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PubMed1978

Systemic and pulmonary effects of nitroprusside during mitral valve replacement in patients with mitral regurgitation.

The effects of sodium nitroprusside on the systemic and pulmonary circulation were assessed in 17 patients with severe mitral regurgitation (MR) during mitral valve replacement. In nine patients, MR was related to rheumatic heart disease, in six resulted from acute myocardial infarction, and in two was due to subacute bacterial endocarditis. Nitroprusside was administered intraoperatively at an infusion rate of 10 to 65 mcg/min. During vasodilation therapy, forward stroke volume increased from 34 +/- 2.8 to 46 +/- 4.8 ml, while left ventricular filling pressure decreased from 28.7 +/- 1.9 to 20.6 < or = 1.8 mm Hg. There was a significant decrease in systemic vascular resistance (from 2379 +/- 204 to 1646 +/- 161 dynes.sec.cm-5) and mean arterial pressure (from 89.8 +/- 4 to 78.1 +/- 5 mm Hg). Similarly, a significant decrease was observed in both pulmonary vascular resistance (from 414 +/- 45 to 208 +/- 31 dynes.sec.cm-5) and mean pulmonary arterial pressure (from 42.5 +/- 2.5 to 29.7 +/- 2.5 mm Hg) with nitroprusside. In all patients there was a decrease in the magnitude of the peak V wave of the pulmonary capillary wedge pressure (from 45.2 +/- 3.9 to 26.1 +/- 3.1 mm Hg). These findings suggest that judicious intraoperative administration of nitroprusside improves right and left ventricular function in patients with MR undergoing mitral valve replacement, by increasing forward stroke volume while decreasing ventricular filling pressures and vascular resistance (preload and afterload).

Blood Pressure↗
PubMed2002

[Surgery for mitral valve insufficiency].

BACKGROUND: Ischemic mitral regurgitation (IMR) is a severe condition which may be best treated by surgery, notwithstanding a relatively high mortality rate. OBJECTIVES: To evaluate the results of mitral valve replacement or repair in patients with IMR. PATIENTS AND METHODS: Retrospective review of the clinical records in 29 patients with IMR who were surgically treated from 1990 to 1999. They represent 8% of surgical procedures on the mitral valve. RESULTS: Mean age was 67 +/- 9 years. Surgery was performed urgently in 19 patients (66.5%). NYHA functional class was 3.4 +/- 0.8. The mechanism of IMR was annular dilatation and spreading of papillary muscles in 18 patients, papillary muscle rupture in 9 and fibrosis in 2. Mitral valve replacement was performed in 14 patients and mitral valve repair in 15. Twenty four patients (83%) had concomitant myocardial revascularization. Overall surgical mortality was 24%; 26% for mitral replacement and 13% for mitral valve repair (p = 0.215). On follow up of 26 +/- 33 months, one year survival was 76 +/- 0.8% and 5 years survival was 59 +/- 12%. Excluding in hospital mortality, survival was 100% at one year and 78 +/- 14% at 5 years. Functional class improved in all survivors, to 1.4 +/- 0.5. Late echocardiographic evaluation of patients with mitral valve repair showed absence of mitral regurgitation in 58%, 1+ MR in 17% and 2+ MR in 25%. CONCLUSION: In spite of a high perioperative mortality, surgery for IMR is a valuable procedure for patients with an otherwise highly lethal disease.

Aged↗
PubMed2005

Percutaneous mitral valve repair for chronic ischemic mitral regurgitation: a real-time three-dimensional echocardiographic study in an ovine model.

