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PubMed1997

Surgical treatment of aortic root abscess with damage of the mitral valve apparatus.

A 35-year-old man with an aortic root abscess successfully underwent aortic valve replacement and mitral valve repair using a prosthetic valve with a skirt which was secured to the sewing cuff. This is a useful technique for reinforcement of a fragile annulus and prevention of annular detachment. A further useful technique is to infuse normal saline from a Foley catheter inserted into the aortic root to estimate mitral valve coaptation.

Abscess↗
PubMed1985

Mitral valve prolapse and hyperthyroidism: effect of patient selection.

Patients with mitral valve prolapse and hyperthyroidism have common symptoms; the most outstanding symptom is palpitation. To determine whether or not common symptoms contributed to the reported association of these conditions, we evaluated 220 patients with symptomatic mitral valve prolapse and 216 first-degree relatives in 72 families; 65 relatives with mitral valve prolapse and 151 relatives without mitral valve prolapse, all greater than or equal to 16 years of age. Thirty subjects, aged 49 +/- 13 years (p less than 0.025 vs entire study group), had thyroid disease (23 subjects had definite thyroid disease, seven subjects had probable); 27 of 30 subjects with thyroid disease (90%) were female (p less than 0.005). The age- and sex-adjusted prevalence of hyperthyroidism was significantly higher in probands with mitral valve prolapse than in family members without mitral valve prolapse (3.5% vs 0%, p = 0.03), while an intermediate prevalence of hyperthyroidism (2.2%) was observed in family members with mitral valve prolapse. Thus, the prevalence of hyperthyroidism is increased among symptomatic patients with mitral valve prolapse as compared to family members without mitral valve prolapse, but the prevalence of thyroid conditions is similar among family members with or without this condition. These findings are explained by the effect of common symptoms on clinical detection of both mitral valve prolapse and hyperthyroidism.

Adolescent↗
PubMed2004

Surgical treatment of infective mitral valve endocarditis.

BACKGROUND AND AIM OF THE STUDY: The approach to mitral valve endocarditis is a surgical challenge, and the optimal procedure remains a matter of debate. In this condition, mitral valve repair appears feasible, but its long-term effects--as opposed to more often practiced valve replacement--have not yet been determined. Herein, the authors' experience of surgical treatment of infective mitral valve endocarditis is presented, with reference to surgical replacement or reconstruction. METHODS: A retrospective analysis was performed of all patients with infective native mitral valve endocarditis treated surgically at the University Hospital Zurich and the City Hospital Triemli Zurich between 1980 and 1996. Of 154 patients, 97 (63%) underwent mitral valve replacement, and 57 (37%) mitral valve reconstruction. RESULTS: The 30-day mortality was 3.2% (5/154); 4% (4/97) after replacement and 1.7% (1/57) after reconstruction (p = 0.67). Survival (Kaplan-Meier) was 93%, 81% and 61% after one, five and 10 years, respectively. There was no significant difference between valve replacement and reconstruction in terms of long-term survival (p = 0.15), but there was a trend towards better survival after reconstruction than replacement if only cardiac deaths were considered (p = 0.1). At follow up, reconstruction patients were significantly less frequently symptomatic (NYHA class III/IV) than replacement patients (0% versus 29%; p = 0.002), had a lower incidence of atrial fibrillation and need for pacemaker implantation (29% versus 47%; p = 0.04), and tended to have less dyspnea in daily life (20% versus 38%; p = 0.07). Reoperation in patients surviving more than 30 days was more common in replacement than in reconstruction patients. CONCLUSION: The present data suggest a trend for better clinical outcome after mitral valve reconstruction than after replacement when treating mitral valve endocarditis. These results encourage mitral valve reconstruction in mitral valve endocarditis, but recommendations to clinicians undertaking surgery on mitral valve endocarditis must be made with caution.

Adolescent↗
PubMed1986

Complications of mitral valve prolapse. Disproportionate occurrence in men and older patients.

