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INTRODUCTION Over the years, surgical education has dramatically improved and has become increasingly innovative. Almost all educational programs in surgery now rely on sophisticated training boxes and simulators that enable surgical instruments to be handled and surgical procedures to be trained in a safe environment. However, simulators need constant feedback from supervising senior surgeons, who only have limited teaching time available. We describe a cardiac surgery simulator with an integrated supervision system for self-learning how to repair a mitral valve. METHODS We developed a mitral surgery simulator with integrated sensors to generate, record, and display quantitative data on trainee performance in relation with the mitral valve repair procedure. A team of experienced cardiac surgeons defined critical areas of the model and an algorithm to identify inconsistent movements, in terms of error types and out-of-bound actions. The device provided real-time feedback on the accuracy of the stitches placed. Four experienced cardiac surgeons and 3 advanced cardiac-surgery used the simulator and were asked to evaluate specific parameters of the system on a scale ranging from 1 to 10. RESULTS All surgeons completed a P2 resection, followed by implanting a 32-mm mitral ring. The simulator detected 2 stitches that were placed in dangerous zones and another stitch that was placed in an inappropriate position. Users scored the real tissue feeling and interactivity of the model 9.5/10. CONCLUSIONS This heart-surgery simulator offers a real-life model for learning about and training in mitral valve surgery, which could potentially replace the experienced surgeon's teaching role.

Secondary mitral regurgitation (SMR, also known as functional mitral regurgitation or FMR) is one of the most prevalent types of valvular heart disease and occurs when the left ventricle dilates, c...

OBJECTIVES This study aimed to evaluate the usability, performance and safety of an innovative mitral valve device in the chronic setting characterized by an intraventricular bridge, which enables artificial chordae anchoring and/or direct posterior leaflet fixation. METHODS Ten female sheep were employed and underwent device implantation. Any interference of the device with leaflet motion, ease of device use, correct chordae length estimation and implantation were evaluated. Post-procedural valve competence and device performance were verified by periodic postoperative echocardiograms and laboratory examinations. Following euthanasia, gross anatomy and histology evaluation of the hearts and valves were performed to detect tissue abnormalities and inflammation reaction related to the device. RESULTS The procedure was successfully completed in all 10 sheep. Lengths of the 2 chordae implanted were 23 (21.5–24) mm and 23 (22.5–24) mm. The time required to suture both pairs of the artificial chordae was 2.7 ± 0.7 min. At the 3-month follow-up, left ventricular function was normal. The transvalvular peak pressure gradient was 9 (7.5–10) and the mean gradient was 4 (3.5–4) mmHg. Upon necropsy and histological evaluation, no damage to left ventricle wall, valve leaflets, chordae and papillary muscles and absence of thrombus formation and inflammatory reaction were observed. Radiological images showed neither fracture of the device nor calcifications. Laboratory tests showed no signs of haemolysis. CONCLUSIONS In vivo late tests confirmed the ease of correct chordal length estimation prior to implantation, short operative time and usability in flailed anterior leaflet repair. The absence of negative impact of the device on mitral leaflets motion, function and structure and successful repair might suggest that the device would be useful in complex degenerative mitral disease.

Objective: Currently, mitral prosthetic rings are intended only to reshape the annulus. We present in vivo results of an innovative device characterized by an intraventricular segment designed to enable artificial chordae implantation and simplify leaflets and subvalvular apparatus correction. Methods: Eight sheep were employed. The first 4 underwent solely device implantation. In the last 4, primary chordae of the anterior leaflet (A2) were torn to induce severe mitral regurgitation. The severed chordae were replaced by 2 pairs of 5-0 Gore-Tex artificial chordae previously measured and anchored to the device bridge. Ease of device and chordae implantation were evaluated, and postprocedural valve competence was verified by postoperative echocardiogram. Results: The procedure was completed in all 8 sheep. In the 4 sheep with induced severe mitral regurgitation, repair could be achieved by means of artificial chordae implantation. Length of the 2 chordae implanted was 21.6 ± 2 mm and 22 ± 3 mm, respectively. The time required to suture the artificial chordae was 2.5 ± 1.2 min. Postoperative echocardiograms showed normal left ventricular ejection fraction and free motion of the mitral leaflets. Mitral regurgitation was absent in 5 cases and trivial in 3. The transvalvular peak pressure gradient was 9.5 ± 6 mm Hg, and mean gradient was 3.7 ± 4 mm Hg. Postprocedural evaluation of the heart and mitral valve showed no damage to the left ventricle wall, valve leaflets, chordae, and papillary muscles. Conclusions: In vivo tests confirm safety of the device, ease of chordal length estimation prior to implantation, short operative time, and no negative impact of the device on mitral leaflet motion, function, and structure.