BACKGROUND: Although surgical annuloplasty is the standard repair for ischemic mitral regurgitation (IMR), its application is limited by high morbidity and mortality. Using 2D and real-time 3D echocardiography in an ovine model of chronic IMR, we evaluated the geometric impact and short-term efficacy of a percutaneous transvenous catheter-based approach for mitral valve (MV) repair using a novel annuloplasty device placed in the coronary sinus. METHODS AND RESULTS: Six sheep developed IMR 8 weeks after induced posterior myocardial infarction. An annuloplasty device optimized to reduce anterior-posterior (A-P) mitral annular dimension and MR was placed percutaneously in the coronary sinus. Mitral annular A-P and commissure-commissure dimensions and MV tenting area (MVTa) in 3 parallel A-P planes (medial, central, and lateral) were assessed by real-time 3D echocardiography with 3D software. The annuloplasty device reduced MR jet area from 5.4+/-2.6 to 1.3+/-0.9 cm2 (P<0.01), mitral annular A-P dimension in both systole and diastole (24.3+/-2.5 to 19.7+/-2.4 mm; P<0.03; 31.0+/-3.9 to 24.7+/-2.1 mm; P<0.001), and MVTa at mid systole in all 3 planes (153+/-46 to 93+/-24 mm2, P<0.01; 140+/-47 to 88+/-23 mm2, P<0.03; and 103+/-23 to 87+/-26 mm2, P<0.03). CONCLUSIONS: Percutaneous coronary sinus-based mitral annuloplasty reduces chronic IMR by reducing mitral annular A-P diameter and MVTa. This suggests the potential clinical application of a new nonsurgical therapeutic approach in patients with IMR.

Animals↗
PubMed1992

Two-dimensional and Doppler echocardiographic determinants of the natural history of mitral valve narrowing in patients with rheumatic mitral stenosis: implications for follow-up.

Fifty patients with rheumatic mitral stenosis were studied with serial two-dimensional and Doppler echocardiography to determine the natural history of changes in mitral valve area and its relation to transmitral gradients and mitral valve morphology. Over the 39-month observation period (range 7 to 74 months) the decline in valve area was 0.09 +/- 0.21 cm2/year. In addition, there were significant increases in total echocardiographic score (p = 0.0001), severity of mitral anulus calcification (p = 0.05) and severity of mitral regurgitation (p = 0.0007). Patients with an echocardiographic score greater than or equal to 8 had a more progressive course. In addition, patients with a more progressive course (decline in valve area greater than or equal to 0.1 cm2/year) had a significantly greater initial mean gradient (p = 0.01), peak gradient (p = 0.007) and total echocardiographic score (p = 0.0008). Initial valve area did not correlate with the rate of stenosis progression. Of 22 patients with an echocardiographic score less than 8 and a peak mitral gradient less than 10 mm Hg, only 1 patient (5%) had a more progressive course, compared with 80% of those with a total echocardiographic score greater than or equal to 8 and a gradient greater than or equal to 10 mm Hg. The rate of mitral valve narrowing in individual patients with rheumatic mitral stenosis is variable. Patients whose valve disease progresses rapidly are those with a greater mitral valve echocardiographic score and higher peak and mean transmitral gradients.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed2001

Effect of cardiac output on mitral valve area in patients with mitral stenosis: validation and pitfalls of the pressure half-time method.

BACKGROUND AND AIM OF THE STUDY: The non-invasive evaluation of mitral valve area is often used in the assessment of patients with mitral stenosis. The pressure half-time method is commonly used to calculate valve area, but is inaccurate in many clinical scenarios. We sought to quantify the effects of changing cardiac output on the accuracy of mitral valve area determination. METHODS: Thirteen patients with mitral stenosis underwent routine stress echocardiography with resting and peak exercise results compared. A previously described and clinically validated mathematical model of the cardiovascular system was used to validate the clinical results. Seven different loading conditions for each of four different stenotic valve areas were modeled. RESULTS: In patients, with increasing cardiac output, pressure half-time decreased (-30.6+/-35.3 ms/l/min) and calculated valve area increased by 0.25+/-0.30 cm2/l/min. By continuity, it appeared that approximately half of this increase was due to actual valve orifice stretching, the remainder reflecting fundamental changes in the relationship between half-time and valve area. Mathematical modeling resulted in similar changes in pressure half-time and calculated valve area (0.06 to 0.12 cm2/l/min, p = 0.20 versus clinical results). CONCLUSION: Changes in cardiac output result in predictable changes in pressure half-time, and should be considered when performing serial examinations in patients with mitral stenosis.

Adult↗
PubMed2003

Detection of mechanisms of immediate failure by transesophageal echocardiography in quadrangular resection mitral valve repair technique for severe mitral regurgitation.

