FREQUENCY OF ACUTE MITRAL REGURGITATION IN POST PERCUTANEOUS TRANSVENOUS MITRAL COMMISSUROTOMY PATIENTS WITH SEVERE MITRAL STENOSIS

Objectives: To determine the frequency of Acute Mitral Regurgitation in Post Percutaneous Transvenous Mitral Commissurotomy (PTMC) patients with severe mitral stenosis (MS). Methodology: A cross-sectional study was conducted at the Tabba Heart Institute, Karachi, Pakistan between September 2019 and April 2021. All patients irrespective of gender, aged between 19-80 years, and those who did not undergo PTMC were eligible to partake in the study. Patients with mitral regurgitation along with mitral stenosis, or those with clot in left atrium, or those suffering with the last stage of renal disease were excluded from the study. A predefined Proforma was used as a research instrument through which medical records of patients of PTMC are collected. The variables of the Proforma include patient’s age, name, sex, echo findings, treatment procedure, post-procedure data and complications. Results: A mean age of 40.6 ± 12.63 years was reported. 86 (81.9%) of the patients developed ‘no complications’, 15 (14.3%) of the PTMC patients suffered from ‘severe mitral regurgitation’, 2 (1.9%) had local hematoma, and one patient had a cardiac tamponade after the procedure. Only one patient died post-procedure. Post-stratification analysis showed that the majority of the female patients and 83% of the patients with no previous commissurotomy history did not have any complications. While a total of 14.7% who had no history of previous commissurotomy suffered from severe MR. Conclusion: Our study revealed that only a small number of patients who underwent PTMC suffered from severe mitral regurgitation. Overall, the procedure is safe with a good outcome.

Diagnostic Pitfalls in Papillary Muscle Rupture-Associated Acute Mitral Regurgitation after Acute Myocardial Infarction

Papillary muscle rupture (PMR) is a rare and fatal complication of acute myocardial infarction (AMI). We report a case of acute mitral regurgitation (MR) due to PMR with pulmonary edema and cardiogenic shock following AMI with small myocardial necrosis. An 88-year-old woman was brought to our emergency department in acute respiratory distress, shock, and coma. She had no systolic murmur, and transthoracic echocardiography was inconclusive. Coronary angiography showed obstruction of the posterior descending branch of the right coronary artery. Although the infarction was small, the hemodynamics did not improve. Transesophageal echocardiography established papillary muscle rupture with severe mitral regurgitation 5 days after admission. Thereafter, the patient and her family did not consent to heart surgery, and she eventually died of progressive heart failure. Physicians should be aware of papillary muscle rupture with acute mitral regurgitation following AMI in patients with unstable hemodynamics, no systolic murmur, and no abnormalities revealed on transthoracic echocardiography.

Early postoperative complications in patients with acute myocardial infarction during emergency coronary bypassing

The article aims to determine the factors of early mortality in emergency coronary artery bypass grafting. Research methods. The research were included 129 patients who were hospitalized in Kyiv “Heart Center” in 2011-2015, 100 – with ST-elevated myocardial infarction, 29 – with non- ST-elevated myocardial infarction (NSTEMI). Research results. In STEMI patients vs. NSTEMI type was a higher risk of acute heart failure (p<0.05) followed by intra-aortic balloon pulsation (p<0.05) and inotropic support (p<0.05). In the STEMI group acute kidney injury was confirmed by higher indexes of absolute and relative risks (p<0.05). All cases of the transient atrioventricular block were registered in patients with STEMI (p<0.05). However, it was established that the likelihood of supraventricular arrhythmia and encephalopathy in the NSTEMI group was reliably higher (p<0.05). The level of early postoperative mortality (12.4%) proved the probable risk (p<0.05) in STEMI (log-rank - 2,74; p = 0,006). Mortality was associated with acute heart failure (56,2%), cardiogenic shock (31,3%), acute mitral regurgitation (12.5%). Emergency surgical revascularization in acute MI is an effective method of treatment and can be used taking into account clinical, hemodynamical, and coronary features of myocardial damage.

