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PubMed1985

[Remote results of mitral valve surgery in mitral valve insufficiency, 1972-1982].

Between 1972 and 1982 315 patients were operated on for isolated or predominant mitral insufficiency at Surgical Clinic A, University of Zurich. The etiology was rheumatic in 51 patients and degenerative in 133. Of these 164 patients, 42 underwent a reconstructive procedure and 122 mitral valve replacement. Patients who underwent mitral valve reconstruction were younger and had a longer average postoperative observation time than patients who had mitral valve replacement. Operative mortality of the total series was 2.4%. Late postoperative survival was very similar in the patients with rheumatic and degenerative mitral incompetence. Seven-year survival after mitral valve reconstruction was 87 +/- 5%, compared to 76 +/- 6% after mitral valve replacement. Mitral valve reconstruction patients required more reoperations than those with mitral valve replacement. On the other hand, the incidence of late embolism and endocarditis was lower after mitral valve reconstruction. Age of patients at operation and a preoperative reduction of ejection fraction and cardiac index were predictors of a less favourable postoperative course. From these observations we conclude that surgery should be carried out before irreversible impairment of left ventricular function, even where symptoms are less than severe. If possible, reconstructive surgery for mitral incompetence is justified in view of the lower postoperative risk of embolism and endocarditis and in spite of the higher incidence of recurrences requiring reoperation.

Adolescent↗
PubMed1992

Genes, gender and geometry and the prolapsing mitral valve.

Mitral Valve Prolapse (MVP) is usually a variant of normal occurring in about 4% of the population. Complications are relatively uncommon, but false associations due to ascertainment bias have had a potential for iatrogenic harm. Adverse outcomes which do occur in a subset of MVP subjects are considered here in relation to the contributions of genes, gender and geometry. There are definite associations between MVP and several dominantly inherited connective tissue abnormalities; it occurs in 85% of adults with Marfan syndrome. All these contribute to a very small proportion of the MVP population. A larger less easily characterised group with dominant inheritance and some features of a connective tissue disorder awaits DNA studies for identification. For most MVP subjects our data define significant family aggregation consistent with polygenic inheritance; the likelihood of a first degree relative having MVP is about two and a half times the population average. There is a higher prevalence in young women than in men-5% versus 3%; this has also been demonstrated for floppy mitral valve (MV) at autopsy. MVP complications of chordal rupture, severe mitral regurgitation and infective endocarditis are, however, two to three times more common in men, are age related and evident after the age of 50 years. Higher blood pressure in men may contribute to this in accordance with a response-to-injury hypothesis to explain progressive valve changes. Leaflet, annulus and left ventricular size differences and septal changes are geometric variants with a potential for increasing tension-related valve injury.(ABSTRACT TRUNCATED AT 250 WORDS)

Australia↗
PubMed2003

Recurrence of mitral valve regurgitation after mitral valve repair in degenerative valve disease.

BACKGROUND: Durability assessment of mitral valve repair for degenerative valve incompetence is actually limited to reoperation as the primary indicator, with valve-related risk factors for late death as a secondary indicator. We assessed serial echocardiographic follow-up of valve function as an indicator of the durability of mitral valve repair. METHODS AND RESULTS: In 242 patients who had undergone mitral valve repair for degenerative valve incompetence, echocardiographic follow-up of valve function, rate of reoperation, survival, and clinical outcome was studied. At 8 years after repair, clinical outcome was excellent, survival was 90.9+/-3.2%, freedom from reoperation was 94.2+/-2.3%, and freedom from anticoagulation bleeding and thromboembolic events was 90.4+/-2.7%. However, freedom from non-trivial mitral regurgitation (>1/4) was 94.3+/-1.6% at 1 month, 58.6+/-4.9% at 5 years, and 27.2+/-8.6% at 7 years. Freedom from severe mitral regurgitation (>2/4) was 98.3+/-0.9% at 1 month, 82.8+/-3.8% at 5 years and 71.1+/-7.4% at 7 years. The linearized recurrence rate of non-trivial mitral regurgitation (>1/4) was 8.3% per year and of severe mitral regurgitation (>2/4) was 3.7% per year. Inadequate surgical techniques (chordal shortening, no use of annuloplasty ring or sliding plasty) could only partially explain recurrence of regurgitation. In selected patients who did not have these risk factors, linearized recurrence rates were 6.9% per year and 2.5% per year, respectively. CONCLUSIONS: The durability of a successful mitral reconstruction for degenerative mitral valve disease is not constant, and this should be taken into account when asymptomatic patients are offered early mitral valve repair.

