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PubMed2004

Independent factors associated with outcomes of parachute mitral valve in 84 patients.

BACKGROUND: Parachute mitral valve (PMV) is defined as a unifocal attachment of the mitral valve chordae to a single or dominant papillary muscle and may cause subvalvar obstruction. We sought to determine factors associated with outcomes. METHODS AND RESULTS: Patients (n=84; 64% male) who presented between 1977 and 2001 at a median age of 3 days (range, birth to 5.4 years) were assessed with PMV (without atrioventricular septal defect). Associated cardiac anomalies in 99% included aortic coarctation in 68%, atrial septal defect in 54%, ventricular septal defect in 46%, aortic valve stenosis in 32%, subaortic stenosis in 20%, and left ventricular hypoplasia in 19%, with complex anomalies in 14%. Noncardiac anomalies were noted in 32%. Survival (n=18 deaths) was 82% at 1 year and 79% at 10 years, with independent risk factors including left ventricular hypoplasia (P<0.001) and atrial septal defect (P<0.003). Freedom from surgical mitral valvotomy (n=11 patients) was 95% at age 6 months and 80% at 10 years, with independent risk factors including the absence of aortic coarctation (P<0.02) and the presence of subaortic stenosis (P<0.04). There was no significant increase in mean gradient of the PMV over time, but higher gradient was independently associated with the presence of supravalvar mitral stenosis (P<0.001), absence of atrial septal defect (P<0.04), presence of ventricular septal defect (P<0.02), and subsequent mitral valvotomy (P<0.01). CONCLUSIONS: Outcomes for patients with PMV are dependent on the spectrum of associated cardiac lesions. The degree of mitral valve obstruction remains stable, and the majority will not require valvotomy.

Abnormalities, Multiple↗
PubMed2006

Meta-analysis of clinical outcomes following surgical mitral valve repair or replacement.

Although the use of mitral valve surgery has been successful at alleviating mitral valve disease, published studies on either replacement or repair have yielded mixed clinical outcomes regarding differences between repair and replacement. Meta-analysis of various outcomes from 29 published studies was conducted. Studies were separated into four groups by etiology of disease: ischemic; degenerative/myxomatous; rheumatic and mixed. The summary odds ratio for early mortality, comparing replacement to repair, was 2.24 (1.78-2.80), while the summary total survival hazard ratio was 1.58 (1.41-1.78), replacement compared to repair, indicating worse outcomes among those undergoing mitral valve replacement. The risk of thromboembolism was lower in the repair group (summary hazard ratio=1.86, replacement vs. repair), while there was no statistical difference in time to re-operation between the two treatment groups (hazard ratio=0.88 [95% confidence interval: 0.48, 1.62]). Analysis stratified by etiologic classification was able to detect strong evidence of differences in 30-day and total survival outcomes favoring repair for three disease groups (rheumatic, mixed and degenerative). Surgery for ischemic mitral valve had lower 30-day mortality for repair than replacement, but no statistically significant difference in the overall survival was detected. The reported information in the published studies used in the current work lacks sufficient detail to allow summary determination of outcomes by mitral valve repair techniques and by type of mitral valve replacement.

Heart Valve Diseases↗
PubMed2005

Update on mitral valve surgery.

Recently, the outcome for patients with mitral valve disease has significantly improved. This may be due to concomitant advances in many fields. In particular, the development of surgical techniques has contributed to this improvement, and many surgical techniques and topics are introduced in this article. After the evaluation of results in mitral valve surgery and exploration of the relationship between the mitral valve and the mitral subvalvular apparatus, it is currently accepted that mitral valve repair is superior to replacement and that replacement with preservation of the mitral subvalvular apparatus is preferable to replacement alone. Another current topic is mitral repair in dilated cardiomyopathy. Mitral regurgitation is a known complication of end-stage cardiomyopathy and is associated with a poor prognosis because of progressive mitral annular dilatation. Recently, to solve this problem, undersized mitral annuloplasty or cardiomyoplasty has been advocated. In the future, mitral valve surgery may be performed off-pump or by a percutaneous approach. Several groups are investigating the use of new devices and new techniques that avoid cardiopulmonary bypass in experimental studies. In this article, we review current topics and discuss our experiences in mitral valve surgery.

