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PubMed1999

Mitral valve thrombus attached to the intact mitral valve associated with distal embolism.

A 61-year-old man was referred for cardiac investigation because embolism was suspected to be the cause of the sudden onset of severe pain in his right leg after a surgical procedure. The electrocardiogram revealed no atrial fibrillation. Transthoracic echocardiography demonstrated a tumor-like echo at the anterior mitral leaflet, and transesophageal echocardiography documented a mass 13x9mm in size, attached by a stalk to the left atrial side of the anterior mitral leaflet. The other parts of the mitral valve appeared to be intact. At emergency surgery, the mass was located in the center of the left atrial side of the anterior mitral leaflet. It mimicked a myxoma and had a stalk arising from the anterior leaflet. After resection of the mitral valve mass, catheter thrombo-embolectomy was performed and several long pieces of fresh thrombus were removed. On histological examination, the mass consisted of fresh thrombus tissue. No cellular component or myxoma tissue was documented. The distal embolus also consisted of fresh thrombus tissue. This is the first case of a thrombus of the intact mitral valve without atrial fibrillation.

Diagnosis, Differential↗
PubMed1982

[Calcification of mitral anulus and mitral valve prolapse. Description of a case with severe mitral valve insufficiency].

We report the case of a women, 40 years old, suffering from a severe mitral insufficiency caused by the simultaneous presence of three anatomical anomalies: mitral valve prolapse, mitral anulus dilation and calcification. Such degrees of calcification are generally found in older people and in association with a similar degeneration of all the fibrous skeleton of the heart. Whereas the association of mitral valve prolapse with mitral anulus dilation has been clearly remarked, a few cases (16 as a whole in our knowledge) with scanty details documented the possibility of an associated mitral anulus calcification.

Adult↗
PubMed1984

[Non-invasive estimation of transmitral pressure gradient and mitral valve area in mitral stenosis by an ultrasonic pulsed Doppler technique].

We attempted to estimate transmitral pressure gradient and mitral valve area (MVA) noninvasively in mitral stenosis (MS) by a bi-directional pulsed Doppler flowmeter combined with an electronic two-dimensional echocardiograph. Eleven patients with MS in sinus rhythm were studied by cardiac catheterization. Fifteen healthy subjects (H) served as normal control. The pulsed Doppler flowmeter operated with a carrier frequency of 2.5 MHz, a pulse repetition rate of either 5 KHz or 10 KHz and a sample volume of 1 X 3 X 3 mm. The velocity of transmitral central flow was measured by this system, monitoring audible Doppler sounds and cardiac images which depict the anatomic location of the sampling site. The Doppler signal was analyzed by a sound spectrograph. In estimating the transmitral pressure gradient and MVA, we employed a Doppler parameter (half time) defined as the time for instantaneous maximal blood flow velocity to reduce to one-half from its rapid inflow peak, which is independent of the angle between the ultrasonic beam and blood flow. Transmitral pressure gradient (delta P100) was measured as the pressure gradient between either left atrial or pulmonary capillary pressure and left ventricular pressure at the point after 100 msec from the nadir of left ventricular early diastolic pressure [( LA or PC--LVDP]100). MVA was obtained using a Gorlin's formula. The transmitral blood flow velocity in both MS and healthy groups revealed a narrow frequency band pattern with two peaks, R and A, in diastole. The former peak occurred during rapid inflow phase and the latter following atrial contraction. In the healthy group, the descent rate of R wave was increased than that in the MS group. The square root of the pressure gradient also reduced linearly with transmitral flow velocity in the MS group. Thus in the MS group, the transmitral velocity was directly proportional to the square root of the pressure gradient as described by a Bernoulli theorem, and the half time was proportional to the transmitral velocity. The square of the half time (delta t2) was highly correlated with delta P100 (r = 0.97), and the inverse of the half time (delta t-1) was correlated with MVA (r = 0.76). There was no significant correlation between delta P100 and diastolic descent rate of anterior mitral leaflet (DDR). The present study indicates that the half time is useful in estimating transmitral pressure gradient and MVA in mitral stenosis.

Adult↗
PubMed2001

Combined mitral valve and coronary artery surgery: ischemic versus non-ischemic mitral valve disease.