The replacement of surgically corrected mitral valves, also known as percutaneous transcatheter repair, is a relatively young field. Even though these procedures are usually successful, they can present significant intraoperative or postoperative challenges. To our knowledge, we present the first case of acute focal dehiscence of mitral ring repair during the mitral valve-in-ring procedure.

Isolated congenital mitral ring is a very rare subtype of congenital mitral valve malformation, which accounts for about one-third of congenital cardiac anomalies associated with left ventricular inflow obstruction. A mitral ring may be easily missed unless the disease is suspected. The mitral valve repair should be considered in symptomatic patients with mitral stenosis. We report a rare case of a 43-year-old woman with an intramitral ring who experienced previous embolic stroke with left hemiplegia. However, stroke happened several years ago and it does not completely prove causality.

With heightened awareness of mitral valve disease and improvement in surgical techniques, the use of mitral valve bioprostheses has increased. There is a large aging population with prior surgical valvular interventions. Limited durability of the prosthesis due to valvular degeneration over time may necessitate the need for repair or replacement of the prior prosthesis in the future. This usually entails another surgical intervention in this population with elevated risk for a reoperation. There is an ongoing clinical need for newer, less invasive options that are feasible and carry a lower complication rate. The advent of transcatheter heart valve (THV) therapies has opened up a wide range of therapeutic options for treatment of a failed bioprosthesis. Their safety and feasibility are now well established. This article serves as a review of the currently available THVs for implantation in the mitral position, the pre-procedural assessment, the challenges associated with implantation, as well as outcomes associated with a mitral valve-in-valve (VIV) and a mitral valve-in-ring (VIR) procedure.

Mitral valve chordae tendineae forces are elevated in the setting of mitral regurgitation (MR). Ring annuloplasty is an essential component of surgical repair for MR, but whether chordal forces are reduced after mitral annuloplasty has never been validated in vivo. Here, we present an extremely rare ovine case of natural, severe chronic functional MR, in which we used force-sensing fiber Bragg grating neochordae to directly measure chordal forces in the baseline setting of severe MR, as well as after successful mitral ring annuloplasty repair. Overall, our report is the first to confirm in vivo that mitral ring annuloplasty reduces elevated chordae tendineae forces associated with chronic functional MR.

Background and Aims\ud The main pathophysiological factor of chronic ischemic mitral regurgitation (MR) is the outward displacement of the papillary muscles (PMs) leading to leaflet tethering. For this reason, papillary muscle intervention (PMI) in combination with mitral ring annuloplasty (MRA) has recently been introduced into clinical practice to correct this displacement, and to reduce the recurrence of regurgitation.\ud \ud Methods\ud A meta‐analysis was conducted comparing the outcomes of PMI and MRA performed in combination vs MRA performed alone, in terms of MR recurrence and left ventricular reverse remodeling (LVRR). A meta‐regression was carried out to investigate the impact of the type of PMI procedure on the outcomes.\ud \ud Results\ud MR recurrence in patients undergoing both PMI and MRA was lower than in those who only had MRA (log incidence rate ratio, −0.66; lower‐upper limits, −1.13 to 0.20; I2 = 0.0%; p = .44; Egger's test: intercept 0.35 [−0.78 to 1.51]; p = .42).\ud \ud The group with both PMI and MRA and that with only MRA showed a slightly higher reduction in left ventricular diameters (−5.94%; −8.75% to 3.13%,). However, in both groups, LVRR was p = .33).\ud \ud Conclusions\ud Using PMI and MRA together has a lower MR recurrence than using MRA alone. No significant LVRR was observed between the two groups nor between the PMI techniques employed.