Heart Valve Diseases↗
PubMed1996

[Nonrheumatic calcification of the mitral valve in patients with stenotic calcified bicuspid aortic valve].

The pathogenesis of nonrheumatic calcification of the mitral valve was investigated by analyzing the clinical and echocardiographic characteristics of patients with mitral valvular calcification without any findings suggestive of rheumatic heart disease or infective endocarditis. Calcification of the mitral valve was observed in nine patients, who all had calcified stenotic (aortic valve area < 1 cm2) bicuspid aortic valve. Calcification of the mitral valve was localized to the basal portion of ventricular aspect of the anterior mitral leaflet and contiguous to that of the aortic valve. Mobility and thickness of the mitral leaflet was normal except for the calcified portion. Calcification of the mitral valve was not contiguous to posterior mitral annular calcification nor was related to direction of aortic regurgitant flow. In patients with calcified stenotic bicuspid aortic valve, calcification of the mitral valve was not associated with location of the two aortic cusps, aortic valve area, aortic valvular peak pressure gradient, direction of the left ventricular outflow, end-diastolic left ventricular outflow tract dimension, end-diastolic dimension of the aortic annulus, incidence of aortic regurgitation, calcification of the aortic arch, or risk factors of atherosclerosis. Six patients with mitral valvular calcification had aortic valve replacement. Preoperative coronary angiogram of these patients was normal. Calcification of the aortic valve was on the ventricular and aortic aspects. The calcification of the aortic valve, anterior mitral ring, or anterior mitral leaflet was not rheumatic in these six patients. Rheumatic disease, risk factors of atherosclerosis, mechanical stress by left ventricular outflow or aortic regurgitant flow, or mitral annular calcification did not appear to be related to mitral valvular calcification. The distribution of aortic and mitral valvular calcification suggested that the calcification of the mitral valve was due to progression of calcification of the bicuspid aortic valve.

Aged↗
PubMed1987

[Noninvasive method of studying intracardiac and systemic hemodynamics in a mitral valve lesion by calculating the mitral regurgitation volume and mean dynamic pressure in the left atrium].

Comparative hemodynamic studies, making use of different techniques, have demonstrated that tetrapolar transthoracic rheoplethysmography is a very accurate instrument of determining effective stroke volume in cases of mitral regurgitation, and that the latter can be detected by echocardiography and rheoplethysmography. Intracardiac hemodynamic disorders can be assessed on the basis of echographic estimates of left-atrial mean dynamic pressure.

Adult↗
PubMed1993

[Right ventricular function in patients with rheumatic mitral valve stenosis. Effect of balloon mitral valvuloplasty].

UNLABELLED: Postrheumatic mitral stenosis might cause impairment of right ventricular (RV) function due to both an increase in RV afterload and rheumatic myocardial disease. Therefore, we investigated in 19 patients with postrheumatic mitral stenosis and sinus rhythm right ventricular volumes and hemodynamics by a computerized thermodilution catheter during rest and supine bicycle exercise. In 14 patients the investigation was repeated within 2 days after balloon mitral valvuloplasty. Resting RV ejection fraction was decreased (43 (15-53)%, median (range)) and correlated significantly with RV end-systolic volume index (r = -0.90), stroke volume index (r = 0.77), RV end-diastolic volume index (r = -0.76), heart rate (r = -0.69), pulmonary artery resistance (r = -0.69), and mean pulmonary artery pressure (r = -0.68). RV end-diastolic volume index was 107 (81-200) ml/m2. Exercise induced a decrease of RV ejection fraction to 36 (13-48)% at 50 Watt (p < 0.001), while it increased RV end-diastolic volume index to 131 (78-231) ml/m2 (p < 0.001). Balloon mitral valvuloplasty improved RV ejection fraction at rest from 41 (15-47)% to 48 (39-55)% (p < 0.005) and from 30 (13-46)% to 43 (27-56)% during exercise (p < 0.005). The increase of RV ejection fraction after valvuloplasty was caused by an increase in stroke volume, but not by a reduction in RV end-diastolic volume. CONCLUSION: Depending on the increased RV afterload, RV function is markedly depressed in mitral stenosis. An immediate and almost complete improvement of RV function occurs with the reduction of RV afterload after balloon mitral valvuloplasty.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1993

Left atrial plication and mitral valve replacement for giant left atrium accompanying mitral lesion.