Disease-Free Survival↗
PubMed2000

Differences in left ventricular response between rheumatic and myxomatous mitral valve disease following mitral valve replacement.

OBJECTIVE: We studied whether differences exist between hearts having rheumatic mitral valves and those having myxomatous mitral valves, in functional, geometrical, and mass changes in the left ventricle after mitral valve replacement. METHODS: Patients who underwent mitral valve replacement without preservation of annular-papillary continuity for pure mitral incompetence were classified into rheumatic and myxomatous based on valvular histopathology. Echographic data measured before surgery was compared to that about 3 weeks after surgery. RESULTS: In the rheumatic group, ejection fraction decreased from 57.5 +/- 10.8 to 47.7 +/- 12.0, indexed left ventricular internal dimension in systole (mm/m2) from 24.7 +/- 6.8 to 20.7 +/- 6.2 (P = 0.0001), and left ventricular mass index (g/m2) from 205 +/- 55 to 138 +/- 54 (P = 0.0002). In the myxomatous group, ejection fraction decreased from 60.4 +/- 11.6 to 39.7 +/- 14.5 (P = 0.0001), indexed left ventricular internal dimension in systole from 24.2 +/- 5.6 to 23.1 +/- 5.5, and left ventricular mass index from 195 +/- 83 to 111 +/- 72 (P = 0.0004). Mean wall thickness index and relative wall thickness showed significant differences between the two groups postoperatively but no significant difference preoperatively. CONCLUSION: Hearts dilated due to chronic mitral incompetence respond differently after valvular replacement with total chordal excision depending on whether a rheumatic or myxomatous mitral valve is involved.

Chordae Tendineae↗
PubMedDate not supplied

Left atrial spontaneous echo contrast assessed by TEE in patients with either native mitral valve disease or mitral valve replacement.

The incidence of spontaneous echo contrast in the left atrium, the factors with which it is associated, and its clinical significance were studied in 128 patients with native mitral valve disease or mitral valve replacement. All patients underwent both transesophageal and transthoracic echocardiography. Spontaneous echo contrast was visualized in 42 patients (33%) during transesophageal and in none during transthoracic echocardiography. Patients with spontaneous echo contrast had a significantly larger left atrial diameter (6.1 [1.1] cm vs 4.9 [0.9] cm, p < 0.001) and a greater incidence of both atrial fibrillation (54% vs 4%, p < 0.001) and left atrial thrombi (60% vs 28%, p < 0.01) compared with patients without spontaneous echo contrast. Multivariant analysis confirmed that these factors were independently associated with spontaneous echo contrast (left atrial size, p < 0.001; atrial fibrillation, p < 0.001; left atrial thrombus, p < 0.01). Patients with pure mitral regurgitation did not have any spontaneous echo contrast and anticoagulation did not influence its incidence. Spontaneous echo contrast was the only factor that was associated with a previous history of systemic embolization (history of systemic emboli in 28.6% of patients with spontaneous echo contrast vs 13.9% without spontaneous echo contrast, p < 0.05). In conclusion, spontaneous echo contrast is a common finding in the left atrium of patients with mitral valve disease or mitral valve replacement and represents a marker of increased thromboembolic risk in these patients.

