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PubMed2005

Abnormalities of ventricular repolarization in mitral valve prolapse.

OBJECTIVES: Mitral valve prolapse (MVP) is associated with arrhythmias and sudden death. Some studies suggest that abnormalities of the autonomic nervous system (ANS) may contribute to these arrhythmias. In a family investigation with genetic analysis of patients carrying a MVP, we performed a Holter study to define the autonomic profile of MVP. METHODS AND RESULTS: A 24-hour digitized 3-lead Holter ECG was recorded in 30 patients with MVP and in two control groups, a group of 30 healthy relatives and a group of 31 healthy volunteers. We studied especially heart rate variability (HRV) and QT dynamicity. The slope of the relationship between ventricular repolarization and heart rate was studied separately during day and night. There was no difference in HRV (SDNN, rMSSD) among the three groups. On the contrary, QT interval duration was increased in patients with MVP as compared to healthy relatives (QT end: 409+/-52 ms vs 372+/-23 ms, P<0.05; QT apex: 319+/-42 ms vs 286+/-23 ms, P<0.01) and to healthy volunteers (QT end: 409+/-52 ms vs 376+/-25 ms, P=0.004; QT apex: 319+/-42 ms vs 289+/-23 ms, P<0.01). Nocturnal ventricular repolarization rate dependence was increased in MVP as compared to healthy relatives (0.16+/-0.06 vs 0.13+/-0.04, P<0.05) and to healthy volunteers (0.16+/-0.06 vs 0.11+/-0.06, P<0.001) whereas the 24-hour and diurnal QT-R-R slope was not disturbed. CONCLUSION: In MVP, QT is increased and the circadian modulation of QT end/RR slope is disturbed with an increased nocturnal rate dependence. These abnormalities of ventricular repolarization might explain the risk of arrhythmic events in MVP.

Autonomic Nervous System↗
PubMed1991

[Immediate results and mid-term follow-up after percutaneous mitral valve replacement].

Percutaneous mitral valvuloplasty (PMV) was performed by the anterograde transseptal approach (double balloon technique) in 154 patients with symptomatic mitral stenosis. The mean age of the patients was high (53 +/- 14 years), 87% were women, 68% were in functional Classes III or IV of the NYHA and 37 (24%) had previously undergone surgical commissurotomy. The echocardiographic score was 8.5 +/- 1.6. PMV could not be completed because of a technical failure or a complication in 14 cases (9%). In the other patients, PMV increased mitral surface area from 1.0 +/- 0.3 to 2.0 +/- 0.8 cm2 (p less than 0.0001). A haemodynamic success (greater than or equal to 25% increase in mitral surface area and final area greater than or equal to 1.5 cm2) was obtained in 104 patients (75%). The predicting factors of success were echocardiographic score (8.1 +/- 1.4 versus 9.4 +/- 1.7; p less than 0.0001) and cardiac output (4.0 +/- 1.1 versus 3.0 +/- 1.0/l/min; p less than 0.0001). The duration of the procedure, the technical failure rate and the frequency of cardiac perforation were influenced by the learning curve. The degree of mitral regurgitation increased after PMV in 34% of cases, usually by one grade and without clinical or haemodynamic consequences. Acute mitral regurgitation was a rare (3%) and impredictable complication. An interatrial shunt was demonstrated in 80% of cases after PMV but the Qp/Qs ratio rarely exceeded 1.5 (11%). This shunt disappeared or decreased in the majority of cases during follow-up. The clinical result was an improvement of at least one functional Class in 83% of cases at 6 months.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed2007

The impact of mitral valve morphology on the long-term outcome of mitral balloon valvuloplasty.

