[Contusion of heart with laceration of aortic valve and prolapse of mitral valve (author's transl)].
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Adult↗
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[Morphological observation of the mitral annulus fibrosus in patients with mitral valve prolapse].
Sixteen cases of mitral valve prolapse (MVP) with mitral regurgitation (MR) in the aged (mainly in their eighth and ninth decades) with both clinical and pathological evidences were investigated. One hundred autopsy cases served as the control. The longitudinally-sectioned mitral annulus fibrosus was pathologically studied in all with special reference to the atrium-valve disjunction reported by Hutchins. Morphologically, the mitral annulus fibrosus was classified either as type A (the mitral valve attaches to the left ventricle), type B (the mitral valve attaches to the left atrium: Hutchins' disjunction), type C (the atrialis continues to the left atrium and the fibrosa to the left ventricle), or type D (mitral annulus calcification). Type B was observed in only 31% of the MVP cases, whereas it was seen in 43% of the control cases. It was concluded that Hutchins' observation could not be regarded as the characteristic pathological finding of MVP.
Aged↗
[Relationship of mitral valve area to hemostatic condition in rheumatic mitral stenosis].
The influence of mitral valve area (MVA) on hemostatic conditions was assessed in patients with rheumatic mitral stenosis (MS) without atrial thrombus who underwent percutaneous mitral valvuloplasty (PMV). The Doppler-derived MVA and hemostatic variables were obtained before and 2-3 months after PMV. Hemostatic tests included measurements of beta-thromboglobulin and platelet factor 4 levels as indexes of platelet activation, fibrinopeptide A and thrombin-antithrombin complex as markers of fibrin generation, and D-dimer and plasmin-alpha 2-plasmin inhibitor complex as indexes of active fibrinolysis. Thirty-three measurements in 17 MS patients were subdivided into three groups: group A, 16 samples when MVA was < 1.5 cm2, group B, 12 samples obtained when MVA was 1.5 - < 2.0 cm2, and group C, 5 samples obtained when MVA was > or = 2.0 cm2. The mean level of beta-thromboglobulin was significantly lower in group C (43.6 +/- 32.4 ng/ml) than in group A (142.5 +/- 132.5 ng/ml) or B (163.8 +/- 179.8 ng/ml) (p < 0.05). The incidence of abnormal beta-thromboglobulin was also significantly lower in group C (20%) than in group A (67%) or B (73%) (p < 0.05). Other mean values or incidence of abnormal values of other hemostatic parameters did not differ between the groups. The hemostatic change induced by PMV was examined in 15 MS patients with no change in cardiac rhythm after PMV therapy. The patients were divided into suboptimal (MVA widening < 0.5 cm2, n = 7) and optimal (> or = 0.5 cm2, n = 8) groups. No favorable hemostatic changes were achieved by PMV in the suboptimal group.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Impact of valve prosthesis-patient mismatch on pulmonary arterial pressure after mitral valve replacement.
OBJECTIVES: We sought to determine the impact of valve prosthesis-patient mismatch (PPM) on pulmonary arterial (PA) pressure after mitral valve replacement (MVR). BACKGROUND: Pulmonary arterial hypertension is a serious complication of mitral valve disease, and it is a major risk factor for poor outcome after MVR. We hypothesized that valve PPM might be a determinant of PA hypertension after MVR. METHODS: Systolic PA pressure was measured by Doppler echocardiography in 56 patients with normally functioning mitral prosthetic valves. Mitral valve effective orifice area (EOA) was determined by the continuity equation and indexed for body surface area. RESULTS: Thirty patients (54%) had PA hypertension defined as systolic PA pressure >40 mm Hg, whereas 40 patients (71%) had PPM defined as an indexed EOA < or =1.2 cm(2)/m(2). There was a significant correlation (r = 0.64) between systolic PA pressure and indexed EOA. The average systolic PA pressure and prevalence of PA hypertension were 34 +/- 8 mm Hg and 19% in patients with no PPM versus 46 +/- 8 mm Hg and 68% in patients with PPM (p < 0.001). In multivariate analysis, the indexed EOA was by far the strongest predictor of systolic PA pressure. CONCLUSIONS: Persistent PA hypertension is frequent after MVR and strongly associated with the presence of PPM. The clinical implications of these findings are important given that PPM can largely be avoided by using a simple prospective strategy at the time of operation.