OBJECTIVES: Mitral valve combined with coronary artery surgery is associated with a higher hospital mortality than each operation in particular. Controversy exists regarding the predictive value of ischemic mitral valve disease (MVD) on outcome. METHODS: Between 1984 and 1997, 262 patients underwent mitral valve operations (replacement, n = 198; repair, n = 64) in combination with coronary revascularization. The etiology of MVD was secondary to ischemic heart disease (group I) in 82 (31%) patients, and non-ischemic (group II) in 180 (69%) patients (rheumatic, 139 patients (53%); degenerative, 41 patients (16%)). Both groups were similar in age, cardiac risk factors and pulmonary artery pressure. Patients of group I had significantly more severe coronary artery disease, more often an impaired left ventricle and myocardial infarction, and were in a worse functional condition. The mean number of bypass grafts was significantly higher in group I. The follow-up was 98% (230/234 patients). RESULTS: With 19.5%, the hospital mortality was significantly increased in group I compared with 6.7% in group II (P = 0.002; overall, 10.7%). Mitral valve repair or replacement had no influence on early outcome, although mitral valve repair was performed more often in group I (37 versus 19%). The survival (valve-related event-free survival) after discharge from hospital in the 1st, 5th and 10th year was 94 (94%), 70 (66%) and 53% (35%) in group I and 96 (95%), 79 (76%) and 54% (41%) in group II, respectively. The long-term functional capacity was equally good in both groups (New York Heart Association mean, 1.86 versus 1.72). CONCLUSIONS: Patients with ischemic MVD are in a worse cardiac condition with significantly higher hospital mortality than patients with non-ischemic MVD and coronary artery bypass grafting. Once discharged from hospital, both groups have comparable long-term outcomes, with the best results in patients with degenerative MVD.

Aged↗
PubMed1998

Assessment of mitral valve volume by quantitative three-dimensional echocardiography in patients with rheumatic mitral valve stenosis.

BACKGROUND: Thickening of mitral leaflets in rheumatic mitral valve stenosis is well described in necropsy studies; however, volume computation of the thickening mitral leaflets has not been attempted. 4trial fibrillation is one of the complications of rheumatic mitral stenosis. Quantitative assessment of thickened mitral valve and its relation to clinical complications is clinically desirable. HYPOTHESIS: The study was undertaken to compare measurement of mitral valve volume in normal subjects and in patients with rheumatic mitral valve stenosis. METHODS: An HP Sonos 2500 echocardiographic system with 5 MHz multiplane transesophageal transducer was used for data acquisition, and TomTec Echoscan computer setup was used to off-line volume computation. Study subjects included 10 normal subjects (mean age 44.8 years) and 36 patients with rheumatic mitral valve stenosis (22 female, 14 male) with an age range of 25 to 69 years (mean age 47 +/- 9.6 years). Mitral valve volumes were compared between the normal subjects and patients with mitral valve stenosis, and further comparison was made between the sinus rhythm (SR) and atrial fibrillation (AF) groups in patients with mitral valve stenosis. In all study subjects, the mitral valve area (MVA) was determined by two-dimensional echocardiography. RESULTS: Quantitative three-dimensional (3-D) echocardiography showed that mitral valve volume was significantly larger in patients with mitral valve stenosis than in normal subjects (9.0 +/- 2.2 and 4.5 +/- 0.7 ml, respectively, p < 0.001). When patients with mitral valve stenosis were divided into the SR and AF groups, mitral valve volume was found to be significantly larger in the AF group than in the SR group (9.76 +/- 2.2 ml. and 7.72 +/- 1.5 ml, respectively, p < 0.01) and patients in the AF group tended to be older (p < 0.05) with larger left atrial diameter (LAD) (p < 0.01). However, MVA between the two groups showed no statistical significance (1.1 +/- 0.43 and 1.0 +/- 0.34 cm2, respectively, p > 0.2). When the study subjects were divided into two groups (< 50 and > or = 50 years) according to age, the comparison of mitral valve volume between these two groups (9.37 +/- 2.18 and 8.56 +/- 2.14 ml, p > 0.2) showed no statistical significance. CONCLUSIONS: Quantitative 3-D echocardiography can be applied for the measurement of mitral valve volume in vivo. Patients with rheumatic mitral valve stenosis with atrial fibrillation have a propensity to have a larger mitral valve volume and are older than the patients with sinus rhythm; however, the age per se does not seem to be a cause for larger mitral valve volume.

Adult↗
PubMed2000

Transfer of the posterior leaflet of the tricuspid valve to the mitral valve.

