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PubMed1995

Mitral valve repair using continuous warm blood cardioplegia.

To achieve satisfactory mitral valve repair, we applied continuous warm blood cardioplegia to seven children with congenital heart disease associated with mitral valve insufficiency. All patients had mild to moderate mitral valve regurgitation before the operation. The competency of the mitral valve was assessed by injecting test solution into the left ventricle through the mitral valve orifice with the heart beating under warm blood perfusion into the aortic root proximal to the cross-clamp. Repair of the mitral valve was performed under normothermic cardiac arrest with continuous antegrade perfusion of warm blood cardioplegia. In all patients, these two procedures could be alternated with ease and safety simply by varying the potassium concentration of cardioplegia. While satisfactory valve repair was obtained with the initial procedure in 4 cases, repair was repeated twice in two and three times in one. There were no operative deaths and no complications directly related to the procedure. Postoperative echocardiography demonstrated good mitral valve function with none to trivial regurgitation in six patients (86%). Continuous warm blood cardioplegia is a useful and safe tool for mitral valve repair.

Child↗
PubMed2001

Ischemic mitral valve reconstruction and replacement: comparison of long-term survival and complications.

OBJECTIVE: This study reviews the 223 consecutive mitral valve operations for ischemic mitral insufficiency performed at New York University Medical Center between January 1976 and January 1996. The results for mitral valve reconstruction are compared with those for prosthetic mitral valve replacement. METHODS: From January 1976 to January 1996, 223 patients with ischemic mitral insufficiency underwent mitral valve reconstruction (n = 152) or prosthetic mitral valve replacement (n = 71). Coronary artery bypass grafting was performed in 89% of cases of mitral reconstruction and 80% of cases of prosthetic replacement. In the group undergoing reconstruction, 77% had valvuloplasty with a ring annuloplasty and 23% had valvuloplasty with suture annuloplasty. In the group undergoing prosthetic replacement, 82% of patients received bioprostheses and 18% received mechanical prostheses. RESULTS: Follow-up was 93% complete (median 14.6 mo, range 0-219 mo). Thirty-day mortality was 10% for mitral reconstruction and 20% for prosthetic replacement. The short-term mortality was higher among patients in New York Heart Association functional class IV than among those in classes I to III (odds ratio 5.75, confidence interval 1.25-26.5) and was reduced among patients with angina relative to those without angina (odds ratio 0.26, confidence interval 0.05-1.2). The 30-day death or complication rate was similarly elevated among patients in functional class IV (odds ratio 5.53; confidence interval 1.23-25.04). Patients with mitral valve reconstruction had lower short-term complication or death rates than did patients with prosthetic valve replacement (odds ratio 0.43, confidence interval 0.20-0.90). Eighty-two percent of patients with mitral valve reconstruction had no insufficiency or only trace insufficiency during the long-term follow-up period. Five-year complication-free survivals were 64% (confidence interval 54%-74%) for patients undergoing mitral valve reconstruction and 47% (confidence interval 33%-60%) for patients undergoing prosthetic valve replacement. Results of a series of statistical analyses suggest that outcome was linked primarily to preoperative New York Heart Association functional class. CONCLUSIONS: Initial mortalities were similar among patients undergoing prosthetic replacement and valve reconstruction. Poor outcome was primarily related to preexisting comorbidities. Patients undergoing valve reconstruction had fewer valve-related complications. Valve reconstruction resulted in excellent durability and freedom from complications. These findings suggest that mitral valve reconstruction should be considered for appropriate patients with ischemic mitral insufficiency.

Aged↗
PubMed1991

Failures in reconstructive mitral valve surgery.

From 1969 to 1985, mitral valve repairs using Carpentier's technique were performed for acquired mitral valve incompetence. 72 patients required a reoperation 3 days to 13 years later (mean 5 +/- 3.5 years). The reoperation rate risk was dependent upon the etiology: Barlow 0.6 +/- 0.2% patient year, fibro-elastic deficiency 0.7 +/- 0.3, endocarditis 1.7% Rheumatic disease 4.6 +/- 1.4%. The risk of reoperation in Rheumatic disease is significantly higher (p less than 0.05) than in degenerative disease. The causes of failures could be categorized into two groups according to whether they are surgeon related or valve related: Group I, Prosthetic ring dehiscence or malposition 15%, anulus dilatation (when no ring was implanted) 4%, triangular resection of the anterior leaflet 4% residual prolapse 8.3%. Group II, Recurrent prolapse 16.6% valve stenosis 17%, leaflet retraction 35%. Failures in Group I can be reduced with "increased" experience as opposed to group II. At reoperation valve repair was possible in 15.3% of the cases whereas valve replacement was necessary in 84.7% with an overall operative mortality of 1.4%. We conclude that mitral valve repair in acquired mitral incompetence carries out a small risk of reoperation. Most of the repair failures are surgeon related in degenerative disease and valve related in rheumatic disease.