Adult↗
PubMed1989

A comparison of mitral valve reconstruction with mitral valve replacement: intermediate-term results.

The continued good results after mitral valve reconstruction prompted this retrospective study to compare operative and late results from our institutional experience since 1976 with 975 porcine mitral valve replacements (MVRs) (1976 to December 1987), 169 mechanical MVRs (1976 to December 1987), and 280 Carpentier-type mitral valve reconstructions (CVRs) (1980 to mid-1988). The operative mortality was 2.0% for isolated CVR, 6.6% for isolated mechanical MVR, and 8.5% for isolated porcine MVR. The overall operative mortality was 5.0% for CVR, 16.6% for mechanical MVR, and 10.6% for porcine MVR. The overall 5-year survival including hospital deaths was 76% for CVR, 72% for mechanical MVR, and 69% for porcine MVR. By multivariate analysis, the predictors of increased operative risk and of decreased survival were age, New York Heart Association functional class IV status, previous cardiac operation, and performance of concomitant cardiac surgical procedures. The type of valvular procedure was not predictive of operative risk or overall survival. The 5-year freedom from reoperation was 94.4% for nonrheumatic patients having CVR, 77.4% for rheumatic patients having CVR, 96.4% for mechanical MVR, and 96.6% for porcine MVR (p less than 0.05, rheumatic patients with CVR versus both MVR groups). The 5-year freedom from all valve-related morbidity and mortality was significantly better for valve reconstruction compared with both types of valve replacement. Thus, the operative risk and late survival obtained after mitral valve reconstruction were at least equivalent to those obtained after MVR. In addition, patients receiving mitral valve reconstruction had less valve-related combined morbidity than patients receiving valve replacement, thus making mitral valve reconstruction preferable in some patients with mitral insufficiency.

Adolescent↗
PubMed2005

CD34+ fibrocytes in normal mitral valves and myxomatous mitral valve degeneration.

We investigated a total of 15 mitral valves with myxomatous degeneration and compared these with normal mitral valves. In normal mitral valves, stromal cells located in the fibrosa and spongiosa showed small bipolar cytoplasmic processes and were found to be positive for CD34, suggesting a close relationship to CD34+ fibrocytes. In cases of myxomatous degeneration, stromal cells showed an altered morphology in that they exhibited multipolar cytoplasmic processes, appeared to be hyperplastic, and were increased in number. This study is the first to report on CD34+ fibrocytes making up the majority of mitral valve stromal cells. Major factors in the development of myxomatous valve degeneration are MMP-9, as well as collagen I and III, which have been reported to be secreted by CD34+ fibrocytes. Therefore, it is likely that CD34+ fibrocytes are involved in the pathogenesis of myxomatous mitral valve degeneration.

Adult↗
PubMed1986

[Pressure gradient across the mitral valve in mitral stenosis estimated by high pulse repetition frequency Doppler method].

High pulse repetition frequency (HPRF) Doppler and continuous wave (CW) Doppler methods were used to estimate the pressure gradient across the mitral valve. Twenty-two cases of mitral stenosis and five cases of ischemic heart disease were studied. Both the HPRF and CW Doppler studies were conducted during catheterization in all cases. In the Doppler study, pressure gradient was calculated using the simplified Bernoulli's formula. The HPRF device used was a type SSD-730 produced by Aloka Co. It had a reference frequency of 2 MHz. Its minimum pulse repetition frequency was 4.2 KHz; its maximum, 19.2 KHz. Among the 27 cases, the maximum flow velocity measured by the HPRF method at the level of the mitral valve orifice was compared with that by the CW method. As the velocity increased, the discrepancy of measured values between the two methods increased, but it was within 0.1 m/sec. Therefore, there was a good correlation between the HPRF and CW methods (r = 0.98). The pressure gradient between time delay-corrected pulmonary artery wedge pressure and left ventricular pressure was compared with that obtained by the HPRF method. Contrary to our expectations, the correlation coefficient between the two was not so high, and the pressure gradients calculated by the HPRF method tended to be underestimated. For eight patients in whom the left atrial pressure could be recorded, the pressure gradient between the left atrium and left ventricle was compared with that obtained by the HPRF method. There was underestimation, and a good correlation coefficient was obtained. When using pulmonary artery wedge pressure as a substitute for left atrial pressure, one must realize that the time delay varies in every case and that the pressure pulse itself is not the same. When the pressure gradient between the left atrium and left ventricle is used, a good correlation coefficient can be obtained. Therefore, the flow velocity obtained by the HPRF method will reflect the true pressure gradient across the mitral valve. The HPRF method proved to have a potential equal to that of the CW method for estimating mitral valve flow velocity in mitral stenosis, and it may be used as a helpful diagnostic tool.