To determine factors influencing the strength of association between mitral valve prolapse and mitral regurgitation, ruptured chordae tendineae, and infective endocarditis, the prevalence of mitral prolapse in patients with disease was compared with both clinical and population control groups. The prevalence of mitral valve prolapse was 4 percent among population and clinical control groups (eight of 196 and 84 of 2,146, respectively) and was significantly higher (p less than 0.001) in patients with endocarditis (11 of 67, 16 percent), mitral regurgitation (17 of 31, 55 percent, and ruptured chordae (27 of 43, 63 percent). Odds ratios for complications in persons with mitral valve prolapse ranged from 4.6 for endocarditis to 41.4 for ruptured chordae in overall analyses, and from 6.8 for endocarditis to 53.0 for ruptured chordae based on age- and sex-matched case-control triplets (p less than 0.001 for each). All complications occurred disproportionately in men with mitral valve prolapse, in whom odds ratios ranged from 2.5 to 7.4 compared with an additional control group of unselected subjects with mitral valve prolapse. Compared with this control group, patients with mitral valve prolapse and endocarditis were slightly more likely to have a previously known heart murmur (odds ratio 3.2, difference not significant) but significantly more likely to have murmurs at the time of evaluation (odds ratio 8.5, p less than 0.01). Patients with mitral valve prolapse and mitral regurgitation and ruptured chordae tendineae were also significantly older than the unselected subjects with mitral valve prolapse (48 +/- 14 and 55 +/- 16 versus 38 +/- 14 years, p less than 0.005 for both). The concentration of risk of endocarditis in men with mitral valve prolapse and patients with antecedent murmur suggests that antibiotic prophylaxis is warranted in these groups but not in women without a murmur of mitral regurgitation.

Adolescent↗
PubMed1989

Influence of mitral valve prosthesis or rigid mitral ring on left ventricular pump function. A study on exposed and isolated blood-perfused porcine hearts.

We have studied the effects on cardiac function of a Björk-Shiley mitral prosthesis or a rigid mitral ring implanted in pigs for as long as 6 weeks. We studied these effects first in the exposed heart and subsequently in the isolated heart. The coronary arteries were cannulated and perfused with fresh whole blood. The left ventricle was filled with an electrolyte solution and was allowed to pump against an artificial load. Studies were completed in 37 of 45 animals (19 controls, 12 with mitral prostheses and six with mitral rings). In the open-thorax situation, surgically treated hearts differed little from controls, apart from a higher pressure drop over the mitral ostium. Compared with controls, isolated hearts with a prosthesis showed a 28% lower peak isovolumic pressure and a 25% lower unloaded maximal stroke volume; hearts with a mitral ring showed 14% and 25% lower values, respectively. Prosthetic valve or ring implantation causes obstruction of the mitral ostium, impedes pressure development, and restricts movement of the basal ventricular wall. Resection of the native valve doubles the loss of contractile function.

Animals↗
PubMed1989

[Function of the right ventricle in patients with mitral valve diseases].

To investigate right ventricular function in mitral valve disease, biplane cineventriculograms of the right and left ventricle were performed in 96 patients-35 with mitral stenosis, 26 with mitral regurgitation, 12 with combined mitral valve disease, 14 with mitral stenosis and tricuspid regurgitation, and nine with mitral regurgitation and tricuspid regurgitation, compared to 18 normals (N). Right ventricular enddiastolic volume index was moderately elevated in patients with mitral stenosis and concomitant tricuspid regurgitation (111.6 +/- 35.3 ml/m2, no significance compared to N: 95.9 +/- 21.8 ml/m2) and with mitral regurgitation and tricuspid regurgitation (107.9 +/- 45.1 ml/m2, no significance compared to N). A reduced right ventricular ejection fraction (RVEF less than or equal to 50%) was found in 40 of the 96 patients. Right ventricular ejection fraction was frequently reduced in patients with mitral regurgitation and tricuspid regurgitation (46.7% +/- 15.1%) and significantly reduced in patients with combined mitral valve disease (45.0 +/- 17.6%, compared to N: 58.0 +/- 7.1%, p less than 0.01). No significant correlations were found between right ventricular ejection fraction and left ventricular enddiastolic volume or left ventricular ejection fraction in patients with mitral valve disease. Moreover, right ventricular ejection fraction did not correlate with systolic pulmonary artery pressure, mean pulmonary artery pressure or mean pulmonary capillary wedge pressure. Local wall motion (mean systolic shortening) was determined for the anterior, anteroapical, and inferior segment in the RAO-projection and for the right ventricular free wall in the LAO-projection. 63% of the patients (n = 25) with reduced right ventricular function (RVEF less than of equal to 50%) showed local wall motion abnormalities, preferably in the anterior segment of the RAO- projection (48%) and the right ventricular free wall (30%).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1999

Mitral valve reconstruction and replacement for ischemic mitral insufficiency: seven years' follow up.

