to treat diseased cardiac valves and the primary aim of prophylactic aortic replacement during concomitant valve replacement is to prevent dreadful complication like dissection, aortic rupture and even death. Although aortic surgeries are complex and have high morbidity and mortality rates, additional double valve procedure with coronary surgery can make it even worse. But for these patients, surgery remains the one and only treatment option for symptom relieve and prolongation of life. We herein present a case of severe aortic stenosis (AS) with severe aortic regurgitation (AR) with severe mitral regurgitation (MR) with coronary artery disease (CAD) and aortic aneurysm treated successfully by us at Square Hospitals; and to our best knowledge and according to the published articles, this is probably the first time, this type of combined cardiac procedure has been accomplished along with aortic surgery, in our country. We recommend that surgeons should perform bypass grafting along with aortic replacement and valve replacement surgery when indicated, without worrying that adding such a procedure will escalate post-operative adverse effect. Cardiovasc j 2021; 14(1): 82-87

Patient Prosthesis Mismatch in Double Valve Replacement - A Retrospective Study at a Tertiary Care Center in Bangalore

BACKGROUND Valve replacement has become the mainstay of management for rheumatic heart diseases. However, an important and frequent complication of valve replacement is patient prosthesis mismatch (PPM). The present study was undertaken to evaluate a single institution experience on the clinical pattern and presentation of PPM, and the outcomes of double valve replacement surgery. METHODS This retrospective, regional study was carried out among 316 consecutive patients who underwent concomitant aortic and mitral valve surgery (with or without tricuspid annuloplasty) in this tertiary care hospital. Particulars regarding the clinical profile and procedure details (valve types and sizes and priority of surgery) of these patients were documented from the medical records. RESULTS In this institute, the valves used were predominantly mechanical (92.6 %) when compared to bioprosthesis in 7.4 % (47/632 valves - 23 mitral position and 24 in aortic position). The most common sizes used in the aortic and mitral position were 21 mm & 27 mm respectively. In spite of the seemingly lower sizes used in the patients undergoing double valve replacement (DVR) the incidence of PPM is less owing to the fact that the population under study had a lower body surface area (BSA) and body mass index (BMI) - 1.17 ± 0.3 & 19.86 ± 3.9 respectively. CONCLUSIONS It may be emphasized that if the valve size required to be implanted is derived based on the patient’s BSA and indexed effective orifice area, the incidence of patient prosthesis mismatch can be minimized drastically and with it the in-hospital mortality and morbidity. KEYWORDS Aortic Stenosis, Double Valve Replacement, Mitral Valve, Prosthesis, Rheumatic Heart Disease

Surgical Aortic Mitral Curtain Replacement: Systematic Review and Metanalysis of Early and Long-Term Results

The Commando procedure is challenging, and aims to replace the mitral valve, the aortic valve and the aortic mitral curtain, when the latter is severely affected by pathological processes (such as infective endocarditis or massive calcification). Given the high complexity, it is seldomly performed. We aim to review the literature on early (hospitalization and up to 30 days) and long-term (at least 3 years of follow-up) results. Bibliographical research was performed on PubMed and Cochrane with a dedicated string. Papers regarding double valve replacement or repair in the context of aortic mitral curtain disease were included. The metaprop function was used to assess early survival and complications (pacemaker implantation, stroke and bleeding). Nine papers (540 patients, median follow-up 41 (IQR 24.5–51.5) months) were included in the study. Pooled proportion of early mortality, stroke, pacemaker implant and REDO for bleeding were, respectively 16.2%, 7.8%, 25.1% and 13.1%. The long-term survival rate ranged from 50% to 92.2%. Freedom from re-intervention was as high as 90.9% when the endocarditis was not the first etiology and 78.6% in case of valvular infection (one author had 100%). Freedom from IE recurrences reached 85% at 10 years. Despite the high mortality, the rates of re-intervention and infective endocarditis recurrences following the Commando procedure are satisfactory and confirm the need for an aggressive strategy to improve long-term outcomes.

Komplikasi Multi Organ pada Pasien yang Menjalani Operasi Double Valve Replacement

Latar Belakang: Penggantian lebih dari satu katup jantung digolongkan sebagai operasi risiko tinggi dengan risiko komplikasi yang lebih tinggi dibandingkan dengan operasi penggantian satu katup jantung.Kasus: Seorang wanita usia 35 tahun dengan stenosis katup aorta berat, regurgitasi katup aorta moderat dan stenosis katup mitral berat disertai atrial fibrilasi menjalani operasi double-valve replacement. Komplikasi yang ditemukan di intensive care unit (ICU) berupa perdarahan yang signifikan, fibrilasi atrial, cedera ginjal akut dan perdarahan intrakranial.Pembahasan: Komplikasi yang mungkin ditemukan setelah penggantian dua katup jantung meliputi koagulopati, cedera ginjal akut, aritmia dan gangguan serebrovaskular. Koagulopati dapat menyebabkan perdarahan yang signifikan dan instabilitas hemodinamik sehingga harus diberikan tatalaksana yang tepat. Aritmia dapat disebabkan oleh imbalans elektrolit. Cedera ginjal akut sering ditemukan pascaoperasi jantung terbuka dan sebaiknya dilakukan hemodialisis sesegera mungkin. Tatalaksana gangguan serebrovaskular dapat bersifat konservatif atau operasi. Keputusan tatalaksana gangguan serebrovaskular harus disesuaikan menurut kondisi klinis pasien.Kesimpulan: Deteksi dini dan tatalaksana yang cepat dan tepat sangatlah penting untuk menghindari morbiditas dan mortalitas pascaoperasi yang signifikan.

