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PubMed2004

[Surgical treatment of acquired mitral valve diseases--five-year analysis of early and late results].

UNLABELLED: The indications for mitral valve repair or mitral valve replacement are worldwide accepted, but they still depend of the personal experience of the surgeon and the tradition in the respective cardio-vascular clinic. Valve repair had many advantages over the replacement, but the long-term durability and the reoperations remain a major problem. In this retrospective review we examine the five years results of the surgical treatment of mitral valve diseases and the factors influencing the choice of the operation, the mortality and morbidity. METHODS: From January 1998 to December 2002, 76 patients underwent mitral valve repair and 194 underwent mitral valve replacement. The mean age was 50.6 years, and 52.8% were NYHA class III or IV. The causes of mitral valve disease were ischemic in 45, rheumatic in 133, degenerative in 68 and endocarditis in 18 patients. Mitral valve repair was accomplished by Carpentier's techniques, Key, Alfeiri or ring implantation and mitral valve replacement with mechanical or biologic valve. RESULTS: In the ischemic group early mortality occurred in 7 patients (15.5%), in endocarditis group in 3-16.6%, in degenerative group in 2 (2.9%) and in the rheumatic group in 3 (2.2%). Overall mortality in the replacement group was 5.1% and in the repair group (6.5%). Six patients needed reoperation in the repair (7.8%) and 12 patients in the replacement group (6.1%). Survival at 5 years was 90% in the repair and 83% in replacement patients. CONCLUSIONS: Mitral valve repair are used almost always in ischemic and degenerative etiology, but they also show good results and long-term survival in cases of rheumatic mitral valve disease. The ischemic etiology, endocarditis and bad function of the left ventricle are the most important predictors for early death and poor long-term survival.

Cardiac Surgical Procedures↗
PubMed1998

Mitral valve repair: an odyssey to save the valves!

The history of mitral valve repair surgery is an interesting odyssey that has nearly spanned the century. However, since the mid 1970s, both European and North American surgeons have developed and expanded these techniques to where repair of myxomatous valves is now expected by most cardiologists and patients. Preoperative functional assessment is most important to determine the specific needs for repair. Today, transesophageal echocardiography is the standard by which cardiologists and surgeons rely for these data. Herein, both methods of assessment and techniques for repair are detailed. The multidisciplinary approach is emphasized. Risks of surgery are detailed as well as long-term outcomes compared with replacement of the mitral valve. Lastly, surgical results from the 235 patients repair series at the East Carolina University School of Medicine are detailed and discussed. This series showed a 1.8% mortality rate for myxomatous valve patients, with a very low reoperative rate. This compared with a higher mortality rate of 5.6% for the overall group, which emphasizes the increased risk associated with an ischemic etiology. The author provides not only an overview but also tips to surgeons beginning to repair valves.

Cardiac Surgical Procedures↗
PubMed1987

Prevalence of mitral valve prolapse in hypertension.

Mitral valve prolapse was found in one of 133 patients with hypertension (0.75 percent) studied by two-dimensional echocardiography. This rarity may be related to the presence of hypertrophied papillary muscles that probably pull the chordae tendinae and mitral valve leaflets away from the left atrium in systole, thus preventing their eversion and prolapse.

Adult↗
PubMed1999

A newly designed adapter for testing an ex vivo mitral valve apparatus.

Few instruments are currently available to test mitral valve function in an ex vivo state due to the technical difficulties involved. To investigate the native ex vivo mitral valve or prosthetic mitral valve with chordae, we developed a mitral valve adapter with an annulus suturing portion and 2 papillary muscle suturing sites that can be changed in angle, direction, and length of chordae. We used this adapter to test an ex vivo mitral apparatus in beagle dogs and evaluated the morphology and function of the mitral apparatus by endoscopy. Our newly designed mitral valve adapter proved extremely useful for examining the ex vivo mitral valve anatomy and function and for testing stentless mitral prostheses with annular-papillary muscle continuity.

Animals↗
PubMed2001

Early experience with a quadrileaflet stentless mitral valve.