A 19-year-old female underwent EP study for symptomatic SVT. Ventricular pacing demonstrated eccentric conduction was present. Diagnosis of AVRT with left-sided accessory pathway was reached while other SVT types were excluded. Ablation was successful after mapping the mitral ring via a transseptal approach.

The IRIS mitral annuloplasty ring is a transcatheter, transfemoral and transseptal-delivered complete, semi-rigid annuloplasty ring. The IRIS system mimics surgical annuloplasty by reducing the mitral septal-lateral dimension and improving leaflet coaptation. We report the early experience with the IRIS system in seven patients. These patients had 3–4+ mitral regurgitation (MR) with annular dilation and were symptomatic NYHA II-IV with LV end systolic dimensions ≤65 mm. Patients were excluded for LVEF 70 mmHg. Baseline and 30-day transthoracic echocardiography and CT imaging was performed. In phase 1, 4 patients had surgical IRIS mitral ring implantation. In phase 2, 3 patients had transfemoral, transseptal delivery of the IRIS mitral ring. There was no procedural death, or MI. The mitral SL diameter was reduced from 38.0±4.1 to 25.9±4.9 mm at 30 days (31.8% SL reduction, n=7). MR was reduced from baseline 3–4+ to 0–1+ in all patients at 30 days. There were improvements in NYHA class and there was a decrease in diastolic LV volumes from 182.4±54.3 to 115.3±98.8 mL at 30 days (36.8% reduction). Based on these initial positive findings, ongoing clinical trials are underway to further evaluate the safety and efficacy of the IRIS ring.

The past 2 decades have seen a proliferation of transcatheter mitral valve (MV) therapies, which are less invasive and distinct from surgical MV repair or replacement. The commonly used MV transcatheter therapies include (1) percutaneous mitral balloon commissurotomy (PMBC) for rheumatic mitral stenosis; (2) edge-to-edge repair with the MitraClip for mitral regurgitation; (3) valve-in-valve implantation in bioprosthetic MV, native MV, or mitral ring; and (4) closure of paravalvular leaks (PVLs). This article will focus on the use of echocardiography in the diagnosis, patient selection, procedural guidance, and postprocedural follow-up for PMBC, with notes on the role of transesophageal echocardiography in transcatheter interventions for prosthetic valve degeneration and PVL closure.

Pannus formation is a known complication of valve replacement surgery. However, few cases describe pannus formation in the mitral position, and they are mostly associated with prosthetic valves rather than only annuloplasty. We describe the case of a 62-year-old woman who first underwent reductive annuloplasty using a Carpentier-Edwards 28 mm ring prosthesis in 2009 that performed well on regular follow-up for 5 years. In 2014, the patient presented with significant weight gain, shortness of breath (New York Heart Association functional class III) and signs of severe mitral stenosis. Echocardiography demonstrated the formation of a pannus and increased pressure gradients. Removal of the ring prosthesis and pannus-like fibrotic tissue was performed. The native valve was left in place as it had supple leaflets and performed well once properly debrided. The patient remained well throughout a 24-month follow-up.

On the basis of a survey of 151 patients, diagnostic criteria for an unfavorable prognosis of mitral valve prolapse were revealed according to echocardiography. Transthoracic and transesophageal echocardiography, daily Holter ECG monitoring were performed. Repeated echocardiography was performed in 12-18 months. Statistical analysis of the material allowed us to identify criteria for poor prognosis of mitral valve prolapse according to echocardiography: severe mitral regurgitation, mitral valve leaflet thickness in diastole 6 mm or more, dilatation of the left ventricular cavity, dilatation of the left atrial cavity, dilatation of the mitral ring.

