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PubMed1986

[Doppler echocardiography diagnosis and classification of the degree of aortic valve insufficiency in patients with aortic stenoses and mitral valve diseases].

To test the capacity of pulsed Doppler echocardiography in the detection and quantification of aortic regurgitation, 64 consecutive patients with aortic and mitral valve disease were examined clinically and by echocardiography before cardiac catheterization. The severity of aortic regurgitation was determined angiographically (I-IV) and compared with the extent of the regurgitant jet in the left ventricle measured by pulsed Doppler echocardiography. In 15 of 64 patients neither angiography nor pulsed Doppler echocardiography showed aortic regurgitation (specificity 100%). Apart from 3 patients with poor echo quality pulsed Doppler echocardiography correctly detected aortic regurgitation in 46 of 49 patients (sensitivity 94%). Clinical examination (63%) and M-mode echocardiography (63%) were significantly less sensitive than Doppler echocardiography (p less than 0.001). The pulsed Doppler echocardiographic degree of aortic regurgitation correlated strongly with angiography (corrected contingency coefficient 0.91). In patients with severe aortic stenosis (systolic gradient greater than 50 mm Hg) aortic regurgitation I was slightly overestimated by pulsed Doppler echocardiography (p less than 0.003). Differentiation of aortic regurgitation III and IV was not possible. Mitral valve disease did not affect quantification of aortic regurgitation (n = 23).

Adolescent↗
PubMed2002

The left atrial roof incision: an asset for minimally invasive mitral valve surgery.

BACKGROUND: The focus in minimally invasive mitral valve surgery has been on reducing thoracic incisions. Several cardiac incisions described in these procedures do not conform with the philosophy of "minimal invasiveness". We describe the left atrial roof incision which has the potential of facilitating an excellent mitral valve exposure through a limited cardiac incision, without major cardiac trauma. The safety, efficacy and technical ease of this technique for minimally invasive mitral valve surgery is evaluated. METHODS: From July 1998 to December 2000, 95 consecutive patients underwent mitral valve surgery by the same surgeon. The patients were divided into 2 groups on the basis of the cardiac incision used for correction of mitral valve disease. Group I patients had left atrial roof incision and group II patients had the traditional paraseptal incision. Each group was further classified into the minimally invasive sternotomy and standard sternotomy subgroups. The clinical variables and complications in the 2 groups were compared. RESULTS: There were 40 male and 55 female patients with a mean age of 63 +/-12yrs (range 29 to 88yrs). LARI was used for mitral valve exposure in 81 patients (85%). In 18 patients (19%), surgery was by minimally invasive technique. The mitral valve was replaced in 82% of patients and repaired in 18%. LARI provided a better exposure of the mitral valve in its anatomical and physiological disposition, without distortion. There was no significant difference in the cross clamp times and postoperative complications between the 2 groups. More patients in the LARI group regained sinus rhythm at discharge. CONCLUSION: LARI is safe and technically easy to perform. It provides an excellent exposure of the mitral valve and left heart cavities in its anatomical disposition with minimal cardiac trauma, making it ideal for minimally invasive mitral surgery.

Adult↗
PubMed1988

The pathology of mitral valve prolapse.

The gross criteria for diagnosing prolapsing mitral valve are: 1. interchordal hooding of the involved leaflets, 2. hooding or doming of leaflets towards the left atrium, 3. elongation of the involved leaflets resulting in an increase in valve area, 4. dilatation of the valve annulus in patients with severe mitral regurgitation. The posterior leaflet is most frequently affected. The involved leaflets, in general, are thickened, soft, greyish white and have a smooth atrial surface. Chordae tendineae are described as elongated, tortuous and attenuated or thinned. Deviations from normal chordal insertion have recently been observed which possibly appear to represent the underlying abnormality. Microscopic findings include significant thickening of the spongiosa and the fibrosa, changes in dense collagen fibers in the atrialis layer, occasionally, with fibrin platelet deposits. Histochemical characterization of changes in the spongiosa may also be helpful in the diagnosis. Ultrastructurally, there may be changes in collagen and elastic fibers as well as myxoid areas. On comparison of findings in surgically-removed mitral valves with those of control specimens from autopsy patients with no cardiac abnormalities, the length of the anterior and posterior leaflet as well as the annular ring diameter was larger in the valves with prolapse. Two-dimensional echocardiography accurately assessed leaflet length when compared to morphologic measurements, however, the annular diameter during systole or diastole was smaller. In patients with mitral regurgitation requiring surgery, mitral valve prolapse is the most common cause. Annular ring dilatation and chordae tendineae rupture appear to contribute substantially to incurrence of the mitral regurgitation. The heart weight is increased in the majority of patients with symptomatic mitral valve prolapse but normal, however, in those without symptoms. The most frequent complication of mitral valve prolapse is mitral regurgitation with or without congestive heart failure. Patients with redundant leaflets may be at high risk of sudden death. Young women with abnormal resting ECG, prolonged Q-T interval, family history of sudden death or complex ventricular arrhythmias may also be at a greater risk of sudden death. The incidence of infective endocarditis appears higher in those with redundant than in those with nonredundant valves. The incidence of cerebral ischemic events is low.(ABSTRACT TRUNCATED AT 400 WORDS)

