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PubMed1994

Arrhythmias in mitral valve prolapse: relation to anterior mitral leaflet thickening, clinical variables, and color Doppler echocardiographic parameters.

Atrial and ventricular arrhythmias have been reported with variable incidence in symptomatic patients with mitral valve prolapse (MVP). The role of clinical and echocardiographic parameters as predictors for arrhythmias still needs to be clarified. One hundred nineteen consecutive patients (56 women and 63 men, mean age 40 +/- 17 years) with echocardiographically diagnosed MVP were examined. A complete echocardiographic study (M-mode, two-dimensional, and Doppler) and 24-hour electrocardiographic monitoring were performed in all patients. Complex atrial arrhythmias (CAAs) included atrial couplets, atrial tachycardia, and paroxysmal or sustained atrial flutter or fibrillation. Complex ventricular arrhythmias (CVAs) included multiform ventricular premature contractions (VPCs), VPC couplets, and runs of three or more sequential VPCs (salvos of ventricular tachycardia). The relation between complex arrhythmias and clinical parameters (age and gender) and echocardiographic parameters (left atrial and left ventricular dimensions, anterior mitral leaflet thickness [AMLT], and presence and severity of mitral regurgitation) was evaluated by multiple logistic regression analysis. CAA were present in 14% of patients and CVA in 30%. According to multiple logistic modeling, CAA correlated separately in the univariate analysis with age, presence of MR, and left ventricular and left atrial diameters; age was the only independent predictor (p < 0.001). CVA, in the univariate analysis, correlated with age, female gender, left ventricular end-diastolic diameter, and AMLT; only female gender and AMLT were independent predictors in the multivariate analysis (p < 0.01). The incidence of mitral regurgitation (59%) was higher than expected in a general population of MVP patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMedDate not supplied

The medicalization of normal variants: the case of mitral valve prolapse.

Mild mitral valve prolapse, hypoglycemia, irritable colon, and premenstrual syndrome are examples of anatomico-physiologic phenomena that largely overlap with normal. Such "overlap syndromes" become labeled disease entities by the medical community through a process called medicalization. This report uses mitral valve prolapse (MVP) to exemplify the effects of medicalization on patients, physicians, and society. Ascertainment bias and insufficient controlled clinical studies have led to the description of a clinical entity replete with false associations (e.g., mitral valve prolapse syndrome) and overly pessimistic prognostication (e.g., risk of sudden death or endocarditis), leading to clinical overreaction, overtreatment, and unnecessary induction of disability. Though some physical complications may be prevented by recognizing severe MVP, there is substantial risk of iatrogenic harm by attributing complex symptoms and illness behavior to mild MVP, which is probably a normal variant. A three-dimensional analysis of illness experience is presented that may be of use in conceptualizing the clinical approach to overlap syndromes such as mild MVP. Conservative criteria for the diagnosis of significant MVP have been developed at the National Institutes of Health. Treatment of patients with mild MVP must emphasize that it is a normal variant without serious consequences. Because the risks of overmedicalization are so substantial, the impact of diagnostic labels on individual patients and society must be analyzed continually.

Adult↗
PubMed1995

Long-term results of mitral valve repair for non-rheumatic mitral regurgitation.

The durability of mitral valve repaired with reconstructive techniques is variable. If the durability continues to be good, mitral valve repair may be the procedure of choice in many patients with mitral regurgitation. Between December 1970 and June 1993, 54 patients had mitral valve repair for non-rheumatic mitral regurgitation. There were 38 men and 16 women with a mean age of 46.8 (range 19-68) years. The pathology which required surgical treatment was torn chordae in 38 patients, elongation of the chordae in five, valve prolapse without elongation or rupture of the chordae in six, infective endocarditis in three, and annular dilatation in two. Forty-four patients had triangular or quadrangular resection of the mitral leaflet, and seven had annuloplasty alone. Choral reconstruction was performed on three patients. There were no operative deaths. Five patients (9%) died late after operation. The actuarial survival rate and the valve-related death-free rate at 10 years were 83.9% and 90.0%, respectively. Seven patients (13%) required reoperation. Freedom from reoperation at 10 years was 84.5%. Improper evaluation of residual regurgitation during operation and suture dehiscence were the principal causes of reoperation. It was concluded that mitral valve repair for non-rheumatic mitral regurgitation showed low operative mortality and stable long-term results. It is suggested that intraoperative transoesophageal colour Doppler echocardiography provides accurate assessment of mitral valve competence and may be helpful in reducing the need for reoperation.

Adult↗
PubMed2001

Aortic and mitral valve replacement with retrograde perfusion in the beating heart.