BACKGROUND: The effect of mitral valve morphology (MVM) on the long-term results of mitral balloon valvuloplasty (MBV) is not well established. The aim of the study was to evaluate the impact of MVM on long-term outcome of MBV. METHODS: Five hundred and eighteen consecutive patients (mean age, 31+/-11 years) who underwent successful MBV were followed up for 0.5-16.5 (mean, 6+/-4.5) years. Patients were divided into two groups according to their mitral echo score (MES) before MBV: group A (n=340; MES 8). RESULTS: We report the immediate and long-term clinical and echocardiographic results of the above-mentioned 518 consecutive patients. The mitral valve area was significantly larger in group A than in group B, both immediately after MBV (2.0+/-0.3 vs. 1.82+/-0.3 cm2, respectively; P<0.0001) and also at the last follow-up (1.8+/-0.33 vs. 1.5+/-0.33 cm2, respectively; P<0.0001). Restenosis occurred in 38/340 (11%) in group A vs. 73/178 (41%) in group B (P<0.0001). Actuarial freedom from restenosis at 5, 10, 15 years were 92+/-2%, 85+/-3%, 65+/-6% for group A vs. 72+/-4%, 44+/-5%, 9+/-6% for group B (P<0.001). Event-free survival rates at 5, 10, 15 years for group A were 93+/-1%, 88+/-2%, 66+/-6% vs. 82+/-3%, 59+/-6%, 8+/-7% for group B (P<0.0001). Stepwise Cox multivariate regression analysis identified MES, preprocedure functional class, and postprocedure mitral valve area<or=1.8 cm2, as predictors of restenosis (P<0.0001, P=0.014, P=0.0015, respectively); MES and age as predictors of event-free survival (P<0.0001, P<0.0001, respectively). CONCLUSION: MBV has excellent long-term results in patients with favorable MVM. Favourable MVM is a strong predictor of good long-term outcome.

Adult↗
PubMed1995

Mitral valve replacement for the treatment of congenital mitral dysplasia in a bull terrier.

A 10-month-old entire male bull terrier was presented with a history of collapse on exercise. Clinical examination, electrocardiography, radiography and echocardiography all supported a diagnosis of mitral valve dysplasia. There was no evidence of congestive heart failure. Surgical intervention consisted of open resection of the dysplastic mitral valve and its replacement with a bioprosthetic valve. The procedure was performed through a median sternotomy and the dog was placed on to full cardiopulmonary bypass. Total cardiopulmonary bypass time was 70 minutes. A full recovery was made and at the time of writing (17 months postoperatively) the dog is clincally normal requiring no medication.

Animals↗
PubMed1986

Percutaneous double-balloon mitral valvotomy for rheumatic mitral-valve stenosis.

Percutaneous transatrial mitral valvotomy with a double-balloon technique produced striking symptomatic improvement in 7 of 9 patients with severe mitral stenosis. In 7 patients the mitral valve area (Gorlin formula) increased significantly and the mitral end-diastolic gradient fell significantly. Similar improvements were noted in follow-up haemodynamic studies at 6 weeks. There were no procedure-related complications. It is concluded that percutaneous double-balloon mitral valvotomy may be an alternative to surgical treatment for mitral stenosis.

Adolescent↗
PubMed1986

Spontaneous pneumothorax and mitral valve prolapse.

We searched for mitral valve prolapse in patients with spontaneous pneumothorax to test the hypothesis that both may be part of a common disorder of connective tissue. Echocardiographic mitral valve prolapse was found in 11 (50 percent) of 22 patients who had suffered spontaneous pneumothorax compared to four (10 percent) of 40 age-matched control subjects (p less than 0.01). The body mass index (BMI) (weight/height2) was lower (p less than 0.001) in the group with pneumothorax; in five patients who were the thinnest in the study (BMI less than 2 standard deviations lower than mean normal value), mitral valve prolapse was present in four. The finding of a strong association of spontaneous pneumothorax with mitral valve prolapse, especially in subjects with an abnormal body build, suggests that in many patients, spontaneous pneumothorax may be a manifestation of a systemic abnormality of connective tissue.

Adult↗
PubMed2003

Early echocardiographic predictors of myxomatous mitral valve disease in dachshunds.

Myxomatous mitral valve disease in dogs is heritable, and it is therefore important to detect the early signs of the disease. This study was conducted to assess the predictive value of early echocardiographic and auscultatory signs of mitral valve prolapse, measured in terms of the leaflet thickness, the area of the regurgitant jet, and the intensity of the murmur, on the increases in left ventricular end diastolic diameter (LVEDD) and left atrial diameter (LAD) in a population of 190 clinically healthy dachshunds followed up for three years. The most significant predictor of an increase in LVEDD was the interaction between the index of mitral valve prolapse and the area of the regurgitant jet (P < 0.0001). In dogs with a jet area greater than 50 per cent of the left atrium, the disease progressed more quickly in terms of increases in LVEDD in relation to the severity of the prolapse at the initial examination. In dogs with smaller jets, the initial prolapse index was not significantly associated with increases in LVEDD. The initial index of mitral valve prolapse, the area of the jet and the intensity of the heart murmur were all significant predictors of an increase in LAD.

