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PubMed2004

Long-term results of bioprosthetic mitral valve replacement: the pericardial perspective.

Pericardial valve bioprostheses were introduced in early 1970s and were widely used in the 1980s. The longterm results with the Ionescu-Shiley valve, the first commercially available pericardial valve, were disappointing because of high rate cusp tears during the first decade after implantation. The enthusiasm for this type of bioprosthetic valve was further hampered by the premature failure of the Hancock pericardial valve. The long-term results of aortic valve replacement with the Carpentier-Edwards pericardial valve, which was introduced in 1981, indicated that that valve was durable and the issue of cusp tears had been resolved by an appropriate design. This knowledge prompted surgeons to revisit the merits of pericardial valves for mitral valve replacement and several other pericardial valves are now commercially available. The largest data on long-term results are with the Carpentier-Edwards pericardial mitral valve. The reported freedom from structure valve failure ranged from 69% to 85% at 10 years in patient population with mean age of 60 to 70 years. Young age is a major determinant of valve failure, which is largely due to calcification. There are also long-term data, albeit more limited on the Sorin Pericarbon and Mitroflow valves used for mitral valve replacement. This paper review the published experience with various pericardial bioprosthetic valves used for mitral valve replacement during the past 3 decades.

Adult↗
PubMed2005

Pre-operative atrial fibrillation as the key determinant of outcome of mitral valve repair for degenerative mitral regurgitation.

AIMS: To examine the impact of pre-operative atrial fibrillation (AF) on the outcome of mitral valve repair (MVR) for degenerative mitral regurgitation (MR). METHODS AND RESULTS: Among 392 patients with moderate to severe MR who underwent MVR between 1991 and 2002, 283 patients with isolated degenerative MR were followed for 4.7+/-3.3 years. Of 27 deaths, nine were due to cardioembolic events and four were due to left ventricular (LV) dysfunction. When compared with patients with pre-operative AF, those with sinus rhythm (SR) had better survival (96+/-2.1 vs. 87+/-3.2% at 5 years, P=0.002) and higher cardiac event-free rates (96+/-2.0 vs. 75+/-4.4% at 5 years, P<0.001). In patients with pre-operative SR, observed and expected survival were similar (P=0.811). Cox multivariable regression analysis confirmed AF [P=0.027, adjusted hazard ratio (AHR) 2.9] and age as independently predictive of survival, and AF (P=0.002, AHR 3.1), New York Heart Association Class, and LV fractional shortening as independently predictive of cardiac event. CONCLUSION: Death due to LV dysfunction was not frequent and cardioembolic events due to AF were the leading cause for cardiac death. Pre-operative AF became a strong independent predictor of survival and morbidity. Patients with pre-operative SR had excellent prognosis. The benefits of preventing cardioembolic events due to AF validate the indication of MVR for patients with high risk for AF.

Adult↗
PubMed2005

Mitral valve repair for functional mitral regurgitation in end-stage dilated cardiomyopathy: role of the "edge-to-edge" technique.

BACKGROUND: The aim of this study was to assess the results of mitral valve (MV) repair in functional mitral regurgitation because of end-stage dilated cardiomyopathy (DCM). METHODS AND RESULTS: Seventy-seven patients with end-stage idiopathic (26 patients) or ischemic (51 patients) DCM underwent MV repair for functional mitral regurgitation (3 to 4+/4+). Fifty-eight patients (75.3%) were in New York Heart Association class III, and 19 (24.6%) were in IV. In 23 patients (29.8%) with a coaptation depth <1 cm, an isolated undersized annuloplasty was used. In the remaining 54 (70.1%), with a coaptation depth > or =1 cm, the "edge-to-edge" technique was associated with the annuloplasty. In most of the cases (88.3%), a complete rigid/semirigid ring was used. Concomitant coronary artery bypass graft was performed in 39 patients (50.6%). Hospital mortality was 3.8% (3 of 77). Actuarial survival was 90.7+/-3.64%, and freedom from cardiac events was 81.8+/-7.96% at 2.7 years. At a mean follow-up of 18.4+/-9.8 months (range, 1 month to 5 years) New York Heart Association class improved from 3.4+/-0.4 to 1.4+/-0.6 (P<0.0001). Mitral repair failure (recurrence of MR > or =3+/4+) was documented in 7 patients (9%): 2 in the edge-to-edge (2 of 54, 3.7%) and 5 in the isolated annuloplasty group (5 of 23, 21.7%) (P=0.03). Freedom from repair failure at 1.5 years was 95.0+/-3.4% and 77+/-12.1%, respectively (P=0.04). The absence of the edge-to-edge was the only predictor of repair failure (P=0.03). When residual MR was absent or mild, a reverse left ventricular remodeling was clearly documented. CONCLUSIONS: In patients with end-stage DCM, MV repair is feasible with low hospital mortality and important symptomatic improvement. The association of the edge-to-edge technique to the undersized annuloplasty can significantly improve the durability of the repair.