BACKGROUND AND AIM OF THE STUDY: Coverage of large commissural defects may present a surgical challenge in mitral valve repair, for which the transfer of posterior tricuspid valve leaflet tissue is an attractive approach. METHODS: Five patients aged between 35 and 55 years underwent this procedure. After wide excision of the diseased mitral commissures, the posterior leaflet of the tricuspid valve was carefully checked, removed with its subvalvular apparatus, and transferred to the commissural area of the mitral valve. The stress on the papillary muscle suture was relieved by reinforcement of the free edge of the transferred leaflet by natural or artificial chordae. The tricuspid valve was repaired using either a sliding plasty or an annuloplasty. RESULTS: One patient who had no reinforcement of the subvalvular apparatus had a papillary muscle rupture and required mitral valve replacement during the early postoperative period. The four remaining patients remained asymptomatic and had no or trivial mitral regurgitation after a median of 13 months (range: 3-18 months), with excellent result at transesophageal echocardiography. CONCLUSION: We conclude that transfer of the tricuspid valve leaflet allows coverage of large commissural defect, and deserves a place among the surgeon's arsenal of reconstructive techniques for mitral valve repair.

Adult↗
PubMedDate not supplied

Mitral valve prolapse.

Mitral valve prolapse is a common valvular abnormality that is the most common cause of severe non-ischaemic mitral regurgitation in the USA. The overall prognosis of patients with mitral valve prolapse is excellent, but a small subset will develop serious complications, including infective endocarditis, sudden cardiac death, and severe mitral regurgitation. We present a comprehensive review of mitral valve prolapse, examining normal mitral anatomy, the clinical and echocardiographic features of mitral valve prolapse, and the pathophysiology and genetics of the disorder. We discuss the contemporary management of both asymptomatic and symptomatic prolapse, with particular attention to the timing and technique of surgical repair. We conclude that echocardiography is the method of choice for diagnosing mitral valve prolapse, that clinical and echocardiographic features can predict which patients with prolapse are at highest risk for complications, and that mitral valve repair is the treatment of choice for symptomatic prolapse.

Echocardiography↗
PubMed1980

[Mobility of the mitral valve cusps in mitral stenosis studied by 2-dimensional echocardiography].

The object of the work was to disclose the possibilities of bimetric echocardiography in appraising the mobility of the mitral valve cusps in patients with mitral stenosis. The shape of the mitral cusp movement was studied in the longitudinal and transverse planes of the heart section. The results of the ultrasonic examinations were compared with the operative findings in 68 patients operated on for mitral stenosis. In satisfactory mobility of the valve, "sail-shaping" of the cusps is recorded in the longitudinal plane of the heart section and a concavity in the transverse plane in the period of diastole. In coarse fibrosis of the cusps, the diastolic movement of the surface of the anterior cusp is recorded as a displacement of a straight line which moves parallel to its initial position in the period of systole. Bimetric echocardiography makes it possible to determine exactly the character of the mitral valve lesion and determine the degree of mobility of the cusps in patients with mitral stenosis. This information may be decisive in choosing the method of surgical correction of the disease.

Adolescent↗
PubMed1970

Immediate and long-term results of mitral valve replacement with University of Cape Town mitral valve prosthesis.

We describe seven years' experience with the University of Cape Town lenticular mitral valve prosthesis in 122 patients. All the patients had severe mitral valve disease. In 98 severe mitral stenosis was present with or without incompetence and in 24 the dominant or sole lesion was mitral incompetence. Other valves, particularly the tricuspid, were also frequently affected. The disability was severe or total in almost every patient. One hundred and five patients were discharged from hospital, and in 90 per cent of these the clinical improvement was most gratifying, with the disappearance of pulmonary oedema, paroxysmal dyspnoea, angina pectoris, and congestive cardiac failure. Return to full normal activity including physical work was the rule. The hospital mortality was 14 per cent and a further 38 per cent died during the follow-up period. The major post-operative complication was systemic embolism which could occur at any time after operation. The most important factor influencing the frequency of this complication was the nature of the valve seat. A bare steel seat was associated with a 100 per cent embolism, and a significant reduction occurred when a cloth-covered seat of Dacron-velour was introduced. Anticoagulant therapy appeared to prevent large or fresh clots but had no effect on the deposition of fibrin or platelet thrombi. The only other factor of importance was the age of the patient: after the age of 50 life expectancy and trouble-free long-term survival was reduced.

Adolescent↗
PubMed1993

Echocardiographic assessment of mitral valve size in obstructive hypertrophic cardiomyopathy. Anatomic validation from mitral valve specimen.

