Santosh Dora

Subannular left ventricular pseudoaneurysm following mitral valve replacement

Delayed development of left ventricular pseudoaneurysm is a rare late complication of mitral valve prosthesis and requires early surgical intervention. Here we describe the occurrence of such a complication diagnosed 6-months after the valve surgery in a 60-year-old lady. The anatomic delineation of subannular left ventricular pseudoaneurysm using multiple imaging modalities including CT angiography is also being discussed.

Doppler echocardiographic assessment of TTK Chitra prosthetic heart valve in the mitral position

AIMS TTK Chitra heart valve prosthesis (CHVP), a tilting disc mechanical heart valve of low cost and proven efficacy, has been in use for the last 15 years. Although various studies substantiating its long-term safety and efficacy are available, no study had assessed its echocardiographic characteristics. The purpose of this study was to determine the normal Doppler parameters of CHVP in the mitral position and to assess whether derivation of mitral valve area (MVA) using the continuity equation (CE) and more commonly used pressure half-time (PHT) method is comparable in the functional assessment of this tilting disc mitral prosthesis. METHODS AND RESULTS Doppler echocardiography was performed in 40 consecutive patients with CHVP in the mitral position. All patients were clinically stable, without evidence of prosthetic valve dysfunction such as significant obstruction or regurgitation, endocarditis, left ventricular dysfunction (ejection fraction <40%), or significant aortic regurgitation. Valve sizes studied included 25, 27, and 29 mm. Mitral valve area was derived both by the PHT method and by the CE, using the stroke volume measured in the ventricular outflow tract divided by the time-velocity integral of CHVP jet. The peak Doppler gradient ranged from 5 to 21 (mean 11.0) mmHg, and the mean gradient ranged from 1.7 to 9.2 (mean 4.1) mmHg. Mean gradient negatively correlated with an increase in the actual orifice area (AOA) derived from the valve orifice diameter given by the manufacturer (r = -0.45, P = 0.004). Mitral valve area calculated by both PHT and CE increased significantly with an increase in the AOA (r = 0.42, P = 0.007 and r = 0.32, P = 0.046, respectively). Mitral valve area by the CE averaged 1.55 +/- 0.36 cm(2) (range 0.85 cm(2) for a 25 mm valve to 2.41 cm(2) for a 29 mm valve) and was smaller than by PHT (mean 2.04 +/- 0.41 cm(2), range 1.40-3.14 cm(2); P = 0.0001; t-test), irrespective of whether PHT is less than or >110 ms. CONCLUSION The Doppler parameters obtained with CHVP in the mitral position are comparable with those obtained with the different prosthetic valves in common use. In the selected group of patients with CHVP, assessment of MVA by the PHT method is comparable with that by the CE. Areas by both methods were smaller than the AOA provided by the manufacturer, as seen in other similar design valves.

Percutaneous valvuloplasty for mitral valve restenosis: Postballoon valvotomy patients fare better than postsurgical closed valvotomy patients

Aim: To compare the results of percutaneous mitral valvuloplasty (BMV) for mitral restenosis in post‐BMV versus postclosed mitral valvotomy (CMV) patients. Methods and Results: Ninety‐two patients who underwent BMV for mitral restenosis were followed up prospectively. Of these, 28 patients had undergone previous percutaneous mitral valvuloplasty (PRIOR BMV) and 64 patients had undergone previous closed mitral valvotomy (PRIOR CMV). BMV for mitral restenosis was a success in 59% patients (57.1% PRIOR BMV, 59.3% PRIOR CMV, P = 1.0). Incidence of severe mitral regurgitation was 3.25%, all in the PRIOR CMV group. In univariate analysis, the major predictor of successful BMV for mitral restenosis was Wilkins score (P = 0.004). At a follow up of 3.47 + 2.07 years, mitral valve area was similar between groups (1.45 ± 0.22, 1.46 ± 0.26, P = 0.35). The combined end points of mitral valve replacement (MVR), need for rerepeat BMV for mitral restenosis or death was higher in the PRIOR CMV group (31.2% PRIOR CMV, 7.1% PRIOR BMV, P = 0.027). Event‐free survival at follow up was lower in the PRIOR CMV group (69% PRIOR CMV, 92.8% PRIOR BMV) mainly due to the higher need for MVR (11 vs. 0 patients, P = 0.03). Conclusions: In conclusion, following BMV for mitral restenosis, patients with PRIOR BMV are found to have lesser event rates on follow‐up compared to patients with PRIOR CMV, though procedural success rates are similar.

Bundle branch reentry ventricular tachycardia in arrhythmogenic right ventricular dysplasia

A 42-year-old male had history of recurrent palpitation and was documented to have wide QRS tachycardia. Magnetic resonance imaging angiogram showed evidence of arrhythmogenic right ventricular dysplasia and severe right ventricular dysfunction. Electrophysiology study showed evidence of bundle branch reentry ventricular tachycardia. It was successfully treated by radiofrequency ablation of right bundle branch. This is probably the first case of bundle branch reentry as a mechanism for ventricular tachycardia in a case of arrhythmogenic right ventricular dysplasia.

Rebuttal: Percutaneous valvuloplasty for mitral valve restenosis†

We thank Nammas et al. [1] for his interest in our report [2], and we could not agree more with many of his statements. Nammas et al. states that ‘‘actually, some prior studies also demonstrated long-term outcome data following redo PBMV in patients with rheumatic mitral restenosis [3–5].’’ We are aware of these prior studies and in fact reference 2 [3] in the letter by Nammas et al. is actually quoted as reference 19 in our manuscript. None of these quoted studies [3–5] are however similar in design to ours and we re-emphasize Nammas’s point that probably our article was the first to present a comparison of outcomes of reballoon mitral valvotomy based on the type of the original procedure. Nammas et al. is concerned over the low rate of immediate procedural success of redo PBMV (59%), being even lower in patients with prior initial PBMV (57.1%), which is far lower than the figures reported in literature for redo PBMV in patients with mitral restenosis (75–92.5%) [3–5]. In our manuscript, procedural success of balloon valvuloplasty was defined as mitral valve area >1.5 cm in the absence of more than mild mitral regurgitation as had been defined earlier [1,6–8]. Our centre is a tertiary level high volume teaching centre doing balloon mitral valvuloplasty, with multiple peer reviewed publications in this field [9–11]. Probably, a referral bias was there so that we saw patients with worse valves than the other studies though this is not reflected in the Wilkins score. We are aware of the multiple scoring systems for the mitral valve in Refs. 12–14. We opted for the Wilkins score for morphological assessment because it is the commonest score used in multiple studies. The initial echocardiograms were scored using this system, so we had to continue with it. Simple scoring systems like, as proposed by Rifaie et al. [14] are easier to use than the Wilkins system. We are now evaluating this novel scoring system in our patients. We do not agree that better selection of valves would have improved the outcome. The major exclusion criteria in our study were consistent with standard of care in the field namely significant mitral regurgitation and bi-commissural calcium. We did not use a specific cut-off value of the Wilkins Score as an exclusion criterion for balloon mitral valvotomy. It is also intuitive that if we had used such a cut off value, more valves would have been excluded than would have been excluded with simpler scoring systems. In addition, the central point in our article was not the procedural outcome following re-balloon mitral valvotomy which has been studied earlier. The focal point in our manuscript was that following balloon valvuloplasty for mitral restenosis, patients with post balloon valvuloplasty are found to have lesser event rates on follow-up compared to patients with post-CMV, though procedural success rates are similar for both groups.