OBJECTIVE: To estimate the value of aortic valves and combined mitral valve replacement with retrograde perfusion in beating hearts. METHODS: Continuous retrograde coronary sinus perfusion with beating hearts was used in 83 patients undergoing aortic valve or aortic valve combined with mitral valve replacement, without application of cardioplegia. After aortic valve replacement, the retrograde perfusion was changed to antegrade perfusion for mitral valve replacement or correction of the other deformities (group A). Cold blood cardioplegia solution (15 degrees C) was infused at intervals in 20 cases (group B). The following parameters were tested: lactate, ET, CTn-T and MDA in blood; myocardial ultra-structure; and cardiac rhythm and cardiac output (CO). RESULTS: All biochemical values increased after cardiopulmonary bypass (P < 0.05-0.01). Empty and beating heart sinus rhythm was maintained in group A. Myocardial ultrastructure did not change significantly. The pump was stopped smoothly as the surgical procedure finished. No postoperative low cardiac output syndrome or arrhythmia was observed. Eight-one patients recovered smoothly, two died from renal failure or infective shock. When the pump stopped, all patients in group B were supported by 5-10 micrograms.kg-1.min-1 dopamine. Transient pacing was used in 9 patients. One patient died from low cardiac output syndrome. CONCLUSION: This method is a good myocardial protection which simulates physiologic status. It is applicable to aortic valve and combined mitral valve replacement of patients with large heart or heart failure and long time aortic cross-clamping. Ideal clinical effect can be achieved.

Adolescent↗
PubMed2006

Posterior leaflet preservation in mitral valve prolapse: a new approach to mitral repair.

The most common repair technique for P2 prolapse is quadrangular resection of the posterior leaflet associated with a plication of the mitral annulus or with a sliding plasty. Although effective, these techniques do not respect the anatomy of the mitral valve, especially the physiological role of the posterior leaflet. Herein is described another technique which does not include P2 removal, thus preserving the posterior leaflet mobility. This technique represents a new approach to mitral valve repair that respects the motion of the two leaflets, allowing a more physiological opening of the mitral valve.

Aged↗
PubMed2000

Decreasing mortality for aortic and mitral valve surgery in Northern New England. Northern New England Cardiovascular Disease Study Group.

BACKGROUND: Although numerous reports have documented declining mortality rates associated with coronary artery bypass surgery in recent years, it is unknown whether similar trends have occurred with valve surgery during this time. METHODS: We conducted a regional, prospective study to assess trends in patient casemix and in-hospital mortality rates over time with aortic valve replacement (AVR), mitral valve replacement (MVR), and mitral valve repair. Data were collected from all patients undergoing AVR (n = 2,596), MVR (n = 759), or mitral valve repair (n = 522) in Northern New England between January 1992 and December 1997. Logistic regression was used to identify significant predictors of in-hospital mortality and to calculate risk-adjusted mortality rates. RESULTS: For AVR, the trend in patient casemix was toward increased risk with increases in patient age and in the proportion of patients with: body surface area less than 1.7, diabetes, coronary artery disease, and prior valve surgery. A decrease was noted in the proportion of patients undergoing additional surgical procedures. For MVR, patient risk improved over the time period with fewer female patients and fewer patients with coronary artery disease. For mitral valve repair patient risk increased over the time period with increases in the proportion of patients with coronary artery disease, diabetes, and whose surgical priority was classified as urgent. In addition, there was a borderline significant increase in the proportion of mitral valve repair patients in New York Heart Association class IV preoperatively. Risk-adjusted mortality decreased 44% from 9.3% in 1992 through 1993 to 5.3% in 1996 through 1997 for patients undergoing AVR (p = 0.01) and decreased 53% from 13.6% in 1992 through 1993 to 8.2% in 1996 through 1997 for patients undergoing MVR (p = 0.01). We observed a statistically insignificant increase in risk-adjusted mortality over the time period for patients undergoing mitral valve repair (from 3.6% in 1992 through 1993 to 5.0% in 1996 through 1997; p = 0.34). CONCLUSIONS: Significant improvement in mortality rates with valve replacement was observed in northern New England during this time period. This improvement persisted following adjustment for changes in patient casemix over this time. These trends mirror improvements in mortality with other cardiac surgical interventions that have been observed in recent years in our region and nationally.

Aged↗
PubMed1993

[Randomized study comparing mitral valve replacement with and without preservation of mitral ring chordae tendinae papillary continuity].