Aged↗
Mitral valve replacement in patients with severe mitral regurgitation and impaired left ventricular function.
We have studied short- and mid-term effects of preservation and excision of the mitral subvalvar support during mitral valve replacement in 40 patients, who had developed moderate to severe degree of left ventricular function impairment, secondary to pure severe mitral regurgitation. These patients had valve replacement, because valve anatomy was unsuitable for reconstructive procedures. Mitral subvalvar support was excised and valve replaced with a Björk-Shiley prosthesis, in 10 patients with moderately impaired left ventricular ejection fraction (mean 32% +/- 1.2%) and in 18 patients with severely impaired left ventricular function (left ventricular ejection fraction: 22% +/- 0.8%). In 12 patients with severely impaired left ventricular function (left ventricular ejection fraction: 20% +/- 1%) posterior subvalvar apparatus was preserved and valve replaced with a bioprosthesis. Prognosis of patients with moderately impaired left ventricular function was not influenced by the loss of chordopapillary support. Actuarial survival at 8 and 10 years was 46% +/- 7.8% for patients with severely impaired left ventricular function with chordopapillary support excised and 70% +/- 10% for patients with severely impaired left ventricular function with chordopapillary support preserved (p less than 0.01). Preservation of mitral subvalvar support is important in patients with severely impaired left ventricular function (left ventricular ejection fraction less than 25%).
Aged↗
REPLACEMENT OF THE AORTIC AND MITRAL VALVES USING THE STARR-EDWARDS BALL-VALVE PROSTHESIS: A REPORT OF 50 CASES.
The aortic and mitral valves were replaced in 50 patients at the University of Alberta Hospital using the Starr-Edwards ball-valve prosthesis. The basis of the selection of 20 patients for isolated aortic valve replacement and 27 for mitral valve replacement using this type of prosthesis is presented, and the techniques of insertion of the aortic and mitral valve are described in detail. Of the 27 patients in whom the mitral valve was replaced by the Starr-Edwards prosthesis six died within 30 days of surgery and two after discharge from hospital at two and a half and four months, respectively. Left atrial thrombosis was the cause of death in four of these patients. In 20 patients in whom the aortic valve was replaced, four died in hospital and two died more than 30 days after returning home. Three of these six patients died from bleeding-the result of the use of anticoagulants. The difficulty in assessing whether or not anticoagulants are needed following replacement by a Starr-Edwards prosthesis is considered. It is felt, in our present state of knowledge, that anticoagulants should be used following mitral valve replacement but are probably not essential following replacement of the aortic valve. Two patients survived replacement of both aortic and mitral valves and have been followed up 18 months and seven months, respectively.
Anticoagulants↗
Combined aortic and mitral valve repair in active infective endocarditis.
We describe a case of successful combined repair of the aortic and mitral valves for an indication of active infective endocarditis involving both valves. Mitral valve repair was achieved by vegetation debridement, fixation of the anterior mitral commissure, resection and suturing of the posterior mitral leaflet, and posterior annuloplasty with autologous pericardium. Aortic valve repair was achieved by vegetectomy and commissural plication. Postoperative clinical course was without signs of recurrent infection, and echocardiogram demonstrated mitral valve competence with trivial aortic regurgitation. We concluded that simultaneous valve repair is a viable option in the context of active endocarditis.
Aged↗
Echocardiographic evaluation of the mitral valve area before and after percutaneous mitral commissurotomy: the pressure half-time method revisited.