Adult↗
PubMed2005

Normalization of cancer antigen 125 after mitral valve replacement in a patient with congestive heart failure due to mitral valve endocarditis.

A 63-year-old woman with a history of uterine cancer was admitted to our hospital with dyspnea and stroke. Echocardiography showed a huge vegetation attached to the posterior mitral leaflet with severe mitral regurgitation. Blood culture identified Streptococcus galactiae. The serum level of cancer antigen 125 (CA125) was elevated at 199.4 U/ml. Resection of infected tissue including mobile vegetation and replacement of mitral valve were performed. The postoperative course was uneventful and the patient was discharged after 4 weeks of antibiotic therapy. The values of CA125 returned to normal (less than 15 U/ml) on the 90th postoperative day. These findings have suggested that a high serum value of CA125 is a possible indicator of infection-related congestive heart failure.

Biomarkers, Tumor↗
PubMed2004

The relationship between echocardiographic features of mitral valve and elastic properties of aortic wall and Beighton hypermobility score in patients with mitral valve prolapse.

The present study was designed to investigate the incidence of benign joint hypermobility syndrome (BJHMS) in mitral valve prolapse (MVP) and the correlation between the echocardiographic features of the mitral valve and elastic properties of the aortic wall and Beighton hypermobility score (BHS) in patients with MVP and BJHMS. Fourty-six patients with nonrheumatic, uncomplicated, and isolated mitral anterior leaflet prolapse (7 men and 39 women, mean age; 26.1 +/- 5.9) and 25 healthy subjects (3 men and 22 women, mean age, 25.4 +/- 4.3) were studied. Patients were divided into two groups according to their BHS (group I, MVP+BJHMS; group II, MVP-BJHMS). Individuals with accompanying cardiac or systemic disease were excluded. Echocardiographic examination was performed in all subjects. The presence of BJHMS was evaluated according to Beighton's criteria. The incidence of BJHMS in patients with MVP was found to be significantly higher than that of controls (45.6%, (21/46) vs 12% (3/25), P < 0.0001). Group I (MVP + BJHMS) had significantly increased anterior mitral leaflet thickness (AMLT, 3.4 +/- 0.4 vs 3.1 +/- 0.3; P < 0.005), maximal leaflet displacement (MLD, 2.4 +/- 0.4 vs 1.7 +/- 0.4; P < 0.005), and degree of mitral regurgitation (DMR, 17.1 +/- 7.2 vs 11.2 +/- 4.4; P < 0.01) compared to group II. However, the index of aortic stiffness (IAOS) was found to be lower (17.6 +/- 6.9 vs 23.9 +/- 7.6; P < 0.005) and aortic distensibility (AOD) to be higher (0.0035 +/- 0.007 vs 0.0024 +/- 0.005; P < 0.005) in group I. There was a significant correlation between AMLT, MLD and DMR, and BHS (r = 0.57/P = 0.007, r = 0.55/P < 0.009, r = 0.51/P < 0.01, respectively). In addition, AOD correlated positively with BHS (r = 0.53/P < 0.005), but the index of aortic stiffness correlated inversely with BHS (r = -0.49/P < 0.007). The incidence of BJHMS in patients with MVP was more frequent than the normal population and there was a significant correlation between the severity of BJHMS (according to BHS) and echocardiographic features of the mitral leaflets and elastic properties of the aortic wall.