Surgical mitral valve annuloplasty has been a cornerstone of surgical mitral valve repair since first described over 50 years ago by Carpentier ([1][1]). In patients without excessive leaflet tethering or left ventricular dilation, mitral ring annuloplasty can effectively correct secondary mitral

OBJECTIVE Demonstrate proof-of-concept validation of a computed tomography (CT) computer-aided design prediction modeling tool to identify patients at risk for left ventricular outflow tract (LVOT) obstruction in transcatheter mitral valve replacement (TMVR). BACKGROUND LVOT obstruction is a significant and even fatal consequence of TMVR. METHODS From August 2013 to August 2017, 38 patients in 5 centers underwent TMVR with compassionate use of balloon-expandable valves for severe mitral valve dysfunction because of degenerative surgical mitral ring, bioprosthesis, or severe native mitral stenosis from to severe mitral annular calcification. All patients had preprocedural CT scans performed for anatomic screening, intraprocedural TEE and invasive hemodynamics performed. Preprocedural prediction modeling was performed utilizing computer-aided design (CAD) of the neo-LVOT post-TMVR. Post-TMVR CT scans were obtained and compared to pre-TMVR LVOT modeling datasets for validation. RESULTS All patients underwent successful TMVR without device embolization. Seven of the 38 patients experienced LVOT obstruction, defined as an increase of ≥10 mmHg LVOT peak gradient post-TMVR. Anatomic screening using CT was validated in 20/38 patients as preprocedural predicted neo-LVOT surface area correlated well with post-TMVR measurements (R2 = 0.8169, P

The HAART 300 (BioStable Science and Engineering, Austin, TX) is a rigid, elliptical device introduced to facilitate aortic valve repair providing annular stabilization in the setting of aortic regurgitation. Percutaneous strategies have been described for patients with dysfunctional biological prostheses or recurrence insufficiency after mitral ring annuloplasty. This report shows the feasibility of aortic valve-in-ring transcatheter aortic valve replacement (TAVR). The sufficient ring stability to support the implanted TAVR-prosthesis and the fact that the elliptical shape of the HAART-ring did not result in a problem concerning paravalvular leakage were important for the success of this procedure.

Objective This meta-analysis investigates MR recurrence and degree of left ventricular reverse remodeling (LVRR) in CIMR patients in mitral annuloplasty employing different ring designs. Background The deeper understanding of complex changes caused by chronic ischemic mitral regurgitation (CIMR) have led to new generations of rings that, by maintaining normal 3D annular geometry are supposed to enhance long-term repair durability. Methods A meta-analysis of all available reports in literature of MV repair through different ring design was conducted. Meta-regression was performed to investigate the impact of mitral ring characteristics related to flexibility, planarity, symmetry and single type utilized. Twenty studies encompassing a total of 1876 patients were included at the end of the selection process. Results At meta-regression recurrence of MR was not influenced by the ring employed. Nonetheless, the event rate of MR recurrence in planar rings was 19%. Vs. 11% observed with non-planar rings. Recurrence rate in patients implanted with symmetric rings was 14% whereas it was 7% in asymmetric rings. The non-planar asymmetric IMR-ETlogix showed the lowest recurrence rate (6%). Furthermore, in planar group the reduction of pre- and post-operative LVEDD was - 4%. In the non-planar group, the LVEDD was reduced by 8.6%. In patients implanted with symmetric rings LVEDD reduction was 10.8%. LVRR in the asymmetric group was −5.8%. Conclusion MR recurrence occurred the least with asymmetric rings with less disproportionate asymmetry. In contrast, LVRR occurred at a greater extent in symmetric rings.

We report a patient admitted with acute pulmonary edema 3 months after mitral valve repair, with no history of inter-current febrile illness. Transesophageal echocardiography (TEE) demonstrated severe mitral regurgitation (MR) and an abnormally positioned annuloplasty ring, suggestive of dehiscence. The extreme extent of ring dehiscence was visualized on 3-dimensional TEE (3D), with near-complete separation of the ring. Strept.Mitis and Cristatus were isolated from the ring following redo mitral valve surgery, confirming endocarditis as the mechanism for dehiscence. This report highlights the additive role and superior ability of 3D TEE in the identification and anatomic delineation of mitral ring dehiscence.