BACKGROUND: Doppler pressure half-time (PHT) is widely used for mitral valve area (MVA) assessment but its accuracy has not been fully evaluated before and after percutaneous mitral commissurotomy (PMC) in a large series of patients. METHODS: In 120 patients with severe mitral stenosis, MVA(PHT) was prospectively evaluated before and 24 to 48 hours after PMC and compared with 2-dimensional planimetry (MVA(2D)) as a reference method. RESULTS: After PMC, MVA(2D) significantly increased (1.81 +/- 0.30 vs 1.03 +/- 0.23 cm2, P < .0001), mean transmitral gradient decreased (5 +/- 3 vs 10 +/- 5 mm Hg, P < .0001), and a good valve opening (MVA(2D) > or = 1.5 cm2) was observed in 107 patients (89%). Before PMC, correlation between MVA(PHT) and MVA(2D) was only fair overall (r = 0.52, P < .0001) and weak in subgroups of older patients (> or = 60 years; r = 0.16, P = .37) and in patients in atrial fibrillation (r = 0.38, P < .05). After PMC, MVA(PHT) (1.62 +/- 0.39 cm2) was significantly lower than MVA(2D) (P < .0001) and correlation was poor overall (r = 0.30, P = .0004; mean difference 0.33 +/- 0.30 cm2) and in all subgroups (r < 0.35). However, for the prediction of a good valve opening, a PHT less than 130 milliseconds (observed in 43 patients, 36%) had an excellent specificity (100%) despite a poor sensitivity (44%). CONCLUSION: For MVA assessment, the PHT method should be used cautiously even before PMC, especially in older patients or those in atrial fibrillation. After PMC, it does not provide an accurate MVA evaluation but can still be used as a semiquantitative method: a PHT less than 130 milliseconds is associated with a good valve opening, which can be useful in difficult cases.
Anatomy, Cross-Sectional↗
Surgical treatment of duplication of the mitral valve.
Two cases of duplication of the mitral valve were found at operation. One was associated with isolated mitral regurgitation (Case 1) and the other with the intermediate type of atrioventricular canal (Case 2). In Case 1, the fibrous band between the major orifice and accessory orifice was cut, and the anterior mitral valve was extended by glutaraldehyde-treated homopericardium after the cleft had been repaired. On the other hand, a small accessory orifice encountered in Case 2 was closed by direct sutures and the same method of mitral valve extension was employed for mitral valve reconstruction as in Case 1. Surgical correction of duplication of the mitral valve is mandatory depending on the associated cardiac malformation, the type and size of the defect, and the surgeon's experience.
Cardiomegaly↗
Minimally invasive mitral valve surgery: the subxiphoid approach.
BACKGROUND: This report describes mitral valve replacement using a unique subxiphoid approach with a lower ministernotomy and a skin crease incision and compares the operative and echocardiographic results to patients undergoing mitral valve replacements using previously described strategies. METHODS: Fifty-four patients underwent mitral valve replacement using a subxiphoid approach (group 1); 32 patients underwent mitral valve replacement, 11 patients underwent mitral valve replacement + tricuspid reconstruction, 2 patients underwent mitral valve replacement + tricuspid valve replacement, and 9 patients underwent mitral reconstruction. This group of patients was compared to 11 patients who underwent mitral valve replacement through a superior ministernotomy (group 2) and 29 patients who underwent mitral valve replacement with full median sternotomy (group 3, 22 mitral valve replacements, 2 mitral valve replacements + tricuspid reconstruction, 2 mitral reconstructions, and 3 mitral reconstructions + tricuspid reconstruction). RESULTS: There was no operative mortality in all groups. The operation lasted significantly longer in group 2 patients compared to group 1 and 3 patients (p < 0.01). Postoperative mediastinal drainage was significantly lower in groups 1 and 2 (p < 0.001). Pain assessment revealed no difference between the groups. Three patients in group 1 presented with pericardial effusion. Except for this complication, early postoperative echocardiographic findings of the patients were similar in all three groups. All patients were in New York Heart Association functional class I or II at the second postoperative month, irrespective of the surgical technique used. CONCLUSIONS: There was no prominent superiority of the ministernotomy approaches over the standard median sternotomy approach. However, the reliability of the subxiphoid approach is documented echocardiographically and any type of mitral replacement can be performed with this approach.
Adult↗
Successful repair of a large aortic abscess causing apical displacement of the anterior mitral valve.