Between January 1982 and November 1992, 38 patients received simultaneous mitral valve replacement (MVR) and left atrial plication (LAP) because of giant left atrium accompanying mitral lesion. Their ages ranged from 33 to 70 years, and the mitral lesion was caused by rheumatic heart disease in all patients. MVR was performed with a St. Jude Medical prosthesis for all patients and the left atrial wall was plicated with running 3-0 Nespolene to reduce the width to 3 to 5 cm. Respiration requiring mechanical ventilation more than 48 hours after operation occurred in four patients (10.5%) and postoperative low cardiac output requiring a high dose of dopamine HCl or intraaortic balloon pumping in nine patients (23.7%). The left atrial diameter measured by echocardiogram was a mean of 7.3 +/- 1.0 cm before operation and 5.8 +/- 1.0 cm postoperatively. The cardiothoracic ratio on the chest roentgenogram registered a preoperative mean of 73.3% +/- 9.8% and was 65.7% +/- 8.4% after operation. The pre- and postoperative values were significantly different (p < 0.01). The postoperative exercise level was a mean of 5.3 metabolic units for 24 patients and the postoperative New York Heart Association functional classification indicated Class I or II for 37 patients with no evidence of left atrial thrombus except in the case of one early death. LAP with MVR for patients with giant left atrium due to mitral lesion appeared to result in improvement in respiratory and circulatory functions.

Adult↗
PubMed1999

Expanding the use of total mitral valve preservation in combination with implantation of the CarboMedics heart valve prosthesis.

BACKGROUND: Preservation of the mitral valve and subvalvular apparatus was introduced into the clinic in the early sixties, but for two decades the standard technique for mitral valve replacement included excision of both leaflets and their attached chordae tendineae. Lately, increased emphasis has again been placed on retention of the mitral subvalvular apparatus during valve replacement because of its role on left ventricular function. METHODS: We have preserved the valvular and subvalvular mitral apparatus, when possible, in connection with mitral valve replacement during the last seven years and the present investigation (partly prospective and partly retrospective) was done with the aim of making up the results of our mitral preservation technique. In the period between January 1990 and December 1995, 30% of the patients who underwent mitral valve replacement had complete retention of all mitral tissue. In 1996, the percentage had increased to 50, and during the first seven months of 1997, 70% of the patients had complete retention of all mitral tissue. Since January 1997, we have exclusively used the CarboMedics mitral heart valve prosthesis. A total of 56 patients were identified to have had a CarboMedics heart valve prosthesis implanted. There were 33 men and 23 women with a mean age of 63 years, range 23-77 years. Coronary bypass was a concomitant procedure in 22 patients. In seven patients, both the mitral and aortic valves were replaced. A severely altered valve with thickened and or calcified leaflets, stenotic leaflets, or shortened, retracted and thickened chordae tendineae were not a contraindication for the procedure. Calcified plaques were removed. Adhesion between anterior and posterior leaflets was treated with sharp dissection. Valve and subvalvular tissue were preserved. The leaflets were reefed within the valve-sutures and compressed between the sewing ring and the native annulus when implanting the valve prosthesis. Chordal tension on the ventricle was thereby maintained and the chordae pulled away from the valve effluent. Echocardiography with measurement of ejection-fraction was performed preoperatively during the postoperative course in case of cardiac problems and on a routine basis 1 month after surgery and at various intervals when the patient was seen in the outpatient clinic. Left ventricular outflow tract gradients were measured during the postoperative course in case of cardiac problems and routinely 1 month postsurgically. RESULTS: Five patients died in the postoperative period and one patient had transient neurological symptoms. In none of the patients was death or transient neurological symptoms a consequence of the retention of mitral leaflets with subvalvular apparatus. The remaining 51 patients were all alive at follow-up. Postoperative echocardiography demonstrated a preserved left ventricular function and a left ventricular outflow tract without obstruction. CONCLUSIONS: We find that the described technique in combination with implantation of a CarboMedics heart valve prosthesis is very useful even in patients with a severely altered valve, when preserving the mitral leaflets with subvalvular apparatus during valve replacement. The technique is without procedure related complications and preserves left ventricular function without obstructing the left ventricular outflow tract.

