Paravalvular leaks are a rare complication following surgical mitral valve replacement but may result in significant mitral regurgitation. In patients with paravalvular leak, percutaneous repair of the leak is an emerging option for patients who are poor surgical candidates. This report presents a case of a severe symptomatic paravalvular leak postsurgical mitral replacement that was treated with a transcatheter approach resulting in complete resolution of paravalvular regurgitation and symptoms.

ObjectivesTo compare early postoperative outcomes between mitral valve repair (MVr) and replacement (MVR) in patients with degenerative mitral valve disease (DMVD) and poor preoperative left ventricular ejection fraction (LVEF).MethodsA retrospective propensity-score matched analysis of 1,138 patients (612 MVr, 526 MVR) undergoing mitral valve surgery for DMVD with LVEF <30% between 2000-2019 was undertaken using the UK National Adult Cardiac Surgery Audit. The primary outcome was in-hospital mortality; secondary outcomes included stroke, postoperative dialysis, re-exploration for bleeding and length of stay >10 days. Binary logistic regression was conducted to further examine the relationship between procedure and outcomes.ResultsIn unadjusted analyses, MVr demonstrated lower in-hospital mortality (7.2% vs 17.1%, p < 0.001), postoperative dialysis (7.2% vs 14.1%, p < 0.001), and prolonged hospital stay (54.5% vs 67.1%, p < 0.001). After propensity matching, unadjusted outcomes continued to favour MVr for mortality (8.5% vs 13.0%, p = 0.040) and dialysis (8.3% vs 12.8%, p = 0.038). However, multivariable adjustment demonstrated no significant difference in mortality (OR = 0.64, 95% CI 0.39-1.05, p = 0.080) or major morbidity between techniques. Independent predictors of mortality included emergency surgery, concomitant aortic valve surgery, peripheral vascular disease, and redo sternotomy.ConclusionsIn patients with DMVD and severely reduced LVEF, MVr demonstrated comparable early mortality and morbidity to MVR after adjustment. These findings suggest that mitral valve repair is safe and feasible in this higher-risk population when appropriate surgical expertise and careful patient selection are applied. Further investigation with larger cohorts and long-term follow-up is needed to assess durability and functional outcomes.

BACKGROUND Autosomal dominant polycystic kidney disease (ADPKD) is the most common inherited renal disorder, typically presenting with hypertension, hematuria, or progressive renal dysfunction. However, it can have a broad range of initial presentations and, in uncommon cases, may mimic other abdominal disorders. This report presents a case of ADPKD manifesting as an epigastric mass in a patient without a family history, highlighting its importance in the differential diagnosis of upper abdominal masses. CASE REPORT A 62-year-old woman presented to our primary care clinic with a 5-day history of a painless epigastric mass and right hypochondriac pain. She had hypertension and dyslipidemia, without a known family history of ADPKD. On examination, a firm mass was palpable in the epigastrium, accompanied by hepatomegaly. Laboratory investigations revealed mild renal insufficiency, microscopic hematuria, and proteinuria. The patient underwent abdominal ultrasonography and contrast-enhanced computed tomography, which demonstrated multiple cysts in both kidneys and the liver, consistent with ADPKD. She was evaluated by the hepatobiliary surgery team, who recommended symptomatic management. She was also assessed by the nephrology team; further evaluation for associated complications, including mitral valve prolapse and intracranial aneurysms, yielded normal findings. She continues regular follow-up with the primary care and nephrology teams for blood pressure optimization and renal function monitoring. CONCLUSIONS This case highlights the need to consider ADPKD in patients who present with upper abdominal masses. Early imaging and a multidisciplinary evaluation are essential for establishing an accurate diagnosis and ensuring appropriate management, particularly in patients without a clear family history.

Patients undergoing salvage cardiac surgery experience markedly elevated mortality, often exceeding the risk predicted by the Society of Thoracic Surgeons Predicted Risk of Mortality score. These patients are typically taken to the operating room while supported by extracorporeal membrane oxygenation (ECMO). In this context, we transitioned from a traditional preoperative mechanical circulatory support strategy using venoarterial ECMO to left atrial venoarterial ECMO (LAVA-ECMO) in patients with cardiogenic shock secondary to valvular dysfunction. We report a single-center, retrospective case series of four high-risk patients with acute severe mitral regurgitation or obstructive aortic stenosis, all with prohibitive Society of Thoracic Surgeons predicted risk of mortality (STS-PROM) scores, who were supported by LAVA-ECMO as a bridge to salvage valve surgery. Left atrial venoarterial-ECMO facilitated hemodynamic stabilization by improving end-organ perfusion and pulmonary decongestion before definitive surgical intervention. All patients survived to hospital discharge, with 0% 30 day mortality despite an extreme predicted operative risk. Our initial experience suggests that LAVA-ECMO may be an effective rescue strategy for patients in cardiogenic shock requiring surgical valve replacement. When combined with a multidisciplinary heart team approach, this cannulation strategy may help improve outcomes in carefully selected patients.