Anatomic continuity between the anterior mitral leaflet and the aortic root may predispose those patients with aortic root pathology to functional changes of the mitral valve without any involvement of this valve. A 34-year-old man presented with aortic valve endocarditis. Transthoracic echocardiograpy showed severe aortic regurgitation with a large aortic root abscess. The anterior leaflet of the mitral valve was displaced towards the apex of the heart causing moderate mitral regurgitation. The patient underwent aortic valve replacement with reconstruction of the aortic annulus and ventriculoaortic continuity. This procedure alone restored the mitral valve structure and function without any need for intervention on the mitral valve. Aortic abscess is a serious complication of aortic valve endocarditis and may alter the function of other structures of the heart, especially the mitral valve. Restoration of aortic wall integrity and left ventricular-aortic continuity usually restores the mitral valve structure and function if the valve is unaffected by the infection. A decision on the mitral valve should be made following correction of the aortic pathology.
Abscess↗
Mitral valve surgery in the adult Marfan syndrome patient.
BACKGROUND: Because mitral valve dysfunction in adults with Marfan syndrome is poorly characterized, this study compares mitral valve pathophysiology and morphology with that of myxomatous mitral disease, documents types of mitral valve operations, and assesses long-term survival and durability of mitral valve surgery in Marfan patients. METHODS: From May 1975 to June 2000, 27 adults with Marfan syndrome underwent mitral valve surgery. Their valve pathophysiology and morphology was compared with that of 119 patients with myxomatous mitral disease undergoing surgery from September 1995 to March 1999. Survival and repair durability were assessed at follow-up. RESULTS: Compared with myxomatous disease patients, Marfan patients had less posterior leaflet prolapse (44% versus 70%, p = 0.01), more bileaflet (44% versus 28%, p = 0.09) and anterior leaflet prolapse (11% versus 3%, p = 0.07), and presented earlier for surgery (age 41 +/- 12 years versus 57 +/- 13, p < 0.0001). Marfan patients had longer and thinner leaflets. Mitral valve repair was performed less frequently in Marfan (16 of 27, 59%) than myxomatous disease patients (112 of 119, 94%). There were no hospital deaths; at 10 years, survival was 80% and freedom from reoperation 96%, with only 1 reoperation among the 16 repairs. CONCLUSIONS: Mitral valve pathophysiology and morphology differ between Marfan and myxomatous mitral valve diseases. Valve repair in Marfan patients is durable and gives acceptable long-term results, even in adults who present with advanced mitral valve pathology. With increasing use of the modified David reimplantation operation and sparing of the aortic valve, mitral valve repair is a greater imperative, particularly since we have not had to reoperate on any Marfan patients with reimplantations.
Adult↗
Variations in the papillary muscles of the normal mitral valve and their surgical relevance.
A mid-mitral plane passing through the middle of the aortic and mural leaflets divides the chordopapillary support of the mitral valve into anterolateral and posteromedial halves. The papillary muscles of the mitral valve were studied in 100 human autopsy hearts collected at random. The anterolateral papillary support had 1 belly in 67 hearts, 2 in 27, 3 in 4, 4 in 1, and 5 in 1 heart. Likewise, the posteromedial papillary support had 1 muscle belly in 50 hearts, 2 in 36, 3 in 11, and 4 in 3. The single papillary muscles were conical, mammillated, flat topped, grooved, stepped, wavy, arched, sloped or saucerized. When there were two bellies they presented a two tiered, interlinked, parallel, arched, V, Y, or H configuration. Three papillary muscles formed a parallel, interlinked or arched arrangement; or two bellies were interlinked or formed a two tiered arrangement with the third belly separate. When four or five bellies existed, they were parallel or interlinked. In the anterolateral and posteromedial group, the papillary muscle bellies were mostly intraluminal in 14% and 11%, mostly intraluminal with the tip anchored in 19% and 28%, equally sessile and intraluminal in 54.5% and 41.5%, mostly sessile in 12.5% and 19.5%, respectively. In the anterolateral group 19% of papillary muscle bellies arose from the upper third of the ventricle, 79.5% from middle third, and 1.5% from lower third. The corresponding figures for posteromedial group are 6%, 92.5%, and 1.5%, respectively. Four to 22 chordae originated from the anterolateral papillary group, ending in 14 to 72 chordal insertions into the corresponding half of the valve. Likewise, 2 to 18 chordae arose from the posteromedial papillary group ended in 12 to 80 leaflet insertions. The chordae in each group are best considered in toto as a fan. The configuration of the fan is unique in each heart. Imaging techniques need to be refined to outline these variations more precisely. The relevance of chordopapillary variations in rheumatic heart disease, reparative procedures, papillary muscle dysfunction, mitral valve prolapse, mitral valve replacement, and use of mitral valve homograft for mitral/tricuspid replacement is discussed.