Adolescent↗
PubMed1997

Mitral valve replacement with a pulmonary autograft: the mitral top hat.

Despite previous unsatisfactory results with inverted pulmonary homografts in mitral valve replacement, we have rekindled our interest in this technique by the use of a pulmonary autograft with the fully flexible 'top hat' type of mounting. The surgical technique and the clinical feasibility of the operation are presented.

Adult↗
PubMed1997

[A successful mitral valve replacement for a 13-year-old girl with mitral stenosis and pulmonary hypertension after renal transplantation].

Mitral valve replacement was successfully performed in a 13-year-old girl due to severely calcified mitral valve stenosis and pulmonary hypertension who had undergone renal transplantation from her father at the age of 8 years old. Although, percutaneous transluminal mitral commissurotomy had been performed for four times until January 1996, severe mitral stenosis could be relieved and she was transported to our hospital in emergency for respiratory failure caused by pulmonary edema. Then we decided to perform mitral valve replacement. The operation was done successfully using trans-septal superior approach with SJMHP 19 mmM. the blood cyclosporin levels were monitored and controlled within normal limits. This is the first successful case of pediatric open heart surgery after renal transplantation to our knowledge.

Adolescent↗
PubMed1994

The cumulative risks of prolapsing mitral valve. 40 years of follow-up.

Prolapsing mitral valve is a common cardiac condition, occurring in approximately 16 million people in the United States alone. Primary prolapsing mitral valve may be familial or nonfamilial and may be associated with myxomatous degeneration of the mitral valve leaflets, such as occurs in Marfan syndrome and other connective tissue disorders. Secondary forms may be associated with such entities as rheumatic fever (especially after commissurotomy) and coronary artery disease (in the presence of ruptured chordae tendineae), and with such congenital conditions as interatrial defect and primary cardiomyopathy with outflow tract obstruction. Prolapsing mitral valve is characterized by late systolic murmur, mid-systolic click, or both. Arrhythmias occur in the form of benign premature atrial contraction, premature nodal contraction, and paroxysmal atrial tachycardia. As the patient ages, atrial flutter and atrial fibrillation tend to develop. In some chronic cases, especially those involving atrial fibrillation, systemic emboli may occur. Rare premature ventricular contractions may be largely benign, whereas more frequent premature ventricular contractions may lead to severe arrhythmic complexes such as ventricular tachycardia or ventricular fibrillation. With advancing age, atrioventricular conduction defects of varying degrees or sick sinus syndrome may necessitate a pacemaker installation. About one quarter of prolapsing mitral valve cases progress, with increasing mitral insufficiency and increasing enlargement of the left atrium and left ventricle, which at times leads to congestive heart failure. Coronary artery disease may occur with the severity commensurate with the patient's age group. About three quarters of patients with prolapsing mitral valve syndrome lead normal lives.

Disease Progression↗
PubMed1975

Thoracic skeletal abnormalities in idiopathic mitral valve prolapse.

Idiopathic prolapse of the mitral valve is a common disorder, but many cases are clinically subtle. Thoracic skeletal abnormalities, reported recently to accompany the syndrome, may serve as an easily identifiable clinical indicator. The prevalence of these abnormalities was defined in 24 patients with proved prolapse of the mitral valve. The valvular syndrome was defined clinically, by echocardiography and, in seven cases, by left ventricular angiography. The skeletal deformities were defined clinically and radiographically. Pectus excavatum was present in 62 percent of the patients, "straight back" in 17 percent and severe scoliosis in 8 percent. Eighteen of the 24 patients (75 percent) had a definite thoracic skeletal deformity. The association of idiopathic prolapse of the mitral valve with these skeletal deformities may represent a forme fruste of Marfan's syndrome. Patients with "straight back" and pectus excavatum should be examined clinically and perhaps by echocardiography to exclude idiopathic prolapse of the mitral valve; when murmurs are present, a diagnosis of "pseudoheart disease" should not be made before mitral valve prolapse has been excluded.