Residual mitral regurgitation (MR) after repair is a risk factor for late reoperation. The use of intraoperative transesophageal echocardiography (IOTEE) decreases the incidence of immediate repair failure. This study identifies the mechanisms of immediate failure by IOTEE in the quadrangular resection technique, a well-standardized mitral valve repair procedure to guide further repair procedures. Two hundred five consecutive patients underwent quadrangular resection due to prolapse or flail posterior leaflet. Twenty-four patients (11%) had immediate failure. Immediate reinstitution of cardiopulmonary bypass ("second pump run") was needed in 21 patients (10%) for further repair. The identified mechanisms of failure were residual cleft provoking interscallop malcoaptation into the posterior leaflet in 8 patients, residual prolapse of the anterior or posterior leaflets in 1 and 4 patients, respectively, residual annular dilation in 3, left ventricular outflow obstruction in 2, suture dehiscence in 2, and other mechanisms in another 2 patients. In 20 patients (95%), IOTEE guided further repair with resolution of the residual MR, whereas 1 patient underwent valve replacement due to pharmacologically untreatable left ventricular outflow obstruction. In conclusion, even if this type of valve repair technique is well standardized, the incidence of immediate failure is not negligible. IOTEE identified the mechanisms of the immediate failure and guided further repair procedures, thus reducing the incidence of valve replacement (0.5%) without increasing perioperative mortality and morbility.

Adult↗
PubMed2005

Comparison of proximal isovelocity surface area method and pressure half time method for evaluation of mitral valve area in patients undergoing balloon mitral valvotomy.

BACKGROUND: The pressure half time (PHT) method is unreliable for measurement of mitral valve area (MVA) immediately after valvotomy. The proximal isovelocity surface area (PISA) method has been used to derive mitral valve area in patients with mitral stenosis. The aim of our study was to compare PISA method and PHT method in patients undergoing percutaneous balloon mitral valvotomy (BMV). METHODS: The PISA was recorded from the apex and MVA was calculated using continuity equation by the formula 2pir(2) Vr/Vm, where 2pir(2) is the hemispheric isovelocity area, Vr is the velocity at the radial distance "r" from the orifice, and Vm is the peak velocity. A plain angle correction factor (theta)/180 was used to correct the inlet angle subtended by leaflet tunnel as a result of leaflet doming. RESULTS: MVA calculated using PISA method (r = 0.5217, P < 0.0001, SE = 0.016) and PHT (r = 0.6652, P < 0.0001, SE = 0.017) correlated well with 2D method in patients with mitral stenosis before BMV. After BMV, MVA by PISA method correlated well with 2D planimetry (r = 0.5803, P < 0.0001, SE = 0.053) but PHT showed poor correlation (r = 0.1334, P = 0.199, SE = 0.036). The variability of measurement of MVA was most marked with PHT method in the post-BMV period. CONCLUSION: The PISA method correlates well with 2D planimetry in patients with mitral stenosis before and after BMV and is superior to the PHT method in the post-BMV period where the latter may be unreliable.

Adult↗
PubMed1989

[Prevalence of tricuspid and aortic valve prolapse in patients with mitral valve prolapse].

Two-dimensional echocardiograms were performed in 30 patients with mitral valve prolapse (15 females and 15 males, with an average of 33.3). The main objective was to observe the prevalence of involvement of tricuspid and aortic valves. Tricuspid valve prolapse was observed in 43.3% with anterior and septal involvement in 92.3% and posterior involvement in 15.3%. The incidence of aortic prolapse was 10% with involvement of both right coronary and non-coronary leaflets. All patients with aortic valve prolapse showed involvement of both mitral leaflets and at least two tricuspid leaflets. It is concluded that involvement of other valves such as tricuspid (43.3) and aortic (10%) is a common finding in patients with mitral valve prolapse.

Adolescent↗
PubMed2001

Mitral valve prolapse in patients with pure rheumatic mitral stenosis: an angiographic study.

Of 122 adult patients suspected of having rheumatic mitral stenosis, 112 fulfilled the hemodynamic and angiographic criteria for pure, isolated mitral stenosis. There were 88 females and 24 males with an age range of 16 to 60 years. The left ventriculograms (30 degrees right anterior oblique) were subjectively assessed for gross bulging of the mitral valve leaflets beyond the mitral fulcrum into the left atrium during a beat with maximal opacification. Seventeen percent of cases had typical evidence of mitral valve prolapse, which is much higher than the 3% to 5% rate reported for the general population. This phenomenon was independent of the patients' age, sex, hemodynamic findings, and/or their underlying cardiac rhythm, thus implying the direct role of rheumatic mitral stenosis in the genesis of secondary mitral valve prolapse.