Cardiac Surgical Procedures↗
Improved regional left ventricular performance in mitral valve replacement with orthotopic refixation of the anterior mitral leaflet.
BACKGROUND AND AIMS OF THE STUDY: To investigate the influence of different surgical techniques of chordal preservation in mitral valve replacement (MVR) on left ventricular size and function, we studied a series of 244 patients who underwent mitral valve replacement either with (n = 161) or without (n = 83) preservation of the subvalvular structures. RESULTS: Preoperatively there were no differences between the two patient groups. Three months postoperatively, echocardiography demonstrated that chordal preservation in MVR resulted in smaller left ventricular end-systolic diameter (LVESD) and end-diastolic diameter (LVEDD): preservation versus resection, LVESD: 43.4 +/- 7.8 mm versus 48.8 +/- 9.2 mm (p < 0.05), LVEDD: 57.3 +/- 7.8 mm versus 62.9 +/- 10.5 mm (p < 0.05) and a significantly decreased LV-L (long axis) (87.1 +/- 4.2 mm versus 97.5 +/- 5.7 mm; p < 0.05). There was no significant difference in cardiac dimensions between the three patient subgroups in whom chordal preservation was possible. In addition, left ventricular ejection fraction in the preservation groups was significantly improved compared with the resection group (54.2 +/- 11.2% versus 48.1 +/- 12.4%, p < 0.05); there were no differences between the preservation subgroups. Regional wall motion analysis revealed significantly improved segmental myocardial performance in all segments if both leaflets were preserved or the anterior mitral leaflet was reattached to the anterior mitral annulus.
Adult↗
Calcification and degeneration following mitral valve reconstruction in patients requiring chronic dialysis.
BACKGROUND AND AIM OF THE STUDY: Abnormal calcium homeostasis in patients with end-stage renal failure results in dystrophic calcification; this limits the use of heterograft tissue valve prostheses in patients on chronic dialysis. Mitral valve reconstruction offers advantages over mitral replacement in many patients without renal failure, and offers theoretical advantages in patients requiring dialysis. This study was performed to determine the outcome of mitral valve reconstruction in patients with renal failure requiring chronic dialysis. METHODS: Ten patients with end-stage renal failure and on chronic dialysis who underwent mitral valve repair were identified retrospectively and followed for clinical and echocardiographic outcome. All patients had good results immediately following surgical valve mitral repair, with no more than mild mitral regurgitation and low transmitral gradients on intraoperative transesophageal echocardiography. RESULTS: Clinical and echocardiographic follow up was available for eight patients at an average of 2.3 +/- 1.4 years after surgery. Despite there being no significant valve calcification at the time of surgery, visible mitral leaflet calcification was evident in seven of these patients, and the transmitral gradient for the group was significantly increased (from 4.8 +/- 1.7 mmHg to 8.3 +/- 3.9 mmHg, p = 0.04). Two patients required reoperation for failed mitral repair; one at six months due to chordal rupture, and one at 15 months due to mitral calcification with stenosis. CONCLUSION: Despite good early surgical results, there was accelerated calcification of the repaired mitral valve, a rapid increase in postoperative mitral gradients, and a high incidence of failure of the reconstruction. Additional prospective studies are required to evaluate the optimal intervention for patients with end-stage renal failure who require mitral valve surgery.