Animals↗
PubMed1993

Replacement of chordae tendineae using expanded polytetrafluoroethylene (ePTFE) sutures during mitral valve replacement in patients with severe mitral stenosis.

Since September 1991, 20 patients with mitral stenosis underwent mitral valve replacement and chordal replacement with expanded polytetrafluoroethylene (ePTFE) sutures. The continuity between the papillary muscles and the mitral annulus was maintained by four mattress sutures of ePTFE, which connected the stumps of the papillary muscle heads to the mitral annulus at the 2, 4, 8, and 10 o'clock positions. Low profile bileaflet prosthetic valves were inserted. There was no mortality either in-hospital or during follow-up. There was no valve related morbidity, such as valve structural failure, thromboembolism, anticoagulant related hemorrhage, prosthetic valve endocarditis, or posterior left ventricular rupture. The technique of replacing chordae tendineae is described in detail.

Chordae Tendineae↗
PubMed2005

Performance of bioprostheses and mechanical prostheses assessed by composites of valve-related complications to 15 years after mitral valve replacement.

OBJECTIVE: Predominant concerns of patients undergoing valve replacement surgery are risks of death, stroke, antithrombotic bleeding, and reoperation related to the replacement prosthesis. The purpose of this study was to compare valve-related reoperation, morbidity (permanent impairment), and mortality between bioprostheses and mechanical prostheses for mitral valve replacement. METHODS: Between 1982 and 1998, a total of 959 bioprostheses were implanted in 943 patients, and a total of 961 mechanical prostheses were implanted in 839 patients. Total follow-ups were 5730 years for bioprostheses and 5271 years for mechanical prostheses. Eight variables were considered as predictors of risk for the composites of valve-related complications. RESULTS: The linearized occurrence rates for valve-related reoperation were 3.7 events/100 patient-years for bioprostheses and 0.5 events/100 patient-years for mechanical prostheses ( P < .001), with all age groups differentiated except older than 70 years. Valve-related morbidity was undifferentiated for bioprostheses and mechanical prostheses. Valve-related mortalities were 1.7 events/100 patient-years for bioprostheses and 0.7 events/100 patient-years for mechanical prostheses ( P < .001). Predictors of valve-related reoperation were age and valve type. The only predictor of valve-related morbidity was age, whereas age and valve type were predictors for valve-related mortality. Actual freedom from valve-related reoperation favored mechanical prostheses in all age groups except older than 70 years (91.7% +/- 2.0% for bioprostheses at 15 years and 96.7% +/- 1.5% at 12 years for mechanical prostheses). Actual freedom from valve-related morbidity was not different between bioprostheses and mechanical prostheses. Actual freedom from valve-related mortality favored mechanical prostheses in all groups except older than 70 years. CONCLUSION: Comparative evaluation gives high priority in mitral valve replacement for mechanical prostheses relative to bioprostheses for freedom from valve-related reoperation and valve-related mortality but not valve-related morbidity. Freedom from valve-related reoperation and valve-related mortality favors mechanical prostheses for all age groups except older than 70 years. Valve-related morbidity, due to neurologic or functional impairments, does not differentiate between bioprostheses and mechanical prostheses.

Adult↗
PubMed1998

Durability of mitral valve repair for degenerative disease.

BACKGROUND: Degenerative mitral valve disease is the most common cause of mitral regurgitation in the United States. Mitral valve repair is applicable in the majority of these patients and has become the procedure of choice. OBJECTIVE: This study was undertaken to identify factors influencing the durability of mitral valve repair. PATIENTS AND METHODS: Between 1985 and 1997, 1072 patients underwent primary isolated mitral valve repair for valvular regurgitation caused by degenerative disease. Repair durability was assessed by multivariable risk factor analysis of reoperation. It was supplemented by a search for valve-related risk factors for death before reoperation. Three hospital deaths occurred (0.3%); complete follow-up (4152 patient-years) was available in 1062 of 1069 hospital survivors (99.3%). RESULTS: At 10 years, freedom from reoperation was 93%. Among 30 patients who required reoperation for late mitral valve dysfunction, the repair failed in 16 (53%) as a result of progressive degenerative disease. Durability of repair was adversely affected by pathologic conditions other than posterior leaflet prolapse, use of chordal shortening, annuloplasty alone, and posterior leaflet resection without annuloplasty. Durability was greatest after quadrangular resection and annuloplasty for posterior leaflet prolapse and was enhanced by the use of intraoperative echocardiography. Death before reoperation was increased in patients having isolated anterior leaflet prolapse or valvular calcification and by use of chordal shortening or annuloplasty alone. CONCLUSIONS: Repair durability is greatest in patients with isolated posterior leaflet prolapse who have posterior leaflet resection and annuloplasty. Chordal shortening, annuloplasty alone, and leaflet resection without annuloplasty jeopardize late results.