Parachute mitral valve (PMV) is a rare congenital malformation of mitral valve; this is a case of PMV and supra mitral ring in a 36 year old woman who presented with stroke.

Simple Summary The Chordae tendineae are part of the atrioventricular apparatus. They are mainly responsible for the mechanical functions of heart valves. Degenerative mitral valve disease is the most common heart disease in dogs and is responsible for about 75% of cases of heart failure. One of the complications of this disease is Chordae tendineae rupture. It is clinically relevant to better understand the biomechanical and structural properties of CT in order to begin further studies about biomarkers suggesting an episode of CT rupture. Such an episode leads to acute pulmonary oedema and worsens the clinical status of the patient. Information about the biomechanical and structural properties of healthy CT and CT affected by the degenerative process are essential in understanding how CT behave in an in vivo environment. Abstract The mitral valve apparatus is a complex structure consisting of the mitral ring, valve leaflets, papillary muscles and Chordae tendineae (CT). The latter are mainly responsible for the mechanical functions of the valve. Our study included investigations of the biomechanical and structural properties of CT collected from canine and porcine hearts, as there are no studies about these properties of canine CT. We performed a static uniaxial tensile test on CT samples and a histopathological analysis in order to examine their microstructure. The results were analyzed to clarify whether the changes in mechanical persistence of Chordae tendineae are combined with the alterations in their structure. This study offers clinical insight for future research, allowing for an understanding of the process of Chordae tendineae rupture that happens during degenerative mitral valve disease—the most common heart disease in dogs.

Shone's syndrome is a rare congenital anomaly defined as the presence of at least two of the following heart obstructions: a mitral supravalvular ring, a "parachute" mitral valve stenosis, subaortic stenosis, and aortic coarctation. A 58-year-old man presented with a mitral ring and a "parachute" mitral valve on two-dimensional transthoracic echocardiography, raising suspicion of Shone's syndrome. Three-dimensional transesophageal echocardiography revealed a subannular mitral ring inserted directly on the mitral leaflets, thus acting as a "valvar ring." This distinction can have therapeutic implications as a "valvar" mitral ring could require valve repair or replacement, instead of simple resection.

Zusammenfassung: Die Shone-Anomalie wurde 1963 erstmals beschrieben und stellt eine seltene kongenitale kardiovaskuläre Missbildung mit verschiedenen linkskardialen stenotischen Läsionen dar. Die klassische Form besteht aus einem fibrösen supravalvulären Mitralring, einer fallschirmartigen Deformation der Mitralklappe mit nur einem Papillarmuskel ("parachute mitral valve"), einer subvalvulären Aortenstenose und einer Aortenisthmusstenose. Es gibt nur vereinzelte perioperative Fallberichte von erwachsenen Patienten mit dieser kardiovaskulären Missbildung. Allerdings können Patienten mit einer undiagnostizierten, inkompletten Form der Shone-Anomalie auch im Erwachsenenalter für nichtherzchirurgische Operationen vorgesehen sein. In dem vorliegenden Fallbericht wird das anästhesiologische Management einer Patientin, die für eine abdominale Hysterektomie vorgesehen war und an einer bisher nichtdiagnostizierten Shone-Anomalie litt, beschrieben

We demonstrate the technical aspects of a novel adjustable mitral ring. This new ring was implanted in a female landrace pig, for training and educational purposes. It can be adjusted independently in the P1, P2 and P3 segments, if required, to treat recurrent mitral regurgitation, and this is a key difference to comparable devices. The first-in-man implantation is anticipated in the near future.

summary We report the case of a MitraClip procedure for recurrent mitral regurgitation after prior mitral valve repair. The unique feature of our case is the partial disinsertion of the Physio-ring’s posterior portion, which caused shadowing, but grasping visualization was sufficient to proceed. It also illustrates a successful MitraClip procedure after surgical valve repair with a relatively small valve area.