Complicating Acute Myocardial Infarction. Current Status and Unresolved Targets for Subsequent Research

Mechanical reperfusion with primary angioplasty, as the treatment of choice in acute myocardial infarction (MI), is associated not only with a high percentage of full epicardial and tissue reperfusion but also with a very good immediate and long-term clinical outcome. However, the Achilles heel of MI treatment is its ensemble of complications, such as cardiogenic shock due to severe systolic and/or diastolic dysfunction or MI mechanical complications, including perforation of the left ventricular free wall, papillary muscle rupture with acute mitral regurgitation and ventricular septal rupture. They are associated with an increased or, sometimes, with an extremely high mortality rate, determining the overall mortality in an MI patient population. In this review we summarize the mechanisms of MI complications, current therapeutic management and alternative directions for overcoming their devastating consequences. Moreover, we have sought to indicate gaps in the evidence on current treatments as the potential targets for further clinical research. From the perspective of mortality trends that are not improving, the forthcoming therapeutic management of complicated MI will require an individualized and novel approach based on their thorough pathobiology.

Diagnostic delay of acute mitral regurgitation during the coronavirus disease 2019 pandemic: a case report

Background Diagnostic errors or delays can cause serious consequences for patient safety, especially in the emergency department. Anchoring bias is one of the major factors leading to diagnostic error. During the coronavirus disease 2019 (COVID-19) pandemic, the high probability of COVID-19 in febrile patients could be a major cause of anchoring bias leading to diagnostic error. In addition, certain evaluations such as auscultation are difficult to perform on a casual basis due to the increased risk of contact infection, which lead to inadequate assessment of the patients with valvular disease. Acute mitral regurgitation (MR) could be a fatal disease in the emergency department, especially if there is a diagnostic error or delay in diagnosis. It is often reported that diagnosis can be difficult even though there is no treatment other than emergent surgery. The diagnosis of acute MR has become more difficult because coronavirus disease 2019 (COVID-19) pandemic could affect our daily practice especially in febrile patients. We report a case of a diagnostic delay of a febrile patient because of anchoring bias during the COVID-19 pandemic. Case presentation A 45-year-old man presented to the emergency department complaining of acute dyspnea and fever. Based on vital signs and computed tomography of the chest, acute pneumonia due to COVID-19 was suspected. Auscultation was avoided because of facility rule based on concern of contact infection. After admission to the intensive care unit, Doppler echocardiography revealed acute mitral regurgitation, and transesophageal echocardiography revealed mitral valve tendon rupture. After confirming the negative result for the polymerase chain reaction of severe acute respiratory syndrome coronavirus 2, mitral valvuloplasty was performed on the third day after admission. The patient was discharged 14 days after admission without complications. Conclusions In COVID-19 pandemic, anchoring bias suspecting COVID-19 among febrile patients becomes a strong heuristic factor. A thorough history and physical examination is still important in febrile patients presenting with dyspnea to ensure the correct diagnosis of acute mitral regurgitation.

A case report of transcatheter mitral valve repair in patient with severe acute mitral regurgitation, cardiogenic shock, and left atrial appendage thrombus as a rescue therapy: facing all enemies at once!

Background Transcatheter mitral valve repair (TMVR) in patients with severe acute mitral regurgitation (MR) and high surgical risk has been described. Moreover, the use of cerebral protection device (CPD) during TMVR in patients without evidence of intracardiac thrombus has been investigated. To the best of our knowledge, TMVR as a rescue therapy in a patient with acute ischaemic MR, cardiogenic shock, and left atrial appendage (LAA) thrombus with concurrent use of CPD has not been reported. Case summary A 59-year-old female with subacute lateral myocardial infarction caused by subacute stent thrombosis after stent implantation in the left circumflex artery 3 weeks previously presented with acute heart failure due to acute severe MR at a peripheral hospital. The patient was transferred to our tertiary centre for operative mitral valve repair. Transoesophageal echocardiogram revealed the presence of LAA thrombus. During the admission, the patient developed an electrical storm and cardiogenic shock. Because of the extremely high surgical risk and the lack of other therapeutic options, the patient was treated with TMVR (MitraClip™, Abbott Structural Heart Devices, Santa Clara, CA, USA) with the use of CPD (Sentinel™; Boston scientific) as a rescue therapy. After the procedure, the clinical and haemodynamic conditions of the patient improved significantly, and she could be discharged home without any neurological sequelae. Conclusion TMVR with concurrent use of CPD as a rescue therapy may be considered in non-operable patients with cardiogenic shock caused by acute severe MR and evidence of LAA thrombus when no other therapy options are possible.