Adolescent↗
PubMed1989

[Incidence and concomitant factors of tricuspid valve insufficiency in patients with aortic and mitral valve diseases].

Invasive data about the frequency and associated factors of tricuspid regurgitation in normals and in patients with aortic and mitral valve disease are still rare. Thus, right ventricular biplane angiograms (RAO/LAO projection), the mean pulmonary artery pressure and the presence of atrial fibrillation were analyzed with regard to tricuspid regurgitation in 30 normals and 165 patients with pure mitral regurgitation, mitral stenosis, aortic regurgitation, aortic stenosis, combined mitral valve disease or combined aortic valve disease. Patients with tricuspid stenosis or coronary artery disease were excluded. In 52 of the 195 patients tricuspid regurgitation was present. Tricuspid regurgitation occurred statistically more often in patients with mitral stenosis (33%), mitral regurgitation (48%) or combined mitral valve disease (68%) than in patients with aortic regurgitation (4%) or combined aortic valve disease (3%). In patients with aortic stenosis and in normals tricuspid regurgitation was not present. In patients with combined mitral valve disease, tricuspid regurgitation was more often present than in patients with pure mitral stenosis (p less than 0.002), despite comparable values of the mean pulmonary artery pressure, the right ventricular enddiastolic and endsystolic volume indexes, the right ventricular ejection fraction and the frequency of atrial fibrillation. Only in patients with pure mitral regurgitation tricuspid regurgitation was associated with an elevated mean pulmonary artery pressure (p less than 0.02). Differences in the right ventricular size and function did not occur between normals and patients with mitral or aortic valve disease. Therefore, the mean pulmonary artery pressure, atrial fibrillation and the size and function of the right ventricle are not major determinants for the occurrence of tricuspid regurgitation.(ABSTRACT TRUNCATED AT 250 WORDS)

Aortic Valve↗
PubMed2004

Mitral valve replacement after percutaneous transluminal mitral commissurotomy.

OBJECTIVES: We reviewed our experience of mitral valve replacement (MVR) after percutaneous transluminal mitral commissurotomy (PTMC) for mitral stenosis (MS). METHODS: From December 1987 to December 2001, PTMC was conducted in 75 patients with symptomatic rheumatic MS. At mean follow-up of 8.4+/-3.5 years, 11 patients (14.7%) underwent MVR for mitral restenosis (9 cases) and mitral regurgitation (MR) (2 cases). The mean interval between PTMC and MVR was 5.2+/-3.2 years. RESULTS: There were 2 hospital deaths (due to low output syndrome and mediastinitis) and 2 complications (prosthetic valve endocarditis and left ventricular rupture). The mitral valve area (MVA) at pre-PTMC, post-PTMC and pre-MVR was 1.02+/-0.48 cm2, 1.55+/-0.59 cm2, 1.04+/-0.23 cm2, respectively. The MVA significantly increased after PTMC (p<0.01), but decreased significantly to the pre-PTMC value at pre-MVR (p<0.05). The left atrial dimension (LAD) significantly increased from 50.4+/-10.8 mm at pre-PTMC to 61.1+/-13.1 mm at pre-MVR (p<0.05). The number of significant tricuspid regurgitation (TR) cases increased from 2 at pre-PTMC to 5 at pre-MVR. The New York Heart Association class got better after PTMC (3 cases in class III at pre-PTMC to 0 at post-PTMC), but at pre-MVR, deteriorated to the same level at pre-PTMC (4 cases in class III). CONCLUSIONS: Our results of MVR after PTMC were reasonable to be considered despite their high risk at MVR resulting in 2 hospital deaths. For the reliable relief of MS and control of TR, not PTMC but MVR combined with tricuspid annuloplasty may be preferable in such two cases suffering from congestive heart failure with significant TR at first intervention. Close follow-ups like periodic ultrasonic cardiography studies should be conducted to gain more information on the mitral restenosis, TR deterioration and dilatation of the cardiac chambers.