Calcinosis↗
PubMed1987

Clinical results after mitral valve replacement with the Björk-Shiley disc prosthesis.

Between September 1971 and June 1985, 230 Björk-Shiley valves were implanted for mitral valve disease at the Department of Surgery, University of Turku. Concomitant cardiac surgical procedures were performed in 35.2% of the cases. The follow-up period was between 1 month-13 years 4 months, with a total follow-up of 986 patient years. The early mortality was 4% in patients with isolated MVR and 10% where concomitant procedures had to be performed. Since the use of cold cardioplegia there has been no mortality for isolated MVR and the mortality rate for patients with concomitant procedures has been 3.9%. During the follow-up the rate of thromboembolism was 0.4 per 100 patient years, that of thrombolic encapsulation 0.4 and anticoagulant-related haemorrhage 0.7. Ninety-five per cent of the patients were free from thrombotic or embolic complications at 5 and 10 years after surgery. The survival rate was 79% at 5 years and 72% at 10 years. Considering these results we still prefer the Björk-Shiley valve in mitral valve replacement.

Adult↗
PubMed1997

Is there an advantage to repairing infected mitral valves?

BACKGROUND: The therapy for native mitral valve endocarditis is in evolution. Antibiotics have significantly improved survival rates, but patients with complications of endocarditis may require surgical treatment. METHODS: Between January 1985 and December 1995, 146 patients underwent surgical therapy (repair or replacement) for native mitral valve endocarditis. All patients had documented bacterial endocarditis. Univariate and multivariate analyses were performed to determine predictors of hospital death, long-term event-free survival, and probability of repair. Patients were evaluated in three groups: all patients, patients with acute endocarditis, and patients with chronic endocarditis. RESULTS: There were ten hospital deaths (6.8%). Patients undergoing repair had a lower hospital mortality rate (p = 0.008) then those having replacement. Event-free survival was improved after mitral valve repair in the overall group (p = 0.02) and in the group with healed (chronic) endocarditis (p = 0.05). Although the acute endocarditis group demonstrated an improved event-free survival rate after mitral valve repair versus replacement (74% versus 20% at 6 years), this did not reach statistical significance. CONCLUSIONS: We conclude that mitral valve repair is preferable to mitral valve replacement when possible, in patients with complications of endocarditis, as repair results in a lower hospital mortality and an improved long-term survival.

Adolescent↗
PubMedDate not supplied

Methodological variation and agreement in assessing mitral valve orifice area by echo-Doppler methods in mitral stenosis.

Two-dimensional echocardiographic planimetry of the directly observed mitral valve orifice, pressure-half-time methods, continuity equation and the Gorlin formula are commonly used to calculate the mitral valve area. However, there have been few comparisons of the four methods. In this study, the mitral valve orifice area was determined by the above four methods using echo-Doppler data in 49 consecutive patients in sinus rhythm (mean area 0.87 to 1.26 cm2). The valve area estimated by these methods correlated well (r = 0.7 to 0.97) with excellent agreement between the continuity equation and the Gorlin formula (mean difference 0.4 cm2, r = 0.97, SEE = 0.26) and between the planimetric area and the pressure-half-time method (mean difference = 0.06 cm2, r = 0.87, SEE = 0.23). However, the limits of agreement were wide and exceeded 1 cm2 in planimetry versus the Gorlin, planimetry versus the continuity equation and pressure-half-time method versus the Gorlin formula. The standard error of estimate varied from 0.23 to 0.51 cm2 for various comparisons. Use of an empirical constant of 51.6 instead of 37.7 in the Gorlin formula provided excellent correlation between the valve area determined by the continuity equation and the modified hydraulic formula (mean difference 0.07 cm2, r = 0.95, SEE = 0.08). Estimates of the valve orifice area by any of the equations tested should be seen as a guide rather than a precise measure of actual orifice area.

Adolescent↗
PubMed2000

[Surgical treatment for mitral regurgitation: mid-term outcome following mitral valve repair].