Double valve replacement in a patient with Maroteaux – Lamy syndrome as an ultimate team challenge

Background The Maroteaux-Lamy syndrome (Mucopolysaccharidosis type VI) is a rare, inherited metabolic disease that results in progressive tissue accumulation of dermatan-sulfated glycosaminoglycans and inflammatory consequences that almost always affects the heart valves. From the anesthesia point of view, managing the airway and ventilation might be a serious challenge due to specific features of the syndrome. Additionally, it is more than probable that the surgical team will perform a non-straightforward procedure. Case presentation A 42-year-old male with Maroteaux-Lamy syndrome was referred to our department with shortness of breath, due to severe aortic stenosis, and at least moderate mitral valve regurgitation. The patient was initially scheduled for aortic valve replacement. After multiple attempts with video assisted laryngoscopy, the endotracheal intubation was achieved with the aid of fiberoptic bronchoscopy, while the ventilation succeeded only with laryngeal mask. The somatic features of the syndrome that made the anesthesia induction extremely difficult, also affected the surgical procedure. Suboptimal exposure of the mitral valve, patch enlargement of the aortic root to host the bigger possible prosthesis, and the hard decision to replace the mitral valve even with a marginal indication were the intraoperative challenges for the surgical team. Finally, the patient underwent a successful double valve replacement with aortic root enlargement and 18 months postoperatively remains improved. Conclusion Patients with Maroteaux-Lamy syndrome represent a challenge for both anesthesiologists and cardiac surgeons. The whole team should be well prepared to deal with difficulties in airway management, ventilation and surgical valve exposure. The cardiac surgeon should be ready to offer additional procedures and even replace “prematurely” a moderately diseased valve in order to avoid a dangerous reoperation. The limited knowledge on the natural history of the Maroteaux-Lamy syndrome valvulopathy and the difficulties in anesthesia induction support this approach.

A Rare Combination of Complex Congenital Heart Disease with Acquired Rheumatic Valvular Heart Disease

Tetralogy of Fallot (TOF) is a complex cyanotic congenital heart disease with a survival beyond middle age. Rheumatic and congenital cyanotic heart disease are common causes of hospital admission. However, coexistence of rheumatic heart disease with complex congenital heart disease like TOF is known to occur very rarely. This report presents a case of rheumatic valvular heart disease (AR & MR) with a complex congenital heart disease (TOF with PDA with PLSVC) in a 30 yrs old female. Patient was treated by conservative management and advised for corrective surgery and double valve replacement. Cardiovasc. j. 2021; 13(2): 235-238

Short Term Outcome of Double Valve Replacement vs. Aortic Valve Replacement with Mitral Valve Repair in Bangladesh: A Comparison

Background: Although all mitral valves are not repairable, most non rheumatic valves and a substantial proportion of rheumatic valves are amenable to repair. Repair preserves the normal valvular tissue, so the left ventricular function is well maintained post-operatively. Combined aortic and mitral valve surgery is associated with increased mortality and morbidity. Several studies have shown the superiority of DVR (Double valve replacement) in this entity to prevent reoperation. Some other data suggested superiority of aortic valve replacement combined with mitral valve repair in double valve disease. No study had been done over Bangladeshi population. Our aim was to compare the short-term outcome of mitral valve repair and aortic valve replacement with double valve replacement. Methods: It was a prospective non-randomized observational study took place in the Department of Cardiac Surgery of National Institute of Cardiovascular Disease. In this study post-operative result of double valve replacement was compared with aortic valve replacement and mitral valve repair. Total 60 patients under went aortic valve replacement with either mitral valve replacement (n=30) marked as group A or (n=30) repair marked as Group B. Results: Aortic cross clamp time and cardiopulmonary bypass time was higher in group B than group A but it was well tolerated without any short-term measurable consequences. Required inotrope support was 49.8±2.3 hours in group B and 87.2±3.5 hours in group A (p<0.05). Duration of ICU stay were 91.1±3.2 hours in group A and 60.3±2.9 hours in group B (p<0.05). Development of postoperative low output syndrome was significantly higher (23.33%) in group A versus 3.33% in group B. Patients of group A suffered more from CHF in the follow up period than the group B. But the result was statistically insignificant. There was an early post-operative fall of ejection fraction in both groups but it was recovered after 3 months. Post-operative thromboembolism was 13.79% in group A and 3.33% in group B. There was no early death in repair group though total three (10%) cases died after DVR. There was no valve failure, re-stenosis or regurgitation in any group in this limited follow up period. Higher dose of warfarin was required in group A to maintain INR. Consequently, post-operative major bleeding occurred in 24.14% patients of group A. On the contrary, no patient of repair group suffered from this catastrophe. Conclusion: This study reveals that the result of mitral valve repair with aortic valve replacement is equally comparable or in some cases superior to that of double valve replacement. Therefore, in feasible cases, mitral valve repair should be attempted who need concomitant aortic valve replacement. Cardiovasc. j. 2021; 13(2): 164-171