BACKGROUND AND AIMS OF THE STUDY: Patients with ischemic mitral incompetence have a high operative risk whether the valve is repaired or replaced. The advantage of repair over replacement is unclear in this subgroup of patients. METHODS: Between April 1986 and December 1998, 337 patients underwent surgery for ischemic mitral valve insufficiency. Coronary artery bypass grafting (CABG) was carried out concomitantly in 314 cases (93.2%). Valve repair was performed in 140 patients (operative mortality rate 12.1%). The surgical risk in patients with a left ventricular ejection fraction (LVEF) of 10-30% was higher (operative mortality rate 33.3%) than in those with LVEF >30% (operative mortality rate 8.4%). Actuarial survival rates were 75.4%, 66.8% and 61.7% after 2, 5 and 7 years, respectively. Mitral valve replacement was performed in 197 patients (operative mortality rate 14.2%). The surgical risk in patients with a LVEF of 10-30% (operative mortality rate 30.3%) was greater than in those with a LVEF of >30% (operative mortality rate 11.0%).Actuarial survival rates after replacement were 78.6%, 73.4% 67.2% after 2, 5 and 7 years, respectively. RESULTS: Our initial analysis showed that, after mitral valve repair, mortality during follow up was greater in patients with residual mitral valve insufficiency of more than grade I. Subsequent outcome was superior when repair was evaluated perioperatively with transesophageal echocardiography. When mitral insufficiency was persistently more than grade I after repair, mitral replacement was performed. A total of 105 patients was analyzed with no or maximum grade I mitral insufficiency following valve repair; actuarial survival rates were 81%, 78.4% and 77.2% after 2, 5 and 7 years' follow up. CONCLUSIONS: Patients with highly impaired LV function and ischemic mitral insufficiency are at high risk during valve repair or replacement, and cardiac transplantation should be considered for this group. However, patients with ischemic mitral insufficiency and moderately impaired LV function can undergo valve repair or replacement with an acceptable prognosis. The goal of mitral valve repair should be to reduce valvular insufficiency to at least grade I. If this is not the case, then the prognosis of repair is worse than after valve replacement. Thus, the surgeon should replace the valve during the same operation.

Adult↗
PubMed2005

Traumatic aortic and mitral valve injury following blunt chest injury with a variable clinical course.

Blunt trauma is uncommonly followed by intracardiac valvar injuries. The resulting valvar insufficiency rapidly or progressively leads to congestive heart failure or death unless surgically corrected. Three patients with sustained blunt chest trauma were found to have two aortic valve and one mitral valve ruptures. They had variable clinical courses. However, after the diagnosis was established, surgical intervention was attempted promptly, which consisted of two aortic valve replacements and one mitral valvoplasty. Their postoperative courses were uneventful. Careful observation and repeated physical examination, aided by echocardiography, were required after the blunt chest trauma.

Accidental Falls↗
PubMed1977

Clinical applications of echocardiographic studies of the mitral valve. A review.

We have reviewed the clinical usefulness of echocardiographic studies of the mitral valve in mitral stenosis, atrial myxoma, mitral valve prolapse, rupture of chordae tendinae and idiopathic hypertrophic subaortic stenosis. Emphasis has been placed on the recognition of different patterns of mitral valve motion and where necessary, to avoid misinterpretations, appropriates recording techniques.

Aortic Valve Insufficiency↗
PubMed2003

Implantation of collar-reinforced sumit valve for patient with large calcified mass obstructing the mitral valve orifice.

A 56-year-old female had a severely calcified mitral valve annulus and a huge subvalvular mass. To avoid critical damages of the coronary artery and left ventricle, the annular calcification and the part of the mass adherent to the left ventricle were not resected. Then we performed mitral valve replacement using SuMit valve and collared reinforcement technique with xenopericardium without any major complications. The SuMit valve is designed to be placed in a supraannular position, and is useful to prevent valves from getting stuck.