Adult↗
PubMed1990

Preservation of all chordae tendineae and papillary muscle during mitral valve replacement with a tilting disc valve.

Mitral valve replacement was performed in 21 patients using a surgical technique that preserves the entire papillary muscle and chordal apparatus. With this technique, the anterior mitral leaflet is split from the center of the free edge toward the annulus. Bilateral incisions are made from the proximal end of this split to the two mitral commissures, detaching the anterior leaflet from the annulus. These two halves of the leaflet, with all chordae intact (corresponding to the anterolateral and posteromedial papillary muscles), are judiciously trimmed to remove areas of leaflet untethered by chordae tendineae and (when necessary) fibrous thickening; then swung posteriorly and sutured to the posterior mitral annulus using mattress sutures with pledgets. This surgical technique is expected to favor the preservation of left ventricular function and avoid occurrence of irreversible left ventricular dilation/dysfunction, and has been used successfully for calcific and degenerative etiologies, using both tilting disc valves and porcine bioprostheses. It is especially useful in the implantation of tilting disc and bileaflet mechanical prostheses because anterior subvalvular chordae tissue may interfere with the disc excursion and relocated to the posterior leaflet annulus.

Adolescent↗
PubMed1996

[Jaundice, anemia and mitral valve insufficiency following mitral valve reconstruction].

A 33-year-old man was admitted because of jaundice. Five months ago a reconstruction of the mitral valve was performed because of mitral valve insufficiency. There was a history of heroin dependence until three years ago. Laboratory tests showed normochromic normocytic anemia, increased nonconjugated serum bilirubin, decreased plasma haptoglobin, hemoglobinuria and hemosiderinuria. The peripheral blood smear contained numerous fragmented red cells, and the bone marrow showed a markedly increased erythropoiesis and absent iron stores. The clinical examination as well as echocardiography revealed severe mitral valve insufficiency; therefore, a mitral valve replacement was performed. Introperatively the mitral valve showed ruptured chordae tendineae of the posterior leaflet and a leaking stitch of the anterior leaflet. We diagnosed a macrovascular hemolytic anemia with subsequent mechanical injury and fragmentation of red cells on a dysfunctioning mitral valve.

Adult↗
PubMed2006

Transesophageal echocardiography during mitral valve repair underestimates mitral valve area by pressure half-time calculation.

