Long-term outcomes of pericardial strip versus prosthetic ring annuloplasty for secondary tricuspid regurgitation by a minimally invasive approach

Background This study was conducted to compare the outcomes of prosthetic ring versus autologous pericardial strip for the treatment of functional tricuspid regurgitation during left-sided valve surgery by minimally invasive approach. Methods From January 2008 and July 2016, autologous pericardial strip (group P-TAP) was used in 109 patients, and prosthetic ring (group R-TAP) in 115 patients. The primary outcomes were long-term overall survival, development of patch degeneration, and significant tricuspid regurgitation recurrence. The second outcome was the assessment of right ventricular functional parameters. Results Operative mortality was 1 case (0.9%) in the R-TAP group. At the time of hospital discharge only one patient (0.9%) in the R-TAP group had grade III+ tricuspid regurgitation, and none had grade IV+. Mean follow-up was 94.1 ± 24.5 months. Mild and moderate tricuspid regurgitation recurrence was 3.7% and 4.5% (P-TAP vs. R-TAP groups, p = 0.99). Severe regurgitation was observed in 1.8% of cases only in the R-TAP group (p = 0.49). There were no reoperations. Late mortality was 3.7% and 5.4% (P-TAP vs. R-TAP groups, p = 0.75). Freedom from death, all causes, were comparable among groups (log-rank p = 0.45). There were no statistically significant differences between two groups in TAPSE, left ventricular end-diastolic diameter, left ventricular ejection fraction, and left atrial diameter. Conclusions Tricuspid annuloplasty using an autologous pericardial strip in patients undergoing minimally invasive surgery is associated to similar long results (survival, late tricuspid regurgitation, and functional echocardiographic parameters) than annuloplasty with a prosthetic ring. In particular, the pericardial strip over time does not develop any degeneration or retraction.

Traumatic Hemolytic Anemia after Valve Surgery: a Case Report

Hemolytic anemia is an uncommon complication after mitral valve repair. We present a case of a 55-year-old man who presented with post-operative hemolytic anemia after mitral valve repair with prosthetic ring. The hemolytic anemia improved after the patient had the prosthetic ring removed and the valve replaced by a prosthetic mitral valve. However, the post-operative course of the redo operation was complicated by acute renal failure and respiratory dysfunction, but the hemolytic anemia was finally abolished and the patient was discharged 20 days post-operatively in good condition. 

1643 A challenging diagnosis in prosthetic mitral valve obstruction

A 53-year-old man was referred to our center for a prosthesic mitral valve obstruction. In December 2017 the patient had a myocardial infarction complicated by papillary muscle rupture and anterior leaflet flail; therefore he underwent a mechanical mitral valve replacement (size 29). A first echocardiographic control in August 2018 was reported as normal. In February 2019 a further echocardiography showed an increase of the trans-prosthetic pressure gradients and a suspected restricted motion of the anterior tilting disk; a cinefluoroscopy view confirmed the tilting disk blockade in the closing position. The patient was referred to our center for further investigations. We performed a 3D TOE that confirmed the prosthesis dysfunction: the anterior tilting disk was blocked (mean gradient 14 mmHg, 3D residual anatomical area 1.4 cm2); the mechanical cause of the obstruction was not identified. A cardiac CT was performed: a clear thrombus or pannus was not visualized, even if a linear hypodensity could be seen along the inner circumferential edge of the blocked disk. Finally the patient underwent the surgical intervention for prosthesis replacement. The visual analysis of the valve revealed a stratified thrombosis in both the atrial and ventricular side of the blocked disk, extending to the prosthetic ring and to the hinges. The patient developed a prosthetic valve dysfunction 9 to 13 months after valve replacement. Thrombus is the most common cause of obstruction of mechanical prostheses (0.3 to 8% per patient-year) while pannus formation usually occur over 5 years after surgery (minimum 12 months later). On the one hand, the patient assured a good anticoagulation regimen in the previous months, thrombosis in mitral valve position usually present with a large formation involving the disk projecting into left atrium, and large prosthesis size is associated with a lower risk of thrombosis. Our TOE confirmed the hemodynamic dysfunction but was not able to detect any cause of the leafleat bloackade. Cardiac CT has a better spatial resolution but only a focused MPR view allowed to identify a linear hypodense formation along the ring surrounding the blocked disk. This thin structure only involved the prostethic ring, apparently not projecting over the disk. These morphologic features are considered more in keeping with pannus, and only the low attenuation values (below the suggested threshold of 200 HU) helped to suspect a thrombotic stratification over the prosthetic ring. The surgical intervention revealed the real nature of the obstruction. In conclusion, thrombus may present with an unconventional appearance as a cause of prosthetic obstruction and, especially when stratified can mimick a pannus. Multimodality imaging is not always able to identify the cause of mechanical valve dysfunction; consequently, when the prosthesis obstruction is evident but imaging is inconclusive cardiac surgery is the only diagnostic and therapeutic resource. Abstract 1643 Figure. Prosthesis valve disfunction