Adult↗
PubMed2001

[A case of pyoderma gangrenosum after mitral valve replacement].

A 48-year-old male with treated hypothyroidism underwent mechanical valve replacement for mitral valve regurgitation. After the operation, the patient developed progressive median chest wound ulceration. The wound did not heal with conventional therapies for mediastinitis such as administration of antibiotics, debridement of necrotic tissue or continuous irrigation. The entire surgical wound opened spontaneously. Bacterial cultures yielded negative and the wound biopsy specimen revealed non-specific inflammatory change. The anti-TSH receptor antigen level was high. Pyoderma gangrenosum based on auto-immune deficiency was diagnosed and high dose corticosteroid therapy was started. The wound healed completely in 5 months.

Autoantibodies↗
PubMed1986

New guidelines for the clinical diagnosis of mitral valve prolapse.

Because the term mitral valve prolapse has pathologic connotations, considerable effort has been expended to establish acceptable diagnostic standards, but without general agreement. This report combines information from the history, physical examination, electrocardiogram, chest x-ray and 2-dimensional echocardiogram in an effort to avoid the artifice of using the 2-dimensional echocardiogram as a categoric reference standard and to establish new clinical guidelines that distinguish pathologic mitral valve prolapse--a primary connective tissue abnormality of leaflets, chordae tendineae and anulus--from normal superior systolic displacement of mitral leaflets. The objective is to avoid implications of heart disease in healthy young persons within the gaussian distribution of normal. To this end, and with the Jones criteria as a model, major and minor criteria are proposed for the clinical diagnosis of mitral valve prolapse as a pathologic entity.

Angiocardiography↗
PubMedDate not supplied

Minimally invasive approach for redo mitral valve surgery: a true benefit for the patient.

OBJECTIVES: Redo mitral valve surgery via sternotomy is associated with a substantial morbidity and mortality. This study evaluated a minimally invasive technique for mitral valve redo procedures. MATERIAL AND METHODS: Out of a series of 394 patients undergoing mitral valve repair or replacement via a right minithoracotomy, 39 patients underwent redo mitral valve surgery (59+/-13 years, 23 female). Previous cardiac surgeries included 17 patients with mitral valve repair, 6 patients with mitral valve replacement, 3 patients with aortic valve replacement, 2 patients with atrial septal defect closure, and 11 patients with coronary artery bypass grafting (CABG). In all cases, femoro-femoral cannulation was performed. The port access technique was applied in patients undergoing redo valve surgery. In patients with prior CABG, the operation was performed using deep hypothermia and ventricular fibrillation. RESULTS: In all cases, sternotomy was avoided. The mitral valve was replaced in 20 patients and repaired in 19. Time of surgery and cross-clamp time were comparable with the overall series (168+/-73 [redo] vs 168+/-58 min and 52+/-21 [redo] vs 58+/-25 min). Mortality was 5.1%. One patient had transient hemiplegia due to the migration of the endoclamp. All other patients had uneventful outcomes and normal mitral valve function at 3-month's follow-up. CONCLUSION: Redo mitral valve surgery can be performed safely using a minimally invasive approach in patients with a previous sternotomy. The right lateral minithoracotomy offers excellent exposure. It minimizes the need for cardiac dissection, and thus, the risk for injury. Avoiding a resternotomy increases patient comfort of redo mitral valve surgery.

Adult↗
PubMed1992

Can mitral regurgitation after balloon dilatation of the mitral valve be predicted?