Calcinosis↗
PubMed2006

Successful perioperative utilisation of inhaled nitric oxide in mitral valve surgery.

Pulmonary hypertension associated with mitral valve disease can significantly complicate mitral valve replacement. Nitric oxide (NO) has an established role in congenital heart surgery and in cardiac transplantation. However the evidence to date suggests that iNO does not provide a clinical advantage in pulmonary hypertension associated with valvular heart disease. We discuss a 56-year-old male with acute mitral incompetence who underwent emergency surgery. Following mitral valve replacement he was weaned off cardiopulmonary bypass with an intra-aortic balloon pump and high doses of inotropic support but continued to be hypotensive. Inspection of the heart showed right-sided dysfunction and evidence of pulmonary hypertension. Following the introduction of iNO he rapidly improved. He was successfully separated from the cardiopulmonary bypass support and subsequently made a full recovery and was discharged. We believe that this case demonstrates the utility of iNO in the management of pulmonary hypertension secondary to valvular disease in the acute setting. This is in contrast to the evidence against its utility in established pulmonary hypertension in chronic valvular heart disease. Further confirmation of this observation may lead to the therapeutic use of NO in this subpopulation of cardiac surgery patients.

Administration, Inhalation↗
PubMed2005

Midterm outcomes using the physio ring in mitral valve reconstruction: experience in 492 patients.

BACKGROUND: Mitral valve reconstruction using standardized Carpentier techniques is the treatment of choice for most patients with regurgitant lesions. Demonstrated predictability and stability make it an attractive alternative to valve replacement. The Physio Ring's inherent flexibility provides a viable alternative in the application of remodeling techniques and appears to be physiologically superior to traditional approaches. METHODS: Between April 1994 and October 2000, 492 consecutive patients underwent mitral valve reconstruction using standardized Carpentier techniques with the Carpentier-Edwards Physio Ring (Edwards Lifesciences LLC, Irvine, CA). There were 267 men (54.3%) and 225 women (45.7%). Mean age was 64.2 years (range, 18 to 86). Almost one-half (44.3%) were 70 years of age or over. The mitral valve etiology was congenital in 7 patients (1.4%), myxomatous in 351 patients (71.3%), ischemic in 88 (17.9%), rheumatic in 26 (5.3%), endocarditis in 9 (1.8%), calcific in 8 (1.6%), and other abnormalities in 3 (0.6%). RESULTS: Isolated mitral valve reconstruction was performed in 282 patients (57.3%), with coronary artery bypass grafting (CABG) in 182 (37.0%), with valve replacement in 11 (2.2%), and with CABG and valve replacement in 17 (3.5%). All patients (100.0%) had ring annuloplasty, 263 (53.5%) leaflet resection, 140 (28.5%) chordal resection, 55 (11.2%) chordal transposition, 48 (9.8%) chordal shortening, and 15 (3.0%) commissurotomy. Overall hospital mortality was 3.5% (17 of 492). Postoperative complications included respiratory insufficiency in 55 patients (11.2%), low cardiac output in 13 (2.6%), stroke in 14 (2.8%), reoperation for bleeding in 13 (2.6%), renal insufficiency in 21 (4.3%), and myocardial infarction in 5 (1.0%), and new onset of atrial fibrillation in 74 patients (15.0%). The cumulative follow-up for the series was 1,522.9 patient years and ranged from 1 to 101.0 months (mean, 38.5 months). There were 11 reconstruction failures (2.3%) requiring ring explant. Actuarial survival was 81.5% +/- 2.1% at 4 years and 67.9% +/- 4.6% at 7 years. Freedom from reoperation at 4 years was 81.5% +/- 2.1% and 67.9% +/- 4.6% at 7 years. CONCLUSIONS: Mitral valve reconstruction with the Physio Ring can be accomplished with low hospital mortality and morbidity even in combined procedures. Moreover, the low incidence of reoperation and late cardiac events suggests that the Physio Ring, with its inherent flexibility, offers a definite advantage in the application of remodeling techniques in mitral valve reconstruction.