Aged↗
PubMed1992

[Changing views on mitral valve prolapse].

Views regarding mitral valve prolapse, in particular its diagnosis and prognosis, have undergone great changes in recent years. The typical auscultation finding of a meso-systolic click and/or late systolic murmur is very specific for prolapse but it is not very sensitive. The basic diagnostic method of mitral valve prolapse is echocardiography. The non-realistic high prevalence of echocardiographic findings of prolapse in otherwise healthy subjects led recently to the introduction of stricter echocardiographic diagnostic criteria. The term mitral valve prolapse syndrome describes not confirmed association of anatomical valvular prolapse with non-specific symptoms of autonomous dysfunction. An attempt to explain non-specific complaints by an anatomical abnormality of the mitral valve has become very popular but, as increasingly apparent, is purely speculative. Controlled investigations provide evidence that the mitral valve prolapse syndrome does not exist that it is only an incidental coincidence of two conditions very frequently encountered in the population. The prognosis of the great majority of people with a mitral valve prolapse is very favourable. Only about 2-4% of subjects with prolapse are seriously threatened by complications such as infectious endocarditis, thromboembolic episodes, complex arrhythmias and sudden death. This small sub-group with a high risk is formed above all by patients with mitral insufficiency with severe haemodynamic impact. Independent negative prognostic signs are age above 50 years and male sex.

Humans↗
PubMed2005

Successful valve repair for congenital bicuspid aortic valve and degenerated prolapsed mitral valve.

A 54-year-old man with congenital bicuspid aortic valve underwent simultaneous valve repair for aortic and mitral regurgitation. Surgical technique consisted of plication of redundant aortic valve repair and mitral annuloplasty with chordal replacement. One-year follow-up transthoracic echocardiography showed no valve regurgitation. Valve repair for both bicuspid aortic valve and mitral valve regurgitation should be the first option in this subset of patients.

Aortic Valve↗
PubMed1996

Use of extended polytetrafluoroethylene (ePTFE) chordae to re-establish annular-papillary connection after mitral valve excision.

Preserving mitral annular-papillary muscle continuity during mitral valve replacement improves left ventricular function and may help prevent ventricular rupture. In patients with severe rheumatic or myxomatous mitral valve involvement, retaining native chordae may not be possible. We describe a technique to recreate the papillary muscle-mitral annular continuity with ePTFE sutures when excision of a portion or all of the subvalvular apparatus is required.

Heart Valve Diseases↗
PubMed1991

Prediction of outcome after mitral valve replacement in patients with symptomatic chronic mitral regurgitation. The importance of left atrial size.

BACKGROUND: The ability to predict outcome after mitral valve replacement remains limited in patients with symptomatic chronic mitral regurgitation. The aims of this study were to determine the preoperative predictors of postoperative cardiac-related mortality and to assess the additive prognostic value of tests performed in such patients. METHODS AND RESULTS: Accordingly, 176 patients (mean age, 57 +/- 14 years) who underwent mitral valve replacement were followed up for 3.8 +/- 0.5 years. Four categories of variables were analyzed to predict postoperative cardiac-related mortality: clinical, laboratory, two-dimensional echocardiographic (2DE), and cardiac catheterization. There were 39 cardiac-related deaths (29 due to congestive heart failure and 10 sudden). When the four categories were analyzed separately, two clinical, one laboratory, two 2DE, and one catheterization variable best predicted postoperative death. When these six variables were examined simultaneously, only three (one clinical and two 2DE) remained significant predictors of cardiac-related mortality: presence of pulmonary rales, left atrial size, and the ratio of left ventricular wall thickness to left ventricular cavity dimension in end systole. A model based on these three variables may predict cardiac-related death with considerable accuracy. Laboratory data did not add to clinical information for predicting death. 2DE variables provided significant additional information in this regard (p less than 0.001). Further addition of catheterization variables was not useful. Prognostic value did not change significantly when 50 patients with prior mitral valve surgery or 49 patients undergoing concomitant aortic valve replacement or coronary artery bypass surgery were excluded from analysis. CONCLUSIONS: We conclude that 1) measures of both left ventricular systolic function and left atrial size are equally important in predicting postoperative cardiac-related mortality in patients with symptomatic chronic mitral regurgitation undergoing mitral valve replacement; 2) left atrial size may be important because it reflects the "history" (severity and duration) of mitral regurgitation; 3) 2DE assessment of left atrial size and left ventricular function provides prognostic information that is significantly greater than that obtained from clinical and laboratory parameters alone; the addition of catheterization variables does not increase the prognostic value of the clinical and 2DE data.