OBJECTIVE: To determine which factors predict the occurrence of mitral regurgitation after balloon dilatation of the mitral valve for rheumatic stenosis. DESIGN: Analysis of a case series of patients with rheumatic mitral valve stenosis who had had successful balloon dilatation of the mitral valve. SETTING: A tertiary care centre with an experience of over 150 balloon dilatations of the mitral valve. PATIENTS: 70 young patients with non-calcified rheumatic mitral stenosis, who had undergone successful balloon dilatation of the mitral valve. No patient had mitral regurgitation or atrial fibrillation before dilatation. INTERVENTION: Dilatation of the mitral valve by the transvenous, transatrial double balloon technique. MAIN OUTCOME MEASURE: Development of mitral regurgitation after balloon dilatation of the mitral valve and its relation to age, mitral valve area before dilatation and after dilatation, the degree of mitral subvalvar pathology, and the size of balloon used for dilatation. RESULTS: In 10 patients (14%) mitral regurgitation developed after balloon dilatation of the mitral valve. No statistically significant differences were found between patients who did not develop regurgitation and those who did in terms of age (mean (SD)) (19.9 (6.46) v 19.4 (5.5)), mitral valve area before dilatation (1.05 (0.33) v 0.94 (0.4) cm2) and after dilatation (2.52 (1.06) v 2.45 (1.1) cm2), mitral subvalvar pathology assessed by the mitral subvalvar distance ratio (0.116 (0.03) v 0.118 (2.32), or balloon diameter corrected for body surface area (21.37 (3.5) v 20.57 (2.32) mm/m2. CONCLUSIONS: In this subset of children and young adults with non-calcified mitral stenosis, none of the morphological, technical, or patient characteristics studied predicted the development of mitral regurgitation after balloon dilatation. The low incidence of mitral regurgitation may have reduced the discriminatory power of this study. None the less, the means and standard deviation for each factor in each group suggest that even in a larger sample size the variables would have little predictive capacity.

Adolescent↗
PubMed1994

Optimal approach for mitral valve surgery.

It seems that mitral valve (MV) replacement technique is already standardized but still under discussion is the surgical approach. At Heart Surgery Clinic of Vilnius University MV replacement was started in 1970 (our total experience in valve surgery is 4396 operations). The most popular surgical approach was through left atrium (LA) from the right side. In cases with small atrium we used right atrial and transseptal and transverse transeptal biatrial (TTBA) approach. Left atrium approach is quite useful in many cases except those with small LA, LV hypertrophy and heart rotation when it can result a greater trauma for the heart, extended time of operation and, possibly, reduced performance after it. From September 1992 till May 1993 we used extended vertical transseptal (EVT) approach in 18 patients for MV replacement or repair, mitral and aortic valve replacement was performed for 5 patients, mitral valve replacement and tricuspid valvuloplasty for 13 patients, 5 patients had mitral valve reoperations and for 3 patients aortocoronary by-pass performed additionally. The technique used was exactly as proposed by O. Alfieri et al, and incorporated bicaval cannulation and vertical transseptal incision extended into the roof of LA. From the first operation it became clear that this approach was superior to all others we had used during 20 years, since it gives perfect visibility of mitral valve, does not require retractors (only traction sutures are applied) and allows even to very easily use the continuous suture for valve fixation. Size of LA is no longer important.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1977

Echocardiographic features of straddling mitral valve.

A case of straddling mitral valve associated with double outlet right ventricle and coarctation of the aorta is presented. Radical operation (Jatene's procedure) was performed under the diagnosis of complete transposition of the great arteries associated with coarctation of the aorta. The patient could not survive the operation. Autopsy revealed that both of the great vessels originated in the right ventricle (double outlet right ventricle). In addition to this abnormality, some of the chordae of the mitral leaflet were attached to the right ventricular wall through the ventricular septal defect (straddling mitral valve). Echocardiograms recorded prior to the operation revealed feactures corresponding to the anatomical abnormalities, including that the anterior mitral leaflet moved far anterior to the ventricular septum. This is the first case of echocardiographic features of straddling mitral valve.

Aorta↗
PubMed1998

[Relative valve area stenosis after replacement of a Starr-Edwards mitral valve (model 6520) for corrected TGA (S, L, L): report of a case].