Adolescent↗
PubMed2003

Effects of the ACE inhibitor quinapril on echocardiographic variables in horses with mitral valve insufficiency.

Twenty horses with mitral valve insufficiency, but without signs of congestive heart failure, and five horses without signs of heart disease were examined before and after medication with an angiotensin-converting enzyme (ACE) inhibitor. The examination included echocardiography assessment as well as heart catheterization. The echocardiographic examination included B-mode, M-mode, conventional and colour Doppler techniques. For 8 weeks, all horses were treated with Accupro 20 (active substance: Quinapril) at an oral dose rate of 120 mg/horse/day. A follow-up of the horses with mitral valve insufficiency after 8 weeks revealed a statistically significant increase in the stroke volume and the cardiac output as well as a decrease in regurgitation velocity time integral (VTI). The regurgitation blood velocity remained the same. The severity of mitral valve insufficiencies revealed a moderate improvement in five horses, from moderate to mild, after therapy. Significant changes of cardiac dimension (B-mode) and shortening fraction (M-mode) before and after treatment could not be observed. The owners' judgement of the horses' performance was that of a minor improvement. In the horses without clinical findings the results of examination before and after treatment remained the same.

Angiotensin-Converting Enzyme Inhibitors↗
PubMed1986

[Two-dimensional echocardiographic diagnosis of mitral valve prolapse].

In recent years, echocardiography has become the standard method of diagnosing mitral valve prolapse. There is a few criteria of diagnosing mitral valve prolapse with two-dimensional echocardiography. In general, the definition of mitral valve prolapse with two-dimensional echocardiography is the motion of a bodily part of the anterior or posterior mitral leaflet superior to the annulus during systole. However, the patients with characteristic phonocardiographic findings of mitral valve prolapse were overlooked by the currently used criteria. I proposed, therefore, an essentially different two-dimensional echocardiographic criterion of diagnosing mitral valve prolapse. The criterion included the systolic dislocation of the anterior and posterior mitral leaflets at the coaptation zone in the parasternal long-axis view. This diagnostic criterion enabled us to obtain a systematic view of the mitral valve abnormality. Quantitation of mitral valve prolapse is necessary to evaluate the severity of the mitral regurgitation and the degree of mitral valve lesion. The grade of severity of mitral valve prolapse was assessed by measuring the distance of dislocation between the anterior and posterior leaflets at the area of coaptation. Analyzed data using this method showed that the degree and extent of mitral valve prolapse increased with age.

Echocardiography↗
PubMed1988

Lifetime risk for patients with mitral valve prolapse of developing severe valve regurgitation requiring surgery.

Severe mitral regurgitation requiring surgery is the most common life-threatening complication of mitral valve prolapse (MVP) and is due to progressive myxomatous change in the valve. We identified all residents of New South Wales, Australia, who had mitral valve surgery for myxomatous valve disease during 1982 and, using these data and the adult population statistics from 1982, estimated the cumulative risk of valve surgery in patients with MVP. In 1982, 50 of the 5.36 million New South Wales residents required surgery for this complication of MVP. Of the 50, 36 were men and 14 were women, which was significantly different from the population sex distribution (p less than 0.02) for mean age +/- SD of 60 +/- 11 years (range, 26-78 years). Using our previously determined 4% prevalence of adult MVP in New South Wales, we estimated the number of male and female patients with MVP at risk for each 5-year age interval and calculated age-specific event rates. The results show that the cumulative risk is minimal below the age of 50 years but then rises steeply, particularly in men. The risks in men aged 50, 60, and 70 years (with 95% confidence intervals) were 1:202 (130-448), 1:53 (37-82), and 1:28 (22-41), respectively. In women, the risk was less than half that in men (p less than 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed2001

Transesophageal echocardiography as predictor of mitral valve repair.