Mechanical complications of ST-elevation myocardial infarction have become rare in high-income settings due to timely reperfusion. However, they remain more prevalent and carry a high mortality in regions lacking access to early reperfusion. We present a 62-year-old man with inferior STEMI managed conservatively without reperfusion. At four months, he developed progressive dyspnea. One year later, echocardiography revealed a large basal ventricular septal rupture and severe eccentric mitral regurgitation, all absent at discharge. The patient's transfer to a cardiovascular surgery center was delayed by two years, a consequence of the COVID-19 pandemic. Imaging confirmed an inferobasal left ventricular pseudoaneurysm, basal ventricular septal rupture, severe mitral regurgitation, and a left ventricular ejection fraction of 45%. Right heart catheterization showed a significant left-to-right shunt; coronary angiography revealed multivessel coronary artery disease. He underwent successful surgical repair and remained asymptomatic at the three-year follow-up.

Cardiac involvement in rheumatoid arthritis (RA) is uncommon and often clinically silent, but may encompass valvular, structural, and conduction system abnormalities. Involvement of the mitral-aortic intervalvular fibrosa (MAIVF) and the membranous interventricular septum is exceptionally rare and has not been previously described in RA. A 61-year-old man with longstanding seropositive RA presented with syncope due to intermittent complete atrioventricular block. Multimodality imaging revealed severe degenerative mitral regurgitation, moderate-to-severe aortic regurgitation, a pseudoaneurysm of the MAIVF extending into the left ventricular outflow tract, and a membranous interventricular septal aneurysm. Infective and congenital etiologies were excluded by repeated negative blood cultures, 18F-FDG PET, and comprehensive imaging. The patient underwent successful surgical mitral and aortic valve replacement. Histopathological analysis demonstrated rheumatoid nodules within both excised valves, confirming immune-mediated valvular involvement. Persistent conduction abnormalities required permanent pacemaker implantation. This report describes the first documented case of a MAIVF pseudoaneurysm in a patient with RA, associated with multivalvular disease and high-grade conduction disturbance. The findings highlight the potential for severe, atypical cardiac manifestations of RA in the absence of active systemic inflammation and underscore the pivotal role of multimodality imaging and multidisciplinary evaluation in establishing diagnosis and guiding management.

Mitral valve (MV) disease, particularly MV prolapse (MVP) and mitral regurgitation (MR), affects 2 to 5% of the population and poses a substantial arrhythmogenic risk, with 43% of MVP patients developing arrhythmias. Although less common in children, the absence of comorbidities can uniquely isolate early electromechanical alterations that may elucidate mechanisms later contributing to arrhythmic risk and devastating effects such as sudden cardiac death. Conventional echocardiography lacks sensitivity for MV electromechanics, motivating advanced approaches. We introduce Electromechanical Wave Imaging (EWI), a high-frame-rate echocardiography modality, to map MV-complex activation and diastolic recovery in N = 21 MVP, MR, and control pediatric subjects (13.10 ± 4.51 y old, 43% male). A preclinical canine study (n = 3) established EWI's ability to observe temporally coupled electromechanical wave propagation across the atrioventricular junction through the closed MV-following atrial and preceding ventricular activation (73.0 ms, 60 BPM). MVP patients exhibited significantly delayed left ventricular (LV) activation (76.04 ± 12.51 ms vs. 47.64 ± 2.57 ms in controls, P = 0.0013), primarily in papillary muscles. Both MVP and MR-only subjects exhibited prolonged LV recovery, with MR-only patients showing significantly longer recovery intervals (MR-only: 277.0 ± 27.61 ms, Control: 248.7 ± 10.43 ms, MVP vs. Control: MR-only vs. Control: P = 0.0395). In two arrhythmogenic MVP cases, EWI localized arrhythmic exit sites adjacent to LV papillary muscles, coinciding with regional delayed sinus activation, aligning with invasive electrophysiology. This study demonstrates that atrioventricular valve function dictates cardiac electromechanical function and establishes full-cycle EWI as a transformative tool for diagnosing MV disease electromechanical effects, assessing arrhythmic risk, guiding interventions, and advancing noninvasive cardiac imaging.