P1463 Severe stenosis due to obstructive prosthetic thrombosis with truevue, a new echocardiographic tool

A 70-year-old woman was admitted to the emergency department because of cardiogenic syncope and acute heart failure. She had a mechanical mitral prosthesis (MMP) (ATS Open Pivot 25 mm) implanted in August 2018, due to degenerative rupture of posterior leaflet. One month before admission anticoagulation was temporally interrupted due to humerus surgery. At admission, a transthoracic echocardiogram demonstrated a significant increase in MMP gradient with preserved ejection fraction and a pulmonary artery pressure of 50mmHg. To improve the assessment of MMP a transesophageal echocardiogram (TEE) was performed showing a restricted mobility of the mitral anterior prosthetic lens and a complete block of the mitral posterior lens leading to a severe mitral stenosis (mean pressure gradient 21 mmHg, peak pressure gradient 34 mmHg and peak velocity 2.9 meters/second) with a CW pattern that simulate an aortic morphology (Image 1A). MMP three-dimensional (3D) images were processed using a dedicated transillumination technology that uses a freely movable virtual light to enhance image details and depth (Image 1B and 1C). This rendering tool allows us to characterize tissue consistency and boundary delimitation, confirming the presence of a large thrombus that surrounded the entire posterior region of the prosthetic ring leading to a MMP 3D effective area of 0.49 cm2. After discussing the case with the valvular Heart Team an urgent surgery was performed to replace MMP. This case shows how the transillumination rendering tools enhance specific image features in prosthetic cardiac valves in critical clinical scenarios as symptomatic MMP thrombosis. Abstract P1463 Figure. Image 1

Results for tricuspid valve surgery in adults with congenital heart disease other than Ebstein’s anomaly†

OBJECTIVES:Tricuspid valve (TV) surgery in the adult with congenital heart disease (ACHD) is a frequently performed procedure. The aim of this study was to analyse postoperative and medium-term outcomes.METHODS:We conducted a single-centre retrospective study of patients with ACHD who underwent TV surgery (January 2000–December 2016); patients with Ebstein’s anomalies were excluded. Operative and clinical records were reviewed. Outcomes considered were survival, grade of insufficiency/stenosis and TV reoperation at follow-up.RESULTS:A total of 128 patients with ACHD had TV surgery for functional regurgitation (n = 95), dysplasia (n = 23) and systemic TV (n = 10). Median age was 40.8 years [interquartile range (IQR) 25.3]; 55.5% were men. Preoperative regurgitation was classified as mild (n = 8), moderate (n = 47) and severe (n = 70). The TV was repaired in 109 as follows: ring annuloplasty (n = 43), de Vega annuloplasty (n = 29), Wooler annuloplasty (n = 13), commissural plasty (n = 9), Kay annuloplasty (n = 7) and others (n = 8). The TV was replaced in 19 patients with biological (n = 10) and mechanical (n = 9) prostheses. The median hospital stay was 12 days (IQR 10). The overall mortality rate was 8.6% (n = 11): 2 hospital deaths (1.6%) and 9 late deaths. Survival was 93% [95% confidence interval (CI) 85–97%] at 5 years and 83% (95% CI 70–91%) at 10 years. The median follow-up period was 4.95 years (IQR 7.7) with 1 TV reoperation. Echocardiographic assessment showed ≥moderate regurgitation in 34 (34.3%) patients. Suture plasty had a significantly higher incidence of TV regurgitation ≥moderate compared to ring annuloplasty (48.9% vs 26.3%; P = 0.033).CONCLUSIONS:TV surgery in the ACHD is frequently associated with other main procedures. Stabilizing the TV annulus with a prosthetic ring guarantees lower recurrence of moderate to severe regurgitation compared to suture plasty repair.