Adolescent↗
PubMed1978

Systolic flutter of the mitral valve.

Systolic flutter of the mitral valve was observed in 11 cases during the past 3-1/2 years. All patients had mitral regurgitation due to mitral valve prolapse or flail leaflets, and nine of the 11 (82%) had prior or concurrent bacterial endocarditis. Systolic flutter is uncommon in the absence of endocarditis and was observed in only two of 15 patients (13%) with proven chordae tendinae or papillary muscle rupture without historical and pathological evidence of infection involving the mitral valve. Systolic flutter was also not seen in a large number of patients with mitral regurgitation due to other causes. It is postulated that the regurgitation jet of blood across the edge of a structurally abnormal but flexible mitral leaflet is important for the development of flutter.

Aged↗
PubMed1989

Clinical and hemodynamic results after mitral valve replacement in patients with obstructive hypertrophic cardiomyopathy.

Mitral valve replacement has been performed in patients with obstructive hypertrophic cardiomyopathy if: (1) the interventricular septum is smaller than 18 mm in the region of usual resection; (2) atypical septal morphology is encountered; (3) a previous left ventricular myomectomy has been performed but residual major obstruction and symptoms persist; or (4) intrinsic mitral valve disease exists. Since 1983, mitral valve replacement has been performed in 58 patients with obstructive HCM only. Thirty-three female patients (mean age, 47.9 years) and 25 men (mean age, 45.7 years) met criteria 1 through 3 for mitral valve replacement. Patients with intrinsic mitral valve disease (criterion 4) were omitted from this study. All patients were in New York Heart Association functional class III or IV and had failed optimal medical therapy. Low-profile mechanical prostheses and bioprostheses were implanted, and the early mortality (less than 30 days or in the hospital) was 8.6% (5/58). Six patients (11.3%) died late, 3 suddenly of probably arrhythmia, 2 of respiratory failure, and 1 of an anticoagulant-related complication. After mitral valve replacement, 40 (83%) of 48 patients surviving operation and returning for evaluation were in functional class I or II, whereas 8 patients were in functional class III. Hemodynamic data obtained 6 months postoperatively showed that pulmonary artery wedge pressure was normal (13.7 +/- 4 mm Hg [+/- standard deviation]), left ventricular end-diastolic pressure had decreased (10.9 +/- 3.4 mm Hg), cardiac index was maintained (2.6 +/- 0.6 L/min/m2), and resting and provoked gradients were unremarkable. Mean follow-up was 24.2 months, actuarial survival was 86% at 3 years, and survival free from thromboembolism, anticoagulant-related complication, reoperation, and congestive heart failure for the same interval was 68%. Complications such as ventricular septal defect and complete heart block are avoided in patients undergoing mitral valve replacement, but device-related and cardiac-related complications can add to the morbidity and mortality in these patients in the long term.

Adult↗
PubMed2000

Homograft mitral valve replacement: five years' results.

OBJECTIVE: Results of mitral valve replacement with a mitral homograft were evaluated at 5 years to assess the suitability of the procedure. METHODS: Thirty-seven patients (25 male subjects) aged 10 to 49 years (mean, 32 +/- 10 years) with rheumatic mitral valve disease underwent total (n = 35) or partial (n = 2) mitral valve replacement with a fresh antibiotic-preserved (n = 23) or cryopreserved (n = 14) mitral homograft. The predominant lesion was mitral stenosis (n = 30). RESULTS: There were 5 early deaths. Operative survivors were followed up for 1 to 60 months (mean, 26.6 +/- 12 months). Among these, 21 patients had severe mitral regurgitation during the follow-up period; 3 died and 8 underwent reoperation. The homograft failure rate was not affected by preoperative physiologic lesion (stenosis vs regurgitation, P =.4), type of homograft (antibiotic-preserved vs cryopreserved homograft, P =.9), papillary muscle pretreatment (yes vs no, P =.9), or addition of posterior collar annuloplasty (yes vs no, P =.2). Among the remaining patients, 5 had moderate mitral regurgitation, 4 had either trivial or mild mitral regurgitation, and 2 were lost to follow-up. Study of the explanted mitral homografts (n = 8) revealed that disruption of one of the donor papillary muscles was responsible for early failures (n = 2), whereas cuspal and chordal degeneration was responsible for late failures (n = 6). Microscopically, the explanted valve lacked any viable cellular elements, and there was no evidence of immunologic injury to the homografts. CONCLUSION: The mitral homograft did not fulfill our expectations as a suitable substitute for the diseased mitral valve.

