No abstract

Long-term superiority of mitral valve (MV) repair compared with replacement is well established in degenerative MV disease. In rheumatic heart disease, its advantages are unclear and it is often performed in conjunction with aortic valve (AV) replacement. Herein, we performed a systematic review and meta-analysis comparing outcomes of MV repair vs replacement in patients undergoing concomitant AV replacement. PubMed, Cochrane and Web of Science databases were searched up to 25 January 2014 for English language studies comparing outcomes of MV repair vs replacement in patients undergoing simultaneous AV replacement. Data of selected studies were extracted. Study quality, publication bias and heterogeneity were assessed. Analysis was performed using a random effects model (meta-analysis of observational studies in epidemiology recommendation). A total of 1202 abstracts/titles were screened. Of these, 20 were selected for full text review and 8 studies (3924 patients) were included in the final analysis: 1255 underwent MV repair and 2669 underwent replacement. Late outcome data were available in seven studies (cumulative follow-up: 15 654 patient-years). The early (in hospital and up to 30 days post-surgery) mortality [risk ratio (RR): 0.68, 95% confidence interval (CI): 0.53-0.87, P = 0.003] and late (>30 days post-surgery) mortality (RR: 0.76, 95% CI: 0.64-0.90 P = 0.001) were significantly lower in the MV repair group compared with the MV replacement group. The MV reoperation rate (RR: 1.89, 95% CI: 0.87-4.10, P = 0.108), thromboembolism (including valve thrombosis) (RR: 0.65, 95% CI: 0.38-1.13, P = 0.128) and major bleeding rates (RR: 0.88, 95% CI: 0.49-1.57, P = 0.659) were found to be comparable between the two groups. In a separate analysis of studies with exclusively rheumatic patients (n = 1106), the early as well as late mortality benefit of MV repair was lost (RR: 0.92, 95% CI: 0.44-1.90, P = 0.81 and RR: 0.69, 95% CI: 0.39-1.22, P = 0.199, respectively), whereas the MV reoperation rate became significantly higher (RR: 5.10, 95% CI: 1.62-16.05, P = 0.005) with MV repair. In patients undergoing concomitant mitral and AV surgery, MV repair is associated with improved early and late survival without any increased risk for mitral valve reoperation. However, in patients with rheumatic heart disease MV repair does not impart any survival advantage while the risk for MV reoperation remains significantly higher.

Lead perforation is a major complication of cardiac rhythm management devices (CRMD), occurring in about 1%. While most lead perforations occur early, numerous instances of delayed lead perforation (occurring >30 days after implantation) have been reported in the last few years. Only about 40 such cases have been published, with the majority occurring <1 year after implantation. Herein, we describe the case of an 84-year-old female who presented with recurrent syncope and was diagnosed to have delayed pacemaker lead perforation 4.8 years after implantation. Through this report, we intend to highlight the increasing use of CRMD in elderly patients, and the lifelong risk of complications with these devices. Presentation can be atypical and a high index of suspicion is necessary for diagnosis.

Right ventricular rupture is a critical cardiac complication associated with cardiac tamponade and death. Occasionally, the site of rupture may be contained by the parietal pericardium and thrombus, thus forming a pseudoaneurysm. Cases of traumatic pseudoaneurysm of the right ventricle have been reported. However, right ventricular pseudoaneurysm following pacemaker implantation has not been previously reported. This case demonstrates two right ventricular pseudoaneurysms following perforation of the right ventricular wall using real-time three-dimensional echocardiography (3DE) after pacemaker implantation although only one definite pseudoaneurysm was diagnosed by routine two-dimensional echocardiography (2DE). We also found that color Doppler 3DE enhanced visualization of the connections between the right ventricle and the pseudoaneurysm. Color Doppler 3DE allowed us to peel away the myocardial tissue and rotate the image to study the jets from different angles. In summary, real-time 3DE and color Doppler 3DE provided excellent visualization of the right ventricular pseudoaneurysm, flow between the ventricle and the pseudoaneurysm, and additional information to that obtained by 2DE.

Background. Due to underrepresentation of patients with chronic kidney disease (CKD) in large Implantable-Cardioverter Defibrillator (ICD) clinical trials, the impact of ICD remains uncertain in this population. Methods. Consecutive patients who received ICD at Creighton university medical center between years 2000–2004 were included in a retrospective cohort after excluding those on maintenance dialysis. Based on baseline Glomerular filtration rate (GFR), patients were classified as severe CKD: GFR < 30 mL/min; moderate CKD: GFR: 30–59 mL/min; and mild or no CKD: GFR ≥ 60 mL/min. The impact of GFR on appropriate shocks and survival was assessed using Kaplan-Meier method and Generalized Linear Models (GLM) with log-link function. Results. There were 509 patients with a mean follow-up of 3.0 + 1.3 years. Mortality risk was inversely proportional to the estimated GFR: 2 fold higher risk with GFR between 30–59 mL/min and 5 fold higher risk with GFR < 30 mL/min. One hundred and seventy-seven patients received appropriate shock(s); appropriate shock-free survival was lower in patients with severe CKD (GFR < 30) compared to mild or no CKD group (2.8 versus 4.2 yrs). Conclusion. Even moderate renal dysfunction increases all cause mortality in CKD patients with ICD. Severe but not moderate CKD is an independent predictor for time to first appropriate shock.