Background Annulo-leaflet mitral ring (ALMR) is a rare congenital cardiac anomaly caused by fibrous tissue on the atrial surface of the mitral valve, which can progress to cause severe stenosis. Because little information is available on the detailed echocardiographic features of the anomaly and their associations with surgical resection, this study was undertaken to address these questions. Methods A retrospective single-center study of clinical and echocardiographic data from patients with ALMR from 2004 through 2012 was conducted. Data were analyzed for associations with surgical resection. Results The median age at diagnosis of the 57 study patients was 1.8 years, and 63% were male. Isolated ALMR was found in six patients (11%). The remaining 51 patients (89%) had associated lesions: additional mitral valve abnormalities in 35 (61%), coarctation in 11 (19%), and subaortic stenosis in 15 (26%). ALMR was best visualized in the apical four-chamber view, and the lesion was indistinct from the parasternal long-axis view in 25% of patients. Seven patterns of ALMR were identified, differentiated by leaflet involvement (anterior, posterior, or both) and location (annular vs intraleaflet). Compared with other patterns, intraleaflet morphology had a higher mean mitral stenosis gradient than in patients without (8.4 vs 5.8 mm Hg, P = .01). Among the 57 patients, 32 (56%) underwent ALMR resection, at a median age of 1.5 years. Younger age at echocardiographic diagnosis ( P = .02) and short chordae ( P = .03) were associated with resection. Conclusions The morphology of ALMR as evaluated by echocardiography is heterogeneous and can be classified on the basis of lesion location and leaflet involvement. Intraleaflet morphology is associated with significant mitral stenosis; younger age at diagnosis and short chordae are associated with ALMR resection.

We report the case of a patient with situs inversus totalis, annuloaortic ectasia complicated by aortic insufficiency and mitral regurgitation which induced congestive heart failure. Both valvular lesions were repaired physiologically using aortic root sparing Yacoub 'remodeling' technique and mitral ring annuloplasty. Valve sparing techniques can be used effectively even in patients with complicated clinical scenarios (like dextrocardia and annuloaortic ectasia) to avoid the potential risks related to prosthetic valve implantation and lifelong anticoagulation therapy.

Mechanical hemolytic anemia, although there is a well-known complication of mechanical valve replacement is reported to be rare after mitral valve repair. In this article, hemolytic anemia after mitral ring annuloplasty, undetectable improvement after repeated blood transfusions and tried to offer patients who underwent mechanical valve replacement.

Despite advances in surgical techniques for mitral valve repair, more than 20% of patients require reoperation within 10 years due to recurrence of severe mitral regurgitation. However, reoperations on the mitral valve are often associated with increased morbidity and mortality. We report a transapical mitral valve-in-ring implantation in a patient who had undergone mitral valve repair for ischemic mitral regurgitation using a complete semi-rigid Memo 3D mitral ring (LivaNova Group, Milan, Italy).

Background Artificial chord implantation has become one of the most applied techniques for mitral valve repair (MVR). Many techniques have been described, with the goal of optimizing neochord implantation. A new annuloplasty device designed to simplify the determination of the appropriate neochord length has been recently introduced. We describe our initial experience with this new device. Methods The semirigid device is equipped with removable loops on the posterior aspect of the ring. Neochords are tied to the loops, which are subsequently removed. The device was implanted in 47 symptomatic patients from January 2015 to August 2016 through a median sternotomy in 33 patients (70.2%) and a right anterolateral minithoracotomy in 14 (29.8%). The cause of mitral valve insufficiency was degenerative in all patients, and most patients presented with isolated prolapse of the posterior leaflet. Before and after cardiopulmonary bypass, all patients underwent evaluation with transesophageal echocardiography, and transthoracic echocardiography was performed at discharge. Results A median of 2 neochords were implanted (minimum, 1; maximum, 6). Mean cardiopulmonary bypass time and aortic cross-clamp times were 141.7 ± 32.3 and 104.8 ± 28.5 minutes for combined and 133 ± 53.9 and 98.3 ± 41.6 minutes for isolated MVR. At discharge, echocardiography revealed no or only mild mitral insufficiency in 45 patients (mean gradient, 2.9 ± 1.3 mm Hg). Conclusions This new annuloplasty ring facilitated determination of appropriate neochord length and was used to successfully treat different degenerative pathologies affecting both leaflets. This new device simplified length determination of the neochords.