BACKGROUND: Mitral valve repair (MVRr) has become the mainstay of surgical treatment for mitral valvular regurgitation. Evaluation of MVRr by intraoperative transesophageal echocardiography (IOE) has been routinely employed to guide the operation. While the main objective of IOE is to assess for residual mitral regurgitation, it is also important to exclude significant mitral stenosis. Utilisation of pressure half-time (PHT) to estimate mitral valve area (MVA) has been shown to be reliable in normal clinical situations. However, in MVRr, the accuracy of MVA calculation by PHT needs to be ascertained. METHODS AND RESULTS: Data from IOE and post-MVRr transthoracic echocardiography (TTE) from the year 1998 to 2002 were analysed and when required, offline PHT measurements were made. The mean time interval between the two echocardiographic examinations was 10.6 (1 to 56) weeks. In our 36 cases, the IOE MVA was found to be 2.1+/-0.5 cm2, with the corresponding TTE MVA to be 2.7+/-1.0 cm2. MVA by PHT with IOE underestimated TTE findings by 0.6+/-0.9 cm2 (95% CI: -0.85 to -0.24, P=0.001). In 6 patients, the IOE MVA was moderately reduced. Subsequent TTE in these patients showed that the MVA was adequate and was significantly underestimated by IOE in 5 of these patients. In all these cases, IOE underestimated MVA by a margin, which may result in a need to revise the repair. CONCLUSION: We find that IOE immediately after MVRr tends to underestimate MVA by PHT calculation. The underestimation by IOE may have clinical importance in cases when MVA by IOE is moderately reduced. Therefore, pressure half-time measurement should not be used to assess mitral valve areas during mitral valve repair.

Adult↗
PubMed1995

[Reconstructive techniques for complete mitral valve repair for mitral valve insufficiency].

Reconstruction of mitral valve, which was performed completely, provides better postoperative ventricular function and less morbidity compared with prosthetic replacement. In this article, reconstructive techniques as a radical mitral valve repair are demonstrated from a viewpoint of long-term performance. Since January, pure mitral regurgitation due to prolapse were repaired with freedom from reoperation of 89% at 5 years and 81% at 10 years. The incidence rate of thromboembolism was 0.8% and no endocarditis or hemorrhagic complications were noted. The technique of leaflet resection-suture is most useful and reliable for the mural leaflet prolapse, and replacement of chordae tendineae is appropriate for the diffuse anterior leaflet prolapse. Prosthetic ring implantation increase leaflet coaptation, reinforce sutures and prevent further annular dilatation.

Adolescent↗
PubMed2001

Very long-term survival and durability of mitral valve repair for mitral valve prolapse.

BACKGROUND: Mitral regurgitation (MR) due to mitral valve prolapse (MVP) is often treatable by surgical repair. However, the very long-term (>10-year) durability of repair in both anterior leaflet prolapse (AL-MVP) and posterior leaflet prolapse (PL-MVP) is unknown. METHODS AND RESULTS: In 917 patients (aged 65+/-13 years, 68% male), surgical correction of severe isolated MR due to MVP (679 repairs and 238 replacements [MVRs]) was performed between 1980 and 1995. Survival after repair was better than survival after MVR for both PL-MVP (at 15 years, 41+/-5% versus 31+/-6%, respectively; P=0.0003) and AL-MVP (at 14 years, 42+/-8% versus 31+/-5%, respectively; P=0.003). In multivariate analysis adjusting for predictors of survival, repair was independently associated with lower mortality in PL-MVP (adjusted risk ratio [RR] 0.61, 95% CI 0.44 to 0.85; P=0.0034) and in AL-MVP (adjusted RR 0.67, 95% CI 0.47 to 0.96; P=0.028). The reoperation rate was not different after repair or MVR overall (at 19 years, 20+/-5% for repair versus 23+/-5% for MVR; P=0.4) or separately in PL-MVP (P=0.3) or AL-MVP (P=0.3). However, the reoperation rate was higher after repair of AL-MVP than after repair of PL-MVP (at 15 years, 28+/-7% versus 11+/-3%, respectively; P=0.0006). From the 1980s to the 1990s, the RR of reoperation after repair of AL-MVP versus PL-MVP did not change (RR 2.5 versus 2.7, respectively; P=0.58), but the absolute rate of reoperation decreased similarly in PL-MVP and AL-MVP (at 10 years, from 10+/-3% to 5+/-2% and from 24+/-6% to 10+/-2%, respectively; P=0.04). CONCLUSIONS: In severe MR due to MVP, mitral valve repair compared with MVR provides improved very long-term survival after surgery for both AL-MVP and PL-MVP. Reoperation is similarly required after repair or replacement but is more frequent after repair of AL-MVP. Recent improvement in long-term durability of repair suggests that it should be the preferred mode of surgical correction of MVP whether it affects anterior or posterior leaflets and is an additional incentive for early surgery of severe MR due to MVP.