BACKGROUND AND AIM OF THE STUDY: Mitral valve repair has recently emerged as the treatment of choice in patients presenting with insufficiency due to valve prolapse. The study aims were to evaluate: (i) the clinical presentation in a consecutive series of patients with mitral valve prolapse undergoing surgical repair; (ii) the correlation between pre- and intraoperative echocardiographic features and surgical findings in these patients; and (iii) whether clinical and echocardiographic data may predict surgical outcome. METHODS: Between March 1997 and May 2000, 152 patients (110 men, 42 women; mean age 59+/-13 years) were recruited into the study. All patients had myxomatous mitral valve disease causing severe regurgitation and underwent systematic examination by transesophageal echocardiography (TEE) for clear delineation of the three scallops of the posterior leaflet and juxtaposed segments of the anterior leaflet. RESULTS: In 119 patients (78%) a flail valve was documented by TEE and confirmed on surgical inspection; an anterior leaflet chordal rupture was not visualized by TEE in one case. In 15 cases (10%) there was flail of the anterior leaflet, and in 105 cases (69%) flail of the posterior leaflet. A bileaflet complex prolapse without chordal rupture was found in 32 cases. On the basis of TEE evaluation, mitral valve replacement was performed electively in 10 patients (7%); the other 142 (93%) underwent mitral valve repair. Adequate repair was obtained in 93% of cases; residual mitral regurgitation (eight cases; grade 3+) and mitral stenosis (one case) were documented by intraoperative TEE, and nine patients (6%) underwent valve replacement. CONCLUSION: The majority of patients with myxomatous mitral valve prolapse and severe regurgitation undergoing valve repair have chordal rupture of the posterior mitral leaflet, a condition in which results of valve repair are excellent. TEE provides a powerful means to define the mechanisms of mitral regurgitation and to identify the suitability of patients for valvuloplasty.

Adult↗
PubMed1995

Left ventricular function after mitral valve surgery.

This study examined the effects of various operative procedures on the mitral valve of patients with mitral regurgitation due to degenerative disease of the mitral valve. A randomized clinical trial on the type of annuloplasty ring used at surgery revealed that early postoperative left ventricular systolic function was better in patients who had a flexible ring than in patients who had a rigid ring. Two years after surgery there were no differences between these groups and most patients were found to have fairly normal left ventricular function. The long term results of mitral valve repair in 184 patients revealed a 10-year actuarial survival of 86% +/- 6%. A randomized trial on the effect of preservation of chordae tendineae during mitral valve replacement revealed that the beneficial effect of this procedure on left ventricular function is a lasting one; five years after surgery patients who had mitral valve replacement with preservation of the chordae tendineae have better exercise capacity, and better left ventricular systolic function and performance. The long term results of mitral valve replacement in 154 patients revealed a 10-year actuarial survival of 69% +/- 5%. Logistic regression analysis indicated that age greater than 65 years and complete excision of the native mitral valve were predictors of late mortality. Of those patients, 70 had had chordal preservation during surgery and 84 did not. These two subgroups were remarkably similar preoperatively, but the 10-year actuarial survival was 80% +/- 6% for patients who had chordal preservation and 63% +/- 6% for those who did not. The mitral valve should be repaired whenever possible; if replacement is necessary it should be performed with preservation of the chordae tendineae.

Actuarial Analysis↗
PubMed1986

[Pathologic aspects of mitral valve prolapse syndrome].

To comprehend clinical pictures of mitral valve prolapse syndrome (MVP), specific pathoanatomical knowledge is required. There is no definite structure of the anterior mitral valve ring. The mitral valve ring is not flat; the anterior segment of the ring tilts up superiorly. The number of scallops of the posterior leaflet depends on the definition of the incisura. The term "rough zone chorda" (Lam et al., 1970) is a misnomer. From the pathological point of view, more than two subgroups of MVP are present. In isolated MVP, pathological lesions are restricted to the local ballooned segment. However, in MVP with connective tissue disorders (for example, Marfan syndrome, etc.), the lesions are principally diffuse. Mitral valve changes in hypertrophic cardiomyopathy with obstruction are caused by torsion and the relatively elongated anterior leaflet due to narrowing of the mitral orifice, septal hypertrophy and displacement of the papillary muscles. MVP in atrial septal defect is caused by the turbulence of a large shunt flow or by the torsion of the mitral ring due to right ventricular volume overload. Further investigation of surgical and necropsied cases will be required to clearly the subgroups of MVP.

Cardiomyopathy, Hypertrophic↗