Calcinosis↗
Mitral valve reconstruction with Carpentier ring for mitral regurgitation: experience with Chinese patients.
Between December 1985 and June 1987, 38 consecutive patients with mitral regurgitation underwent mitral valve reconstruction (MVP) with Carpentier rings. There were 16 men and 22 women, ranging in age from 16 to 63 years (mean 36.4 +/- 14.4). The underlying causes were rheumatic heart disease (55%), degenerative valvular disease (42%), and congenital heart disease (3%). Thirty patients were categorized in the New York Heart Association's functional classification III or IV preoperatively. The concomitant procedures included aortic valve replacement (AVR) in 6 patients, tricuspid valve repair (TVP) in 9, and closure of atrial septal defect in one. Hospital death happened to one patient (3%). All but one patient were followed up at 31 months postoperatively (rate 98.6%). There was one late death due to myocardial failure not related to the valves. The actuarial survival rate at 31 months was 96.8%. The thromboembolic rate was 1.44% per patient-year. No reoperation or endocarditis was encountered. All 36 survivors were in functional classes I and II. Twenty-one patients underwent Doppler echocardiography 3 to 12 months after surgery and 17 (81%) showed no or mild mitral regurgitation and 4 (19%) had moderate regurgitation. We conclude that MVP with Carpentier rings is a satisfactory method with low mortality and complication rates in Chinese patients.
Adolescent↗
Mitral valve repair with aortic valve replacement is superior to double valve replacement.
OBJECTIVES: Double valve replacement has been advocated for patients with combined aortic and mitral valve disease. This study investigated the alternative that, when feasible, mitral valve repair with aortic valve replacement is superior. PATIENTS AND METHODS: From 1975 to 1998, 813 patients underwent aortic valve replacement with either mitral valve replacement (n = 518) or mitral valve repair (n = 295). Mitral valve disease was rheumatic in 71% and degenerative in 20%. Mitral valve replacement was more common in patients with severe mitral stenosis (P =.0009), atrial fibrillation (P =.0006), and in patients receiving a mechanical aortic prosthesis (P =.0002). These differences were used for propensity-matched multivariable comparisons. Follow-up extended reliably to 16 years, mean 6.9 +/- 5.9 years. RESULTS: Hospital mortality rate was 5.4% for mitral valve repair and 7.0% for replacement (P =.4). Survivals at 5, 10, and 15 years were 79%, 63%, and 46%, respectively, after mitral valve repair versus 72%, 52%, and 34%, respectively, after replacement (P =.01). Late survival was increased by mitral valve repair rather than replacement (P =.03) in all subsets of patients, including those with severe mitral valve stenosis. After repair of nonrheumatic mitral valves, 5-, 10-, and 15-year freedom from valve replacement was 91%, 88%, and 86%, respectively; in contrast, after repair of rheumatic valves, it was 97%, 89%, and 75% at these intervals. CONCLUSIONS: In patients with double valve disease, aortic valve replacement and mitral valve repair (1) are feasible in many, (2) improve late survival rates, and (3) are the preferred strategy when mitral valve repair is possible.
Adult↗
Intraoperative echocardiographic studies of the mitral valve: assessment of commissurotomy and repair.
Mitral echocardiograms obtained by direct application of the ultrasonic probe to the epicardial surface were compared with echocardiograms obtained by the conventional chest surface technique in 32 patients. The groups comprised 16 patients with stenosis, nine with incompetence, and seven patients with normal mitral valves. In every patient, prior to the exploration of the mitral valve, echocardiograms were obtained from the surface of the chest and from the epicardial surface of the heart. In 13 patients, direct epicardial and chest surface echocardiograms were repeated after mitral valvotomy or repair. The initial mitral valve lesion in these patients was stenosis in seven and incompetence in six. The diastolic closure rates (E-F speed) obtained by direct epicardial surface echocardiography revealed a significant statistical correlation (P less than 0.001) which was comparable to that recorded from the chest surface. This technique offers a further means of detecting residual mitral stenosis, before closure of the chest, after commissurotomy or repair.
Adolescent↗