Aged↗
PubMed2000

Ruptured mitral valve aneurysm in a patient with quadricuspid aortic valve.

Mitral aneurysm is commonly associated with infectious endocarditis of the aortic valve. In rare instances, it is associated with other underlying inflammatory or metabolic disorders. A 62-year-old man with mitral valve insufficiency with moderate aortic valve insufficiency underwent operation. Operative findings were the ruptured aneurysm of the mitral valve in association with the calcified quadricuspid aortic valve. There was no evidence of infection in the mitral valve and the aortic valve. The mitral valve was repaired, the aortic valve replaced, and Cox Maze procedure added. A rare combination of mitral and aortic valve lesions without endocarditis suggested that mechanical stress alone may induce mitral valve aneurysm.

Aneurysm, Ruptured↗
PubMed2005

Congenital double-orifice mitral valve with mitral regurgitation due to flail leaflet in an elderly patient.

We report here on a case of double-orifice mitral valve with mitral regurgitation in a 75-year-old female who had complaints of mild dyspnea. Transthoracic and transesophageal echocardiography showed two orifices that were supplied by their own chordae from a different papillary muscle. Color Doppler echocardiography revealed moderate to severe mitral regurgitation due to the flail posterior leaflet of the anterolateral orifice. Except for the persistent left superior vena cava, no other congenital anomaly was demonstrated. The patient became asymptomatic with the administration of angiotensin-converting enzyme inhibitor and diuretics, and she has been scheduled for long term follow-up.

Aged↗
PubMed1999

Mitral valve homograft for mitral valve replacement in acute bacterial endocarditis.

Homograft use for aortic valve replacement (AVR) in aortic valve acute bacterial endocarditis (ABE) has gained in popularity, due mainly to the relative resistance of homografts to infection. Recent success with mitral valve homograft use led us to apply homograft mitral valve replacement (MVR) in a patient with severe ABE that was not amenable to valve repair. Following surgery, the patient improved rapidly with normalization of infection parameters and chest radiography, and was discharged home on postoperative day 11. Follow up echocardiography showed good function of the homograft mitral valve with no regurgitation. After four months, the patient had normal valve function, with no evidence of infection. In conclusion, MVR with a mitral valve homograft in the setting of ABE was satisfactory, though patient follow up was relatively short (four months).

Echocardiography, Transesophageal↗
PubMed1981

Mitral valve prolapse syndrome associated with congenital bicuspid aortic valve.

Mitral valve prolapse (MVP) associated with congenital bicuspid aortic valve (CBAV) is an uncommon finding. In a study of 257 black patients with MVP, the author identified eight patients with associated CBAV. This paper discusses the association of the two lesions in relation to etiologic and surgical implications.

Adult↗
PubMed2002

The long-term outcome of mitral valve repair for mitral valve prolapse.

The rationale of early surgery for severe chronic mitral regurgitation (MR) due to mitral valve prolapse (MVP) has been developed over the past decade on the basis of the understanding of the natural history of this disease and the predictors of outcomes after surgical correction of MR. The important decrease in operative mortality associated with the advancements in myocardial preservation, and more importantly the improved reparability of the myxomatous mitral valve, were an additional incentive to develop the concept of early surgery. Previous studies showed that mitral valve repair offers a survival advantage at short- and 10-year follow-up, and therefore suggested that it should be the treatment of choice for severe MR due to MVP. Moreover, very recent data provided new insight on the very long-term follow up, ie, beyond the usual first 10 years in which the initial survival benefit of repair may be negated by a late deterioration.

Humans↗