Adolescent↗
PubMed1989

[Postoperative thromboembolism of acquired mitral valve disease--comparison between valve replacement and commissurotomy].

Thromboembolism after mitral commissurotomy (MC) was compared with that after mitral valve replacement (MVR). In 216 surgical cases of acquired mitral valve diseases, including combined operative cases of other valves, thromboembolic complications after MC were observed in 9/137 cases (13 times, 0.94%/patient-year), and those after MVR in 8/70 cases (11 times, 2.55%/patient-year). No thromboembolism occurred in 9 cases of annuloplasty. Thromboembolism-free period after MVR (49 +/- 44 months) was significantly shorter than that after MC (102 +/- 43 months, p less than 0.05). Postoperative CTR of thromboembolic cases (69.5 +/- 8.2%) was significantly larger than that of non-thromboembolic cases (61.4 +/- 9.9%) in MVR group (p less than 0.005), but no significant difference existed between thromboembolic and non-thromboembolic cases in MC group. Thromboembolism after MVR occurred in severe cases, but that after MC often occurred in mild cases. Postoperative echocardiogram of MC group showed significantly lower DDR in thromboembolic cases (1.9 +/- 0.7 cm/sec) than in non-thromboembolic cases (3.2 +/- 1.2 cm/sec, p less than 0.025). Mitral valve area (MVA) of all re-stenotic cases in thromboembolic cases after MC was under 1.5 cm2, comparing that in non-thromboembolic cases there were only two cases that had MVA under 1.5 cm2. After MC, careful management including anticoagulant therapy and reoperation is necessary especially in patients with atrial fibrillation, DDR under 2 cm/sec, and MVA under 1.5 cm2, even though they don't have cardiomegaly.

Adult↗
PubMed1984

Intermittent premature mitral valve closure in combined acute severe aortic and mitral regurgitation.

We have described the clinical, hemodynamic, and echocardiographic features of torn aortic cusps with mitral valve fenestration in a patient with infective endocarditis. Hemodynamic studies showed left atrial pressure intermittently exceeding left ventricular end-diastolic pressure. This phenomenon corresponded with intermittent premature mitral valve closure, which may serve as a marker for M-mode echocardiographic diagnosis in combined severe acute aortic and mitral regurgitation.

Acute Disease↗
PubMed2001

[Early outcome with the Alfieri mitral valve repair].

OBJECTIVES: Mitral regurgitation in cases of prolapse of the anterior leaflet, posterior leaflet with calcified annulus, or prolapse of both leaflets is thought to be difficult to repair. The Alfieri repair has been developed to address these conditions. METHODS: Seven patients (four men and three women, mean age 71 +/- 9 years) underwent the Alfieri repair for mitral regurgitation at Austin and Repatriation Medical Centre between January 1999 and December 1999. The mechanism of mitral regurgitation was prolapse of the posterior leaflet with calcified annulus in one patient, prolapse of the anterior leaflet in two, and prolapse of both leaflets in four. Mitral regurgitation before operation was severe in all patients. The Cosgrove ring was used in all patients. Four patients underwent combined operation, coronary artery bypass surgery in three and tricuspid annuloplasty in one. RESULTS: There was no hospital death. Two patients had postoperative complications, transient ischemic attack in one patient and rapid atrial fibrillation in one. The mean hospital stay was 11.3 +/- 8.7 days. Mitral regurgitation after operation was mild in five patients and trivial in two. Mean pressure gradient of the transmitral valve was 4.0 +/- 1.4 mmHg. CONCLUSIONS: The Alfieri mitral valve repair is a simple and satisfactory technique to repair mitral regurgitation in selected patients. Long-term follow-up is required to evaluate the durability of this technique.

Aged↗