BACKGROUND: In patients with hypertrophic cardiomyopathy, obstruction to left ventricular outflow is produced by systolic anterior motion of the mitral valve. In many of these patients, the mitral leaflets are elongated and increased in overall size. Mitral valve size may be responsible, in part, for the presence and magnitude of the outflow gradient and the pattern of systolic anterior motion of the leaflets. It may also influence the effectiveness of ventricular septal myotomy-myectomy in relieving subaortic obstruction. Therefore, the present study was undertaken to determine whether mitral valve dimensions could be assessed in quantitative terms from the echocardiogram in patients with hypertrophic cardiomyopathy. METHODS AND RESULTS: A group of 37 patients with hypertrophic cardiomyopathy was selected for this study by virtue of having a high-quality transthoracic or intraoperative echocardiogram suitable for certain quantitative measurements from stop-frame images as well as a morphologically intact mitral valve specimen (removed during surgery). Seven measurements of mitral valve dimensions were obtained from the two-dimensional and M-mode echocardiograms. A univariate regression analysis identified the mitral valve opening area as the best single predictor of actual mitral leaflet area measured from the specimen (r2 = .75; r = .87). The linear relation between mitral valve opening area as assessed by two-dimensional echocardiography and actual mitral leaflet area measured from the mitral valve specimen accounted for approximately 75% of the variability in mitral leaflet area. With such statistical models, it was possible to reliably identify from the echocardiogram enlarged mitral valves (> or = 12.0 cm2) in 16 of 19 patients (84%) and normal-sized valves in 15 of 18 patients (83%). CONCLUSIONS: In a selected group of patients with obstructive hypertrophic cardiomyopathy, a model derived from a regression analysis of quantitative echocardiographic measurements permitted (with good precision) estimation of actual mitral leaflet area and consequently overall mitral valve size and the discrimination of enlarged from normal-sized mitral valves.

Adolescent↗
PubMed2000

Exposure of the mitral valve by transecting the ascending aorta during aortic and mitral valve replacement.

Combined aortic and mitral valve operations are still considered major cardiac surgical procedures. The duration of aortic cross-clamping and cardiopulmonary bypass is longer, which increases morbidity and mortality for these combined, complicated operations. Aortic valve exposure is generally satisfactory, but mitral valve exposure may be difficult and add to the length of the aortic cross-clamping time. We have exposed the mitral valve by transecting the ascending aorta, and retracting both ends apart, to give direct access through the dome of the left atrium in 7 patients. This approach gave good exposure and did not increase the risk of complications. Exposure of the mitral valve through the left atrium using a superior approach, by transecting the ascending aorta, is a good option for patients with multiple cardiac conditions who are undergoing combined aortic and mitral valve operations.

Aorta↗
PubMed1986

Vertical left ventricular angulation assessed by thallium 201 myocardial perfusion imaging in patients with mitral valve prolapse.

Mitral valve prolapse has been associated with septal to aortic root angle abnormalities determined by echocardiography. Thallium 201 imaging in the anterior view permits visualization of the left ventricular long axis. In the present study, the vertical angle was defined as the angle formed by the long axis of the left ventricle and a horizontal line. The vertical angle was determined in 25 patients who had 201 TL stress testing and M-mode echocardiography. Group I (11 patients) had mitral valve prolapse and group II (14 patients) did not have mitral valve prolapse. The vertical angle and ultrasound were read blinded to each other. Height, weight, and body surface area were compared for the two groups, and receiver operator curve analysis performed. Vertical angle measured by TL 201 was significantly more vertical in patients with mitral valve prolapse. Receiver operator curve analysis showed that an angle of greater than 30 degrees successfully identified 9/11 patients with mitral valve prolapse, with a sensitivity of 82% and a specificity of 79%. There were no significant differences in height, weight, or body surface area between the two groups. Thus, patients with mitral valve prolapse have more vertically positioned hearts than patients without mitral valve prolapse, independent of body habitus. The different appearance of a vertically oriented heart may contribute to false-positive readings of TL 201 images.

Adult↗
PubMed1986

Systolic anterior motion of the mitral valve after Carpentier ring valvuloplasty for mitral valve prolapse.

Between July 1983 and March 1985, 45 patients with severe mitral regurgitation underwent mitral valvuloplasty with insertion of a semirigid Carpentier ring. No patient had echocardiographic evidence of systolic anterior motion (SAM) preoperatively, whereas 5 patients had this echocardiographic finding postoperatively. All 5 had mitral valve prolapse as their underlying disease process and SAM developed at varying intervals after valvuloplasty. The development of SAM is related to insertion of the semirigid ring, persistence of a redundant anterior mitral leaflet, narrowing of the left ventricular (LV) outflow tract and the Venturi effect. LV and aortic pressure measurements with simultaneous Doppler echocardiography have confirmed the presence of a significant LV outflow tract gradient in these patients. Although all 5 patients are functionally improved after mitral valvuloplasty, the long-term implications of SAM after valvuloplasty are unknown.