Adult↗
PubMed2000

Superiority of mitral valve replacement with preservation of subvalvular structure to conventional replacement in severe rheumatic mitral valve disease: a modified technique and results of one-year follow up.

BACKGROUND AND AIM OF THE STUDY: Mitral valve replacement with preservation of the subvalvular apparatus (MRVP) has been proven superior to conventional mitral valve replacement (MVR). We devised a simple modified MVRP method in this prospective, randomized study to investigate the clinical effects and one-year follow up echocardiographic results of MVRP compared with MVR in patients with severe rheumatic mitral insufficiency (MI). METHODS: Sixty-eight patients with severe rheumatic MI with or without stenosis were randomized to MVRP (n = 35) and MVR (n = 33) groups. In MVRP patients, the preserved tissue was pulled back posteriorly to the posterior wall of the left ventricle, then plicated and reaffixed to one-fourth of the annular circumference in the posterior annulus, in order to prevent left ventricular outflow tract (LVOT) obstruction. Clinical data including cumulative ventricular arrhythmias and use of inotropes were collected. Echocardiography examination was performed before surgery, and at five days, three months and one year thereafter. RESULTS: There were no preoperative differences patient data. The cross-clamp time was 2.2 min longer in MVRP patients. The one-month mortality rate after surgery was lower in MVRP patients (2.9% versus 15.2%, p = 0.074). Mechanical ventilation and ICU times were shorter in the MVRP group (17.6 versus 24.8 and 52.5 versus 70.6 h, p = 0.001 and 0.1, respectively). There were fewer ventricular arrhythmias and less need for inotropic support in this group. One year follow up echocardiography data showed better preserved left ventricular ejection fraction (LVEF) and better recovery of heart size after MRVP. There was no indication that preserved valvular tissue interfered with mechanical valve function, or caused LVOT obstruction. CONCLUSION: This modified MVRP technique is simple, effective and without risk of LVOT obstruction. In severe rheumatic MI patients the outcome of MVRP is superior to that of conventional MVR in term's of mortality, postoperative care needs, left ventricular function and heart dimensions.

Adult↗
PubMed2005

A case of mitral valve replacement with a collar-reinforced prosthetic valve for heavily calcified mitral annulus.

Mitral valve replacement in the presence of extensive calcification of the mitral annulus is a technical challenge. Dense calcification of the annulus can cause a great difficulty in the insertion of a prosthetic valve and later periprosthetic leakage. A radical calcium debridement may cause left circumflex coronary artery injury, atrioventricular rupture, and thromboembolic events. We report a case of a 65-year-old woman suffering from mitral regurgitation with a severely calcified mitral annulus. She underwent mitral valve replacement using a collar-reinforced prosthetic valve, which allowed the surgeon to safely insert a prosthetic valve, avoiding the calcification completely without any major complications. We recommend this method as a feasible technique for mitral valve replacement in the presence of heavily calcified or disrupted fragile mitral annulus.

Aged↗
PubMed2002

Mitral stenosis after mitral valve repair for non-rheumatic mitral regurgitation.

BACKGROUND: Mitral stenosis after mitral valve repair for non-rheumatic mitral regurgitation is rare. METHODS: From 1990 to 1999, 478 patients had mitral valve repair for myxomatous and 40 patients had mitral valve repair for ischemic mitral regurgitation. The Carpentier annuloplasty ring (Edwards Lifesciences, Irvine, CA) was used in 72 patients, the Duran ring (Medtronic, Minneapolis, MN) in 152, a posterior band in 221 and no ring or band in 73 patients. RESULTS: Four patients developed mitral stenosis late after mitral valve repair: 2 for myxomatous disease and 2 for ischemic mitral regurgitation. All 4 patients had Duran annuloplasty rings (sizes 25 to 31). The diagnosis of mitral stenosis was made by Doppler echocardiography. The mitral valve area in these 4 patients decreased from 2.7 cm2 (range, 2.3 to 3.2 cm2) early postoperatively to 0.85 cm2 (0.4 to 1.2 cm2) after a mean follow-up of 66 months (range, 38 to 110 months). Three patients had mitral valve replacement and the etiology of the mitral stenosis was the same in all patients (ie, pannus overgrowth on the annuloplasty ring with extension onto both leaflets rendering them stiff and immobile). The fourth patient had a mitral valve area of 1.2 cm2, which was mildly symptomatic with normal pulmonary artery pressure, and this patient has not had reoperation. CONCLUSIONS: Mitral stenosis may develop after mitral valve repair for myxomatous disease or ischemic mitral regurgitation when a Duran ring is used for annuloplasty. The stenosis is caused by pannus on the annuloplasty ring with extension onto the leaflets.