Atrial Function, Left↗
PubMed2003

Postoperative outcome in patients with accessory mitral valve tissue.

Accessory mitral valve tissue (AcMVT) is a rare congenital malformation causing left ventricular outflow tract obstruction (LVOTO). The analysis of various published reports reveals 90 patients presenting with AcMVT, ranging in age from newborns to 77 years old. Severe LVOTO is present in most cases, though mild LVOTO was found in 15 patients (16.7%), and 3 other patients (3.3%) presented with no LVOTO. In our practice, we found this anomaly in 5 patients; one presenting with severe LVOTO, two with mild LVOTO, and another who developed moderate LVOTO after a myocardial infarction episode. 68 patients (75.5%) underwent cardiac surgery, with a postoperative mortality of 6 (8.9%). Postoperatively, a residual mild gradient across the left ventricular outflow tract was identified in 9 patients (13.2%). Nine other patients (13.2%) required reoperation due to severe LVOTO. Mild-to-moderate postoperative mitral or aortic valve regurgitation was found in 7 (10.3%) and 5 (7.3%) patients, respectively. Based on reported intraoperative findings, we have classified this anomaly as Type I-FIXED TYPE (A - nodular, B - Membranous), Type II-Mobile type (A - Pedunculated, B - leaflet-like). Type IIB is divided into 1) rudimentary chordae and 2) developed chordae. Based in our own experience and after the analysis of various reports, we conclude that patients with AcMVT causing LVOTO may undergo safe mass excision with acceptable postoperative mortality and morbidity. The removal of the AcMVT should in no way compromise mitral valve function, and its excision should be made subject to careful evaluation of the surrounding structures.

Adolescent↗
PubMed2004

Mitral valve surgery for chronic ischemic mitral regurgitation.

BACKGROUND: Early and midterm clinical and echocardiographic results after mitral valve (MV) surgery for chronic ischemic mitral regurgitation were investigated to evaluate the validity of the criteria for repair or replacement applied by us. METHODS: From 1988 to 2002, 102 patients with ischemic mitral regurgitation underwent MV surgery (82 repairs and 20 replacements). End-systolic distance between the coaptation point of mitral leaflets and the plane of mitral annulus was the key factor that allowed either repair ( 10 mm). Patients who had MV replacement showed higher New York Heart Association class (3.2 +/- 0.5 versus 3.4 +/- 0.5; p = 0.016), lower preoperative ejection fraction (0.33 +/- 0.9 versus 0.38 +/- 0.12; p = 0.034), and higher end-diastolic volume (161 +/- 69 mL versus 109 +/- 35 mL; p < 0.001) compared with repair. Mitral regurgitation was 3.2 +/- 0.7 in both groups. RESULTS: Thirty-day mortality was 3.9% (2.4% MV repair versus 10.0% MV replacement; not significant). During the follow-up 26 patients died. Of the 72 survivors, 55 (76.3%) were in New York Heart Association classes I and II. Five-year survival was 75.6% +/- 4.7% in MV repair and 66.0% +/- 10.5% in MV replacement (not significant). Survival in New York Heart Association classes I and II was 58.9% +/- 5.4% in MV repair and 40.0% +/- 11.0% in MV replacement (not significant). Cox analysis identified preoperative New York Heart Association class, ejection fraction, end-diastolic volume, end-systolic volume, and congestive heart failure as risk factors common to both events. In 46 patients, late echocardiograms showed no volume or ejection fraction modifications. In patients who underwent MV repair, 50% had no or mild mitral regurgitation. CONCLUSIONS: Correction of chronic ischemic mitral regurgitation through either repair or replacement provides a good 5-year survival rate, with more than 75% of the survivors in New York Heart Association classes I and II.

Aged↗