Echocardiography↗
PubMed1980

Influence of mitral valve surgery on tricuspid incompetence concomitant with mitral valve disease.

Twenty adult patients with predominant mitral valve disease and variable degrees of tricuspid incompetence (TI) were reinvestigated 6-28 months after mitral valve operation. Postoperatively, 10 of the 20 patients were in sinus rhythm, compared with four of 20 preoperatively. Right ventricula peak systolic pressure decreased from 48 to 33 mm Hg (p less than 0.005), pulmonary vascular resistance declined from 234 to 141 dyn-sec-cm-5 (p less than 0.05), and cardiac index increased from 2.4 to 3.0 l/min/m2 (p less than 0.01) after operation, but right ventricular end-diastolic pressure and right atrial pressure failed to improve. TI, as graded by semiquantitative criteria from right ventricular angiocardiograms taken in the right anterior oblique projection, was decreased unequivocally in only six patients, unchanged in degree in 13 patients, and worse in one. Improvement in TI was associated with an enhancement of systolic shortening of the tricuspid annulus (24 vs 15%, p less than 0.02), whereas in patients with unchanged TI, tricuspid annulus shortening was also unchanged. These data suggest that TI associated with mitral disease is not invariably decreased after mitral surgery, despite improved hemodynamics. A depressed extent of shortening of the tricuspid annulus in systole seems to be important in the pathogenesis of TI.

Adult↗
PubMed1988

Mitral valve dimensions and motion and familial transmission of mitral valve prolapse with and without mitral leaflet billowing.

To test the hypothesis that mitral valve prolapse may be due either to billowing of mitral leaflets into the left atrium or to dynamic expansion of the mitral anulus, mitral leaflet and annular dimensions and motion were measured by computer-assisted two-dimensional echocardiography in 35 normal adults and 48 subjects with auscultatory and M-mode echocardiographic evidence of mitral prolapse. Among normal subjects, mitral leaflet and annular dimensions tended to be larger compared with body size or left ventricular size in women than in men. Mitral leaflet billowing was observed in 24 (50%) of 48 patients with mitral prolapse and 0 of 35 normal subjects (100% specificity). The 24 patients without leaflet billowing had greater systolic expansion of the mitral anulus (p less than 0.0001) than did normal adults or patients with leaflet billowing (41 +/- 14% versus 27 +/- 12% and 22 +/- 11%, respectively) and a significantly lower body mass index (p less than 0.005 versus normal group). The ratio of anterior plus posterior mitral leaflet length to end-systolic annular diameter was lower in patients with prolapse without leaflet billowing than in normal subjects (1.09 +/- 0.12 versus 1.19 +/- 0.15, respectively, p less than 0.01) or patients with leaflet billowing (1.21 +/- 0.17, p less than 0.05). Among 35 relatives with mitral prolapse in the families of 23 patients with prolapse, the pattern was the same as in the proband in 31 (89%) (p less than 0.000002).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed2003

Intraoperative assessment of mitral valve and peri-operative results of surgical treatment of mitral valve disease in patients who previously underwent closed surgical and percutaneous transluminal mitral commissurotomy.

BACKGROUND: Surgical open or closed mitral commisurotomy and percutaneous transluminal mitral commissurotomy (PTMC) are the well-established therapies in patients with mitral valve stenosis. However, due to various factors the long-term effects may not be optimal in some patients, so they should undergo surgical mitral valve replacement. AIM: The intra-operative assessment of the morphology of mitral valve and the evaluation of the peri-operative results of surgical treatment in patients with mitral valve disease who previously underwent closed surgical commissurotomy followed by PTMC. METHODS: Twenty one patients (20 males, mean age 49 years) who underwent surgery due to mitral valve disease after closed mitral commissurotomy and PTMC, are presented. The time from closed mitral commissurotomy to PTMC was 3-42 years, and the time from PTMC to mitral valve replacement - 9 days to almost 9 years. RESULTS: One patient died on the second day after the operation because of left ventricular failure. The outcome of the remaining patients was good. Advanced changes of the mitral valve and subvalvular apparatus were present in the majority of patients. CONCLUSIONS: The results of the implantation of mitral valve prosthesis in patients who previously underwent closed surgical mitral commissurotomy and PTMC are good. In some patients with a history of closed surgical mitral commissurotomy, PTMC delays surgical replacement of the mitral valve. Advanced changes in the mitral valve leaflets and subvalvular apparatus are the causes of PTMC failure.

Adult↗