Female↗
PubMed1995

Mitral valve rupture following percutaneous mitral commissurotomy: existence of predictive factors.

The purpose of this study was to describe the mechanism and determine predictive factors of mitral valve rupture requiring valve replacement following percutaneous mitral commissurotomy. Of the 350 consecutive patients treated by balloon mitral commissurotomy, the procedure was not completed in 16, and 11 developed acute severe mitral regurgitation requiring valve replacement: seven cases of anterior leaflet rupture, three cases of posterior leaflet rupture and one case of anterior chordal surface. These 27 group I patients were compared to the remaining 323 (group II) in whom the procedure was completed. The 11 excised valves were evaluated by an experienced pathologist. Eight of the 11 patients had an echocardiographic score < 8 (mean score 6.5 +/- 1), no valvular calcification at X-ray and double balloon percutaneous mitral commissurotomy. Microscopy in six patients showed focal fibrous thickening at the site of the rupture but no calcification. One patient developed severe mitral regurgitation due to chordal rupture with an Inoue balloon. The two remaining patients had an echo score of ten and valve calcification on X-ray. Microscopy revealed severe homogeneous chronic rheumatic mitral disease. In one of these two patients, leaflet rupture was related to an 'oversized balloon' (2 x 19 mm + 15 mm). Statistical analysis showed only echo score differences between the two groups (6.9 +/- 1.4 in group I vs 8.2 +/- 1.6 in group II, P < 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMedDate not supplied

Mitral valve replacement for severe mitral regurgitation in infants with anomalous left coronary artery from the pulmonary artery.

Infants with anomalous left coronary artery from the pulmonary artery (ALCAPA) may present with heart failure, mitral regurgitation, and dilated cardiomyopathy. Reestablishment of a two coronary artery system markedly improves the morbidity and mortality. However, the mitral regurgitation may continue to deteriorate despite surgical correction of the ALCAPA because of previous ischemic damage to the papillary muscles and chordae. Surgical intervention, including mitral valve replacement, may be required even during infancy. We present two infants with ALCAPA who required early mitral valve replacement for severe mitral regurgitation and have done well subsequently.

Coronary Vessel Anomalies↗
PubMed1998

[Successful surgical treatment for severe mitral valve annulus enlargement and mitral regurgitation 5 years after aortic root replacement in Marfan syndrome: a case report].

Major cardiovascular lesions associated with Marfan syndrome include aortic diseases such as aortic root dilatation and mitral disease. If untreated, cardiovascular manifestations of the Marfan syndrome cause death in one half of patients during the first four decades of life. Although aortic diseases in the Marfan syndrome are responsible for most of serious morbidity and mortality, 60-80% of patients with Marfan syndrome have mitral valve dysfunction. The results of surgical treatment for aortic diseases in Marfan patients have recently shown significant improvement. However, there is no acceptable consensus about the timing and the technique of surgical intervention for mitral diseases. Especially mitral valve diseases is the most common cause of morbidity and mortality in infants with the Marfan syndrome. We report herein a case of Marfan syndrome (21-year-old female) who had undergone two operations for aortic root dilatation five years before she underwent the surgical treatment for progressive heart failure due to severe mitral annulus enlargement and mitral regurgitation.

Adult↗
PubMed2000

Biological versus prosthetic ring in mitral-valve repair: enhancement of mitral annulus dynamics and left-ventricular function with pericardial annuloplasty at long term.