The incidence of allergic reactions due to mechanical prosthesis or rings is not well established. We report the case of a 56-year-old man who presented a persistent urticarial rash and anaphylactic shock after a mitral valve repair operation. Prick skin tests were positive for nickel. After the nucleus from the mitral annulus was removed, the urticarial rash disappeared.

Rationale: Tachycardia-induced cardiomyopathy (TIC) is defined as systolic and/or diastolic dysfunction of the left ventricle resulting from prolonged elevated heart rates, completely reversible upon control of the arrhythmia. Atrioventricular reentrant tachycardia (AVRT) is one of the most frequent causes of TIC. In its incessant form, it is unlikely to be controlled by pharmacological treatment, catheter ablation being the principal therapeutic option. The coexistence of left bundle branch block (LBBB) in patients with AVRT may cause difficulties in the early diagnosis and management of tachycardia because of the wide complex morphology, making it harder to localize the accessory pathway (AP). Patient concerns: A 60-year-old woman, presented incessant episodes of palpitations and shortness of breath due to a LBBB tachycardia leading to hemodynamic instability. Diagnosis: The patient had a wide QRS tachycardia, with LBBB morphology and a heart rate of 160/minute. Echocardiography showed global hypokinesia with 25% left ventricular ejection fraction (LVEF). Considering the patient's clinical picture, TIC was suspected. Interventions: The electrophysiological study revealed a left lateral accessory pathway. Catheter ablation was successfully performed at the level of the lateral mitral ring. Outcomes: One week after the ablation the patient had no signs of heart failure and the LVEF normalized to 55%. During 6-months follow-up the patient presented no more episodes of tachycardia or heart failure and the LVEF remained normal. Lessons: AVRT is rarely associated with intrinsic LBBB, being a potential cause of TIC. In these patients, it is unlikely to control the arrhythmia pharmacologically, catheter ablation being the best therapeutic option. The variation of QRS complex duration between LBBB pattern in SR and AVRT could be useful for early diagnosis of an ipsilateral AP on surface ECG.

A 50-year-old woman, who underwent mitral valve repair (MVRe) with a complete rigid mitral ring annuloplasty (Carpentier-Edwards 30; Edwards Life-sciences) 8 years ago for severe mitral regurgitation (MR) due to Barlow’s disease, was apparently asymptomatic for 5 years and then started to

Aim of the study: The aim of this study was to determine the clinical and echocardiographic predictors of recurrent mitral regurgitation after undersized ring implantation for ischemic mitral regurgitation (MR). Recurrent MR occurs in up to 30% of patients after undersized ring implantation. Understanding the causes of recurrent MR should improve the results of this kind of surgery. Material and methods: The pre- and postoperative echocardiograms of 134 patients operated on for ischemic mitral regurgitation using ring implantation were analyzed. The median follow-up period was 13 months. Results: The strongest influence on MR recurrence was exerted by coaptation length (OR 0.022; p = 0.001), effective regurgitant orifice area (EROA) (OR 1.85; p < 0.002), and vena contracta measured preoperatively (OR 1.42; p = 0.007). The independent predictors of recurrent MR included: the postoperative length of leaflet coaptation, preoperative left ventricular ejection fraction, the severity of regurgitation, and body surface area (BSA). The coaptation length cut-off value of

A 55-year-old man with a history of aortic valve (AV) replacement (27-mm Carpentier-Edwards Magna Bovine pericardial bioprosthesis), mitral valve (MV) repair (32-mm PhysioRing and edge-to-edge repair), and coronary artery bypass grafting 8 years before, presented with signs of congestive heart