BACKGROUND: Presently no ideal prosthesis for mitral valve replacement exists. The quadrileaflet mitral valve (SJM-Quattro-MV; St. Jude Medical, Inc, St. Paul, MN) is a chordally supported stentless bioprosthesis. Due to its specific geometry it seems to be particularly suited for mitral valve replacement. METHODS: From March 1999 to October 2000, 12 patients (ages 71+/-2 years) received the SJM-Quattro-MV. Six patients suffered from valvular stenosis and 6 patients from incompetence. Preoperatively, all patients were in New York Heart Association functional class III, with left ventricular ejection fraction amounts of 54%+/-17%. RESULTS: Eleven patients received a medium size SJM-Quattro-MV and one patient received a large size SJM-Quattro-MV. Cross-clamp time was 99.8+/-4.9 minutes. Additional procedures were coronary artery bypass grafting (n = 3) and left atrial microwave ablation (n = 2). Postoperative mortality (n = 1) was procedure related. At follow-up of 11.6+/-5.4 months, all patients were well, the transvalvular pressure gradient was 5.0+/-1.4 mm Hg, and the effective orifice area 2.7+/-0.2 cm2. CONCLUSIONS: Our preliminary experiences with the SJM-Quattro-MV presented good clinical results and promoted an optimistic way of thinking about the further development of these valve prostheses.

Aged↗
PubMed1998

Reconstructive surgery in congenital mitral valve insufficiency (Carpentier's techniques): long-term results.

BACKGROUND: Previous publications have stressed the benefits of mitral valve repair over mitral valve replacement in children. However, few communications have reported the long-term results and none with a follow-up of more than 10 years. This article reports our results in a series of 145 patients operated on for congenital mitral valve insufficiency by means of the same technique (Carpentier's technique) in a single center. METHODS: Between 1970 and 1995, 145 patients younger than 12 years old underwent surgery for congenital mitral valve insufficiency. Mean age was 5.7 +/- 3.1 years, ranging from 0.17 to 12 years. Mitral valve insufficiency associated with atrioventricular defect, atrioventricular discordance, straddling mitral valve, acquired diseases, Marfan syndrome, and degenerative disease was excluded from this study. According to Carpentier classification, 31 patients had type I mitral valve disease (normal leaflet motion), 79 patients type II (leaflet prolapse), and 35 type III (restricted leaflet motion), with 15 having normal papillary muscles and 20 abnormal papillary muscles. Associated lesions were present in 51 patients (35%). A conservative operation was possible in 138 patients (95%). Among them, 70 patients required a prosthetic annuloplasty and 21 patients valve extension with a pericardial patch. Valve replacement was necessary in seven patients (5%). RESULTS: In-hospital mortality was 5% (95% CL: 2.5% to 9.9%) (seven patients). No early death was observed in the group of patients who underwent valvular replacement. In-hospital mortality was as follows: type I, 9.6%; type II, 2.5%; and type III, 13%. No statistically significant difference was noted among patients with the different types of disease. Mean follow-up was 9.3 +/- 6.9 years (1 to 26 years), and cumulative follow-up was 1142 patient-years. Ten late deaths occurred. Actuarial survival at 10 years was 88% in patients who underwent valve repair and 51% in patients who underwent valve replacement. Late reoperation was required in 15% (n = 21) of patients who had undergone valve repair and 28% (n = 2) in patients with valve replacement. Causes of reoperation were recurrent left ventricular failure (n = 1), residual or recurrent mitral valve insufficiency (n = 17), mitral valve stenosis (n = 3), and calcification of the bioprosthesis (n = 2). No failure resulting from leaflet extension was observed. In the repair group, actuarial freedom from reoperation was 68% (95% CL: 80.5% to 51.5%) at 15 years, and the linearized rate of exposure to reoperation was 1.9% per patient-year. No thromboembolic event was observed in any group. CONCLUSION: Congenital mitral valve insufficiency can be repaired in infancy with a low mortality. Conservative surgery with Carpentier's techniques is feasible in the majority of cases of congenital mitral valve insufficiency. This technique offers stable long-term results with a low rate of reoperation. Leaflet extension associated with prosthetic ring annuloplasty could prevent reoperations in selected cases.

Child↗
PubMed1990

Orthostatic hypotension, catecholamines, and alpha-adrenergic receptors in mitral valve prolapse.

The reported association of mitral valve prolapse with autonomic dysfunction and neuroendocrine abnormalities is derived from studies of patients selected because of symptoms or specifically referred for investigation. To determine whether such associations occur in nonreferred and unselected women with mitral valve prolapse, we measured blood pressure, heart rate, and norepinephrine response to standing in 13 volunteers with mitral valve prolapse and in 11 control subjects. Platelet alpha-adrenergic receptor quantity and affinity on standing also were determined in all persons. No significant differences were found between the groups in any of these measurements. Although small subsets of women with mitral valve prolapse may indeed have associated neuroendocrine epiphenomena and autonomic dysfunction, it is probably incorrect to generalize these findings to the vast spectrum of those with mitral valve prolapse.

Adolescent↗
PubMed1997

Preservation of anterior and posterior leaflet in mitral valve replacement with a tilting-disc valve.