PURPOSE: To demonstrate the importance of the preservation of mitral annulus-chordae tendineae-papillary muscles continuity in mitral valve replacement. METHODS: We studied 21 patients who were submitted to mitral valve replacement, divided in two randomized groups: group 1, 12 cases who undergone mitral valve replacement, with preservation of the posterior leaflet and correspondent chordae tendineae; and group 2-9 cases who undergone conventional mitral valve replacement, excising the mitral valve apparatus. The left ventricular function was studied both, in the pre and post operative period, by echocardiography, cardiac catheterization, and radioisotopic study. The statistical analysis was done by the Wilcoxson's test. RESULTS: There were no early post operative deaths. Analyzing the results of the ejection fraction by the radioisotopic study we found a significant difference (p = 0.03) between the percentual decrease of the two groups. The results of the fractional shortening were higher in group 1 than in group 2, however not significant. The left ventricular diastolic diameters average was lower in group 1 than in group 2, so as the left atrium diameter. We found a decrease in left ventricular end-diastolic pressure in group 1, however there was an increase in group 2, by the cardiac catheterization. There was a proportional increase in group 1 both in lung artery and lung capillary pressures. There was a significant difference (p = 0.05) between the average values of right ventricular diastolic pressure. CONCLUSION: There is better preservation of left ventricular function in group 1.

Adult↗
PubMed2006

Unusually large left atrial myxoma causing mitral valve occlusion and hiding a severe mitral regurgitation: a case report.

We report a case of a 68-year-old woman with a large left atrial myxoma occluding the mitral valve. The tumor was diagnosed by preoperative echocardiogram. During the operation and after the myxoma resection, a severe mitral valve regurgitation, which was not observed during the preoperative echocardiogram, was noticed. Mitral valve defect was corrected by an annuloplasty ring, and the patient had an uneventful recovery. Careful evaluation of the mitral valve during a myxoma resection operation is recommended.

Aged↗
PubMed2006

Mitral valve surgery for dilated cardiomyopathy with mitral regurgitation.

Outcomes of surgery for non-ischemic non-valvular dilated cardiomyopathy with associated mitral regurgitation were assessed in 8 consecutive patients who underwent 9 mitral valve operations between 2001 and 2004. Mitral valve replacement was performed when the coaptation depth exceeded 10 mm. Two patients initially underwent mitral valvuloplasty, and 6 underwent valve replacement. One patient had valve replacement soon after valvuloplasty. Transthoracic echocardiography was performed immediately before surgery, before discharge, and during follow-up. Transesophageal echocardiography was carried out intraoperatively to assess valvular and ventricular function. Postoperative mean functional class was significantly better than the preoperative value (2.4 +/- 0.7 vs. 3.3 +/- 0.7), and the improvement was sustained during follow-up (2.0 +/- 0.7). The ejection fraction and left ventricular end-diastolic dimension did not improve. One patient died without leaving hospital and two died during follow-up. The 2- and 4-year survival rates were 75.0% and 37.5%. Mitral valve surgery improved functional class without obvious changes in ejection fraction or left ventricular end-diastolic dimension.

Adult↗
PubMed2004

TGF-beta-dependent pathogenesis of mitral valve prolapse in a mouse model of Marfan syndrome.

Mitral valve prolapse (MVP) is a common human phenotype, yet little is known about the pathogenesis of this condition. MVP can occur in the context of genetic syndromes, including Marfan syndrome (MFS), an autosomal-dominant connective tissue disorder caused by mutations in fibrillin-1. Fibrillin-1 contributes to the regulated activation of the cytokine TGF-beta, and enhanced signaling is a consequence of fibrillin-1 deficiency. We thus hypothesized that increased TGF-beta signaling may contribute to the multisystem pathogenesis of MFS, including the development of myxomatous changes of the atrioventricular valves. Mitral valves from fibrillin-1-deficient mice exhibited postnatally acquired alterations in architecture that correlated both temporally and spatially with increased cell proliferation, decreased apoptosis, and excess TGF-beta activation and signaling. In addition, TGF-beta antagonism in vivo rescued the valve phenotype, suggesting a cause and effect relationship. Expression analyses identified increased expression of numerous TGF-beta-related genes that regulate cell proliferation and survival and plausibly contribute to myxomatous valve disease. These studies validate a novel, genetically engineered murine model of myxomatous changes of the mitral valve and provide critical insight into the pathogenetic mechanism of such changes in MFS and perhaps more common nonsyndromic variants of mitral valve disease.

Animals↗
PubMed1992

Clinical, echocardiographic, and Doppler imaging characteristics of mitral valve stenosis in two dogs.

Mitral stenosis was diagnosed noninvasively by echocardiography and Doppler imaging in 2 Bull Terriers. Two-dimensional echocardiography revealed severe atrial and moderate left ventricular dilatation; severely reduced mitral valve opening excursion; doming of the cranial mitral valve leaflet into the left ventricle during diastole; thickened, nodular cranial mitral valve leaflets; and reduced mitral valve orifice. M-mode echocardiographic findings additionally indicated greatly diminished mitral valve E to F slope and abnormal caudal mitral valve leaflet motion. Color flow Doppler imaging revealed bright bursts of color with aliasing originating from the stenotic mitral valve orifice, extending into the left atrium during systole, and into the left atrium during diastole. Spectral Doppler recordings revealed transvalvular mitral valve gradients and prolonged pressure half-times. Necropsy performed on 1 dog revealed extremely thickened, nodular, and stiff mitral valves with short, thickened, and fused chordae tendineae. The diagnosis of mitral valve stenosis was easily facilitated with diagnostic ultrasonography.