The patient was a 38-year-old man who had undergone mitral valve replacement with a Starr-Edwards disc valve (model 6520, 3 M, phi 30 mm, functional valve area: 2.85 cm2) at the age of 15 years for TR combined with corrected TGA. He developed dyspnea on exertion and palpitations at the age of 30 years, and paroxysmal supraventricular tachycardia appeared at the age of 35 years. Cardiac catheterization revealed that the PCWP was 30 mmHg and the TVA was 1.1 cm2, and a diagnosis of stenosis of the prosthetic valve was made. Thus, replacement of the Starr-Edwards disc valve using a BICARBON double leaflet valve (phi 27 mm, functional valve area: 2.85 cm2) was performed. The operative findings of the Starr-Edwards disc valve revealed a normal appearance and no pannus growth. Postoperative echocardiography and cardiac catheterization found that the TVA was 3.7 cm2 and the PCWP was 13 mmHg. The actual valve area of the disc valve sewn on the ventrical, which was anatomically RV construction might have been smaller than the ideal area; however, the double leaflet valve proved efficient in our patient. This case report serves to demonstrate that because of the postoperative difference in measurement between the actual valve area and the prostheticin ball or disc valve, patients undergoing mitral valve replacement must be followed up carefully.

Adult↗
PubMed2001

Valvuloplasty with glutaraldehyde-treated autologous pericardium in patients with complex mitral valve pathology.

BACKGROUND: Severe mitral regurgitation associated with complex mitral valve disease often precludes successful surgical repair. The feasibility and the results of valvuloplasty with glutaraldehyde-treated autologous pericardium remain largely unknown. METHODS: The cases of 63 patients who underwent operation within an 11-year period were studied. A pretreated autologous pericardial patch was used for leaflet extension plasty, for paracommissural plasty, as a substitute for part of the leaflet, and for reimplantation of ruptured papillary muscles to eliminate severe mitral regurgitation. Patients with a severely calcified annulus after en bloc decalcification had straddling endoventricular pericardial patch annuloplasty for reconstruction of the affected atrioventricular groove. Chordal replacement with a strip of pericardium was chosen if no suitable chordae were available. Pericardium-reinforced suture annuloplasty was used in patients with acute endocarditis resistant to medical therapy. Associated valvuloplasty procedures with Carpentier techniques were also employed. RESULTS: There were no operative deaths in this series. At a mean follow-up of 61.1 months (range, 4 to 132 months), mitral regurgitation was absent or trivial in 92.1% of patients by echocardiography. Freedom from reoperation was 95.2% at 1 year and 5 years. Thromboembolic events have not been detected. Thirty percent of patients returned to sinus rhythm. Two patients required valve replacement. CONCLUSIONS: Our beneficial results indicate that glutaraldehyde-treated autologous pericardium is suitable for valvuloplasty. It provides durable and predictable repair of valves that might otherwise need to be replaced because of the complex mitral valve disease. The technique is reliable, allows further efficacious repair possibilities, and improves postoperative outcomes. Whether it can prevent late deterioration and calcification requires more investigation.

Adult↗
PubMed1986

Age and the clinical profile of idiopathic mitral valve prolapse.

The prevalence of mitral valve prolapse was determined in two independent populations (6887 consecutive adults and children referred for echocardiography during a three year period and 206 non-referred first degree relatives of 65 patients with mitral valve prolapse). In the 118 adults with echocardiographic evidence of prolapse those aged greater than or equal to 50 years were significantly more likely to have pansystolic murmurs and increased echocardiographic dimensions than those aged less than 50 years; and patients with complications of mitral valve prolapse were significantly older than those without. In the population referred for echocardiography and in the non-referred relatives there was a significant increase in prevalence in the two decades after adolescence (20-39 years) compared with that in the first two decades. The data suggest that prolapse principally becomes manifest in late adolescence when the growth spurt is complete and that thereafter the severity of prolapse increases with age in an important subset of patients. The latter findings accord with the predictions of the response to injury hypothesis for the pathogenesis of progressive changes.

Adolescent↗