An operative technique for mitral valve replacement with preservation of chordae tendineae to both the anterior and posterior leaflets is described. The anterior mitral valve leaflet is completely detached from the annulus and divided into three to four islands of tissue, each with attached chordae tendineae. These islands are transposed under the posterior leaflet and secured with 4-0 polypropylene sutures. The posterior leaflet is completely preserved with no division or manipulation. This technique allows safe implantation of tilting-disc or bileaflet prostheses with excellent preservation of left ventricular function.

Heart Valve Prosthesis↗
PubMed1980

Simplified intraoperative technique to test mitral valve repair.

The success of mitral valve repair for regurgitation or stenosis can largely be determined at the time of operation. Mitral valve repair is tested by creating aortic regurgitation, which fills the left ventricle with systemic aortic perfusion pressure. The competent mitral valve is salvaged and the incompetent valve is replaced.

Heart Valve Prosthesis↗
PubMed2006

Mitral valve repair robotic versus sternotomy.

OBJECTIVE: Robotically assisted mitral valve repair were compared with sternotomy mitral valve repair. Prospectively we evaluated safety and efficacy in performing simple mitral repairs. METHODS: Between February 2004 and September 2005, 25 patients with posterior leaflet insufficiency underwent mitral valve repair using the da Vinci system. They were matched retrospectively with 25 patients who underwent the same repair via a median sternotomy. The minimal invasive repairs were performed with peripheral cardiopulmonary bypass, transthoracic aortic cross-clamp, and antegrade cardioplegia. Repair was performed with two ports and a 4-cm intercostals lateral incision in the right chest for access. All patients had posterior leaflet resection and placement of a ring annuloplasty. RESULTS: All patients had successful valve repairs. There were no deaths. There was one conversion to an extended thoracotomy in the minimal invasive group due to a bleeder on the left atrial appendage. Overall mean study times showed a longer aortic cross-clamp (range, 96.1 min vs 69.6 min) and cardiopulmonary bypass (range, 122.1 min vs 85.7 min) for the minimal invasive group. Length of stay was less for the minimal group (7 days vs 9 days). At postoperative echocardiography two patients in both group developed 2+ mitral regurgitations. All other patients had a competent mitral valve repair with no insufficiency. CONCLUSIONS: Simple mitral valve repair can be successfully performed with the da Vinci robotic system. This approach is as safe as a sternotomy and long-term follow-up is needed to determine the durability of the mini invasive repair.

Aged↗
PubMed1987

High occurrence of mitral valve prolapse in cardiac catheterization patients with pure isolated mitral regurgitation.

The aetiological spectrum of angiographically verified pure isolated mitral regurgitation (MR) was studied in 48 consecutive adult patients (35 males). Severe MR was found in 35 patients (73%) and moderate MR in 13 patients (27%). Mitral valve prolapse (MVP) syndrome was found in 21 patients (44%). These were younger than the rest of the study population (55 +/- 13 vs. 62 +/- 6 years, p less than 0.05) and 15 (71%) of them were men. Endocarditis and chordal rupture occurred in 19% and 43% of the MVP patients. Sixteen patients (33%) had MR secondary to myocardial infarction while only three patients (6%) had MR of rheumatic aetiology. Bacterial endocarditis, hypertensive heart disease, hypertrophic obstructive cardiomyopathy and mitral annulus calcification were less frequently found. Mitral valve replacement was done in 20 (57%) of the patients with severe MR and MVP was the underlying disease in 15 (75%) of these patients. In conclusion, MVP is a frequent cause of pure isolated MR and of mitral valve replacement. In contrast to the preponderance of young females amongst MVP patients in population surveys, most of the MVP patients with MR in this study are middle-aged and elderly men.

Adult↗
PubMed1988

A technique to facilitate mitral valve replacement.

Replacement of the damaged mitral valve with a biological or mechanical prosthesis occasionally can be difficult. A technique is described that facilitates (a) exposure of the mitral valve, (b) safe excision of the mitral and subvalvular apparatus, (c) good access to the annulus for placement of interrupted sutures in an operative setting that provides good venous return, adequate myocardial protection, and the opportunity for complete removal of air. The procedures described are particularly helpful in reoperative mitral valve surgery when adhesions may limit exposure. The principles have been derived from the need for superb mitral valve exposure during reparative surgery. Perivalvular leak and myocardial rupture have been virtually eliminated by adoption of the principles outlined.

Cardiac Surgical Procedures↗
PubMed1996

Mitral valve replacement in a heart transplant recipient with iatrogenic mitral regurgitation.

A 65-year-old cardiac transplant recipient suffered rupture of the mitral valve apparatus during endomyocardial biopsy of the left ventricle. Severe mitral regurgitation resulted, and because of heart failure with progressive clinical deterioration the patient was finally subjected to mitral valve replacement. He had a favorable postoperative course and is now asymptomatic.