OBJECTIVE: The effects of different annuloplasty rings on mitral annulus dynamics and left-ventricular (LV) function after mitral-valve repair (MVR) are still controversial. This study sought to compare biological versus prosthetic rigid rings for annular remodelling in MVR at long term. METHODS: Forty-four consecutive patients were retrospectively enrolled. All patients had isolated posterior-leaflet prolapse and underwent identical surgical mitral-valve reconstruction (quadrangular resection of the posterior leaflet associated with annuloplasty). Twenty-three patients underwent mitral annuloplasty with an autologous pericardial ring (group I), whereas 21 patients had MVR with a Carpentier-Edwards rigid ring (group II). No differences existed between the groups in terms of pre-operative patient profile. Post-operative LV systolic indices have been assessed by two-dimensional echocardiography at rest and during supine bicycle exercise. Mitral annular motion has been examined by means of the extent of mitral annulus systolic excursion (MASE), as measured in four longitudinal LV segments (anterior, inferior, septal and lateral). Mean and peak trans-mitral flow velocities (TMFV) have been also evaluated by continuous-wave Doppler. RESULTS: The mean follow-up did not differ between the groups, those being 41+/-12 months in group I (range17-65 months) and 46+/-15 months in group II (range 23-83 months), respectively. Post-operative echocardiographic study did not show significant mitral regurgitation at rest or at peak exercise in any patient. ANOVA analysis for repeated measures showed a significant interaction in peak TMFV (F((1,42))=5.23; P=0.03), and in left-ventricular ejection fraction (LVEF; F((1,42))=7.61, P=0.01). The analysis of contrasts showed a significant increase in TMFV in both groups (group I from 1.22+/-0.22 to 1.79+/-0.32 m/s, t=-8.8, P<0.0001; and group II from 1.19+/-0.17 to 1.96+/-0.33 m/s, t=-12.8, P<0.0001). Recruitment of LVEF reserve during exercise was observed only in group I (from 59.5+/-6 to 65.8+/-6%, t=-3.95, P<0.005), whereas no substantial change occurred in LV performance in group II. A trend towards better MASE at all the studied longitudinal segments at rest and during exercise was observed in group I. No minor or major calcifications have been observed on pericardial rings. CONCLUSIONS: The autologous pericardium seems to be superior to rigid prosthetic rings for annuloplasty in MVR since it provides more favourable mitral annulus dynamics and preserves LV function during stress conditions. Effective and durable annular remodelling with the autologous pericardium is achieved up to 6 years from surgery, with no echocardiographic sign of degeneration in the long term. Further studies are required to compare biological versus flexible prosthetic rings in MVR.

Adult↗
PubMed1994

Two-dimensional transesophageal echocardiographic determination of mitral valve area in adults with mitral stenosis.

Two-dimensional transthoracic echocardiography has been shown to be a reliable and accurate method of measuring stenotic mitral valve orifice area. Little data exist on the role of two-dimensional transesophageal echocardiography for this purpose. Thus in 45 adult patients with mitral stenosis mitral valve area was determined by direct planimetry with the use of two-dimensional transesophageal and transthoracic echocardiography. Transesophageal was less feasible than transthoracic echocardiography in the 45 patients (69% vs. 89%, p < 0.025). In 14 patients, two-dimensional transesophageal echocardiography was not feasible, primarily because of leaflet dropout. In 30 patients, transesophageal and transthoracic echocardiography were feasible, and measurements of mitral valve area by the two techniques correlated well (r = 0.91, SEE = 0.33 cm2, p < 0.0001). Mean mitral valve orifice area determined by transesophageal echocardiography (1.54 +/- 0.75 cm2; range 0.56 to 3.49 cm2) and by transthoracic echocardiography (1.55 +/- 0.78 cm2; range 0.62 to 3.68 cm2) did not differ (p = NS). The absolute (0.24 +/- 0.22 cm2) and percent (19% +/- 21%) differences between mitral valve area determined by transesophageal versus transthoracic echocardiography were small. These data show that mitral valve area in patients with mitral stenosis can be accurately measured by direct planimetry with two-dimensional transesophageal echocardiography. Technical refinements such as lateral-gain-compensation features may improve the feasibility of two-dimensional transesophageal echocardiography for measurements of mitral stenosis area, and this technique may become an adjunct to transthoracic echocardiography in the assessment of severity of mitral stenosis.

Adult↗