Mid-term results of mitral valve repair for mitral regurgitation were evaluated in 173 consecutive patients (mean age 53 years, 107 males, 66 females) treated from July 1991 to March 1998. Pathological causes of the mitral valve disease were degenerative in 118 patients, infective endocarditis in 25, rheumatic in 13, and ischemic in 8 (ischemic cardiomyopathy in 7). The principal technique was chordal replacement with expanded polytetrafluoroethylene sutures for prolapse of the anterior leaflet, and Carpentier's sliding leaflet technique for prolapse of the posterior leaflet. Most patients received ring annuloplasty with a rigid ring and flexible band (physiological remodeling annuloplasty). Intraoperative transesophageal echocardiography was used after 1993. There were 7 operative deaths (4%) and 7 mitral valve replacements (4%) during the same operation. Successful repair was achieved in 96% of patients with mitral regurgitation. Mean follow-up was 35 months (range 2 to 78 months). Survival at 6 years was 85 +/- 10% of all patients, 98 +/- 2% in degenerative cases. Six patients required reoperation (1.2%/patient-year) and mean time interval between initial operation and reoperation was 33.1 months. Four patients with atrial fibrillation had thromboembolic events (0.8%/patient-year). There were no anticoagulant-related complications. Freedom from reoperation and all valve-related event at 6 years was 88 +/- 6% and 84 +/- 6%. Late postoperative Doppler echocardiography revealed satisfactory results in 93% of the patients. Mitral valve repair using chordal replacement, sliding plasty and ring annuloplasty provides excellent mid-term results.

Disease-Free Survival↗
PubMed1992

Surgical pathology of the mitral valve: gross and histological study of 1288 surgically excised valves.

A consecutive series of 1288 mitral valves surgically excised from 1981 through 1989 were studied macroscopically and histologically. The explanted valves were affected by: chronic rheumatic disease (1179, 91.5%), floppy mitral valve (84, 6.5%), bacterial endocarditis (19, 1.5%), and post-ischemic mitral incompetence (6, 0.5%). Among 1179 post-rheumatic cases, mixed mitral stenosis and incompetence was the most frequent malfunction (747, 58%). Isolated mitral incompetence was diagnosed in 72 (6.11%) cases only, and isolated stenosis in 360 cases. In 52 valves, excised because of chronic rheumatic disease, the histology showed unexpected signs of acute rheumatism of the leaflets and the papillary muscles. In these patients clinical symptoms and blood tests were negative for rheumatic disease. Mitral incompetence, possibly due to papillary muscle dysfunction, was the prevalent lesion (61.5%). A total of 181 patients (14.05%) with pure mitral incompetence underwent surgery. In 84 patients (46.4%), the floppy mitral valve was the most frequent cause of valve dysfunction, 72 (39.8%) had rheumatic disease, 19 (10.5%) infective endocarditis, and 6 (3.4%) ischemic heart disease. In the group with floppy mitral valve, males were more prevalent than females (51:33). The mean age of the 4 patients with Marfan's syndrome and non-Marfan patients was noticeably different (17 vs 49 yr). Moreover leaflet deformation, tendinous cord elongation and annulus dilatation were the most common causes of valve incompetence. Floppy mitral valve and infective endocarditis were the cause of cordal rupture in 43.5% of the cases. This was a severe complication which always required emergency surgery.

Adult↗
PubMed1987

Effect of aortic regurgitation on the assessment of mitral valve orifice area by Doppler pressure half-time in mitral stenosis.

Evaluation of the severity of mitral stenosis by continuous-wave Doppler pressure half-time measurement is now well established. However, few data exist regarding the effect of aortic regurgitation (AR) on the validity of this method. Therefore, 73 patients were studied in whom cardiac catheterization and Doppler echocardiographic examinations were performed. Mitral valve orifice area was determined by the Gorlin equation, 2-dimensional echocardiography and Doppler pressure half-time. Doppler pressure half-time and catheterization estimates of mitral valve area correlated well (r = 0.85) in patients without significant mitral regurgitation. This correlation was maintained in patient subgroups with and without significant (at least 2+) AR (r = 0.86 and 0.83, respectively). Similarly, Doppler and 2-dimensional echocardiographic assessment of mitral valve area showed a strong correlation (r = 0.84). Again, the correlation between the 2 methods was similar in patients with and without significant AR (r = 0.86 and 0.82, respectively). Thus, Doppler pressure half-time estimates of mitral valve orifice area are accurate even in patients with AR.

Adult↗