Aged↗
PubMed1989

CT of aortic and mitral valve calcification.

In a retrospective study of 100 patients 40 years of age or older, routine CT of the thorax demonstrated calcification of the aortic valve in five and mitral valve in five. The prevalence of valvular calcification increased with increasing age; calcification was present in 36% of patients over 70 years of age and 75% over 80. None had a history of rheumatic fever; in nine of 10 cases valvular calcification appeared to be degenerative in etiology. In one younger patient, aortic valvular calcification occurred in a congenitally bicuspid valve. Aortic valvular calcification on CT is specific for aortic stenosis; CT also demonstrates the calcification earlier than either plain radiographs or echocardiography. In the elderly, mitral valve calcification on CT seems to occur as a manifestation of degenerative changes in the mitral valve and anulus and may be associated with mitral insufficiency, mitral valve prolapse, or conduction abnormalities. Two-dimensional echocardiography and doppler interrogation of the valves should be done in any patient in whom CT demonstrates aortic or mitral valvular calcification.

Adult↗
PubMed2004

Diverticulum arising from mitral valve.

Diverticula arising from the mitral valve are very rare. They are usually detected by echocardiography as masses arising from the cardiac valves. We present a case of an incidental finding of a diverticulum arising from the mitral valve. This was initially detected by transesophageal echocardiography, and later confirmed by pathologic appearance. The case illustrates the unique findings on echocardiography that would help to differentiate diverticula from other valvular masses.

Aortic Valve Insufficiency↗
PubMed2004

[Acute mitral valve insufficiency caused by chordae rupture].

The common causes of mitral valve chordae rupture are myxomatous valve disease, infective endocarditis. Acute mitral valve insufficiency from chordae rupture, severe clinical symptoms such as dyspnea and shock are observed. Diagnosis is made with clinical symptoms, chest X-ray and echocardiography. Echocardiography is very useful to evaluate the exact lesions. First, inotropic agents, dilators and intraaortic balloon pumping (IABP) are used to stabilize hemodynamic status. Once hemodynamic status becomes unstable in spite of such therapy, surgical correction of mitral regurgitation (MR) is considered. Mitral valve repair should be the first choice of surgical repair, because it preserves left ventricular function, avoids anti-coagulation therapy. Quadrangular resection and suture, annuloplasty and artificial chordae are reliable surgical techniques. If mitral valve repair is difficult, mitral valve replacement is another option. From 1994 to 2002, there were 12 patients who underwent emergency mitral valve surgery because of chordae rupture. There were 7 men and 5 women with mean age of 52.7+/-14.3 years old. Nine of them received mitral valve repair. Two patients were infective endocarditis. Preoperative MR grade was 4.0+/-0.0. Postoperative MR grade was 0.2+/-0.2. Mean follow-up period was 3.8 years. There were no cardiac events and reoperations. Repair technique is quite reliable even in patients with multiple lesions, and the surgical results were almost same as single lesion patients. Repair technique should be the first choice to treat acute MR caused by chordae rupture.

Aged↗
PubMed2001

Emergency pulmonary autograft mitral valve replacement in a child.

Mitral valve replacement in small children imposes significant clinical difficulties because of the relatively small mechanical prosthetic valves required and the need for lifelong anticoagulation therapy. A child weighing 10.4 kg presented with thrombosis of her 19-mm mechanical mitral prosthesis 4 weeks after implantation despite appropriate oral anticoagulation therapy. An emergency mitral valve replacement with a pulmonary autograft was successfully performed with encouraging short-term results.

Emergencies↗
PubMed2002

Chordal-sparing mitral valve replacement using artificial chordae tendineae for rheumatic mitral stenosis: experience of the "oblique" method.

Chordal-sparing mitral valve replacement (CSMVR) has been proven to be beneficial for postoperative left ventricular (LV) function. In patients with mitral stenosis, however, diseased chordae tendineae (CT) often have to be replaced using artificial CT to achieve CSMVR. Previously, we reported that resusupension of artificial CT in an oblique direction enhances systolic LV function. Among 40 consecutive patients with mitral valve replacement (MVR), 17 (4 men and 13 women; mean age 66.5 years) with rheumatic mitral stenosis underwent CSMVR with oblique resuspension. Echocardiography was done before the operation, early (mean 25 days) after the operation, and at a late stage (mean 14 months). There was no mortality or major morbidity. LV ejection fraction late after the operation (68 +/- 8%) was better than that in the early period (61 +/- 8%, p < 0.01), and comparable to the preoperative level (65 +/- 9%). The oblique method may help to improve the results of MVR.

Aged↗