Animals↗
PubMed1999

Prevalence and clinical outcome of mitral-valve prolapse.

BACKGROUND: Mitral-valve prolapse has been described as a common disease with frequent complications. To determine the prevalence of mitral-valve prolapse in the general population, as diagnosed with the use of current two-dimensional echocardiographic criteria, we examined the echocardiograms of 1845 women and 1646 men (mean [+/-SD] age, 54.7+/-10.0 years) who participated in the fifth examination of the offspring cohort of the Framingham Heart Study. METHODS: Classic mitral-valve prolapse was defined as superior displacement of the mitral leaflets of more than 2 mm during systole and as a maximal leaflet thickness of at least 5 mm during diastasis, and nonclassic prolapse was defined as displacement of more than 2 mm, with a maximal thickness of less than 5 mm. RESULTS: A total of 84 subjects (2.4 percent) had mitral-valve prolapse: 47 (1.3 percent) had classic prolapse, and 37 (1.1 percent) had nonclassic prolapse. Their age and sex distributions were similar to those of the subjects without prolapse. None of the subjects with prolapse had a history of heart failure, one (1.2 percent) had atrial fibrillation, one (1.2 percent) had cerebrovascular disease, and three (3.6 percent) had syncope, as compared with unadjusted prevalences of these findings in the subjects without prolapse of 0.7, 1.7, 1.5, and 3.0 percent, respectively. The frequencies of chest pain, dyspnea, and electrocardiographic abnormalities were similar among subjects with prolapse and those without prolapse. The subjects with prolapse were leaner (P<0.001) and had a greater degree of mitral regurgitation than those without prolapse, but on average the regurgitation was classified as trace or mild. CONCLUSIONS: In a community based sample of the population, the prevalence of mitral-valve prolapse was lower than previously reported. The prevalence of adverse sequelae commonly associated with mitral-valve prolapse in studies of patients referred for that diagnosis was also low.

Adult↗
PubMed1992

A case of accessory mitral valve leaflet associated with solitary mitral cleft.

Accessory mitral valve leaflet is a rare congenital anomaly. More than half of the cases show other congenital cardiac defects and almost all of the cases show subaortic obstruction. We report a case of an accessory mitral valve tissue without outflow obstruction associated with mitral cleft of the posterior mitral leaflet. To our knowledge, this is the first reported case of the combination of these two congenital anomalies.

Adult↗
PubMed1997

Reoperation for failure of mitral valve repair.

BACKGROUND AND OBJECTIVE: Mitral valve repair is the procedure of choice to correct mitral regurgitation of all types. Up to 10% of patients who undergo mitral valvuloplasty require late reoperation for recurrent mitral valve dysfunction. To determine the causes of failed mitral valve repair, we examined the surgical pathology of patients who underwent reoperation for failed mitral valve repair. PATIENTS AND RESULTS: From 1986 to 1994, 81 patients had 86 reoperations for recurrent mitral regurgitation after mitral valve repair. Mean age was 59.2 +/- 1.4 years; 55 were men. Primary valve disease was degenerative in 48 patients (59%), rheumatic in 16 (20%), ischemic in 13 (16%), endocarditic in 3 (4%), and congenital in 1 (1%). Mean time interval between initial mitral valve repair and reoperation was 15.6 +/- 2.5 months. Causes of repair failure were procedure-related (50 cases, 58%), valve-related (33 cases, 38%), or unknown (3 cases, 3%). Procedure-related valve failure was caused by suture dehiscence (21 cases), rupture of previously shortened chordae (19 cases), or incomplete initial correction (10 cases). Valve-related repair failure was caused by progressive primary valve disease (27 cases), endocarditis (5 cases), or extensive leaflet retraction (1 case). Repair failure was procedure-related in 70% of patients with degenerative valvular disease versus only 13% of patients with rheumatic valvular disease (p = 0.0001). At reoperation, mitral valve replacement was performed in 64 patients (79%) and repeat mitral valve repair in 17 (21%). CONCLUSION: We conclude that (1) most mitral valve repair failures are procedure-related in degenerative disease and valve-related in rheumatic disease; (2) rupture of previously shortened chordae is a common cause of late failure in patients with degenerative mitral valve disease; and (3) repeat mitral valve repair results in successful treatment for a minority of patients.

Adolescent↗