Adolescent↗
PubMed1990

[Disorders of cardiac rhythm in combined ventricular pre-excitation syndrome and primary mitral valve prolapse].

Primary prolapse of the mitral valve was diagnosed in 27 (11.7%) out of 230 patients with preexcitation syndrome: 10 of them presented with Wolff-Parkinson-White syndrome, 15 with Clerc-Lévy-Critesco syndrome, and two patients with combination of both syndromes. Preexcitation syndrome combined with mitral valve prolapse manifested itself by different disorders of the cardiac rhythm, mainly by the supraventricular forms: by PST in 17, nonparoxysmal tachycardia in 1, atrial fibrillation paroxysms in 7, sinus tachycardia in 2, supraventricular extrasystole in 3, pacemaker migration in the atria in 1 patient. Clerc-Lévy-Critesco syndrome initiated with atrial fibrillation paroxysms in 7 patients with mitral valve prolapse and with the enlargement of the left atrium. The prognostically unfavourable varieties of the preexcitation syndrome and mitral valve prolapse manifested themselves in ventricular tachycardia progressing to ventricular fibrillation, paroxysmal supraventricular tachycardia with a high frequency of ventricular contractions up to 213-230 and atrial tachyarrhythmia up to 250-280 per minute, which were regarded as factor at risk for potential transformation to ventricular tachycardia; as well as in continuously recurrent attacks of arrhythmia in the presence of multiple AV additional tracts or combined with sinoatrial and atrioventricular block.

Adolescent↗
PubMed2003

Natural history of moderate mitral valve stenosis.

BACKGROUND: With the introduction of surgery and percutaneous balloon valvuloplasty for relieving severe mitral stenosis the natural history of the disease has markedly altered. OBJECTIVES: To determine the natural history of the disease in patients with moderate mitral valve stenosis. METHODS: Demographic, clinical and echocardiographic data were evaluated in 36 patients with moderate mitral stenosis during a follow-up of 71 +/- 15 months. RESULTS: The 36 patients comprised 32 women and 4 men with a mean age of 43.7 +/- 12.2 years; 28 were Jewish and 8 were of Arab origin. During follow-up, there was a significant decrease in mitral valve area, with an increase in mean mitral valve gradient and score. Mean loss of mitral valve area was 0.04 +/- 0.11 cm 2/year. No correlation was found between disease progression and age, past mitral valve commissurotomy, baseline mean gradient or mitral valve score. Larger baseline mitral valve area (P = 0.007) and Arab origin (P = 0.03) had an independent correlation to loss of mitral valve area. Fifteen patients (42%) did not demonstrate any loss in mitral valve area during the follow-up period. CONCLUSIONS: The rate of mitral valve narrowing in patients with moderate mitral stenosis is variable and cannot be predicted by patient's age, past commissurotomy, valve score or gradient. Secondly, larger baseline mitral valve area and Arab origin showed an independent correlation to loss of mitral valve area; and finally, in many patients valve area did not change over a long observation period.

Adult↗
PubMed1994

[An echocardiographic analysis of the insufficient mitral valve: its intraoperative functional anatomy in relation to valvular reconstruction].

Mitral valve repair in patients with mitral regurgitation requires a precise evaluation of the mechanism of valvular pathology before surgery. Transesophageal echocardiography has become the principal method for imaging valvular pathology, especially with the latest introduction of multiplanar transesophageal technology. Traditionally, echocardiographic analysis of regurgitant mitral valves has concentrated on the description of abnormalities of leaflet motion such as prolapse, while surgical correction aims at restoring the coaptation of the edges of the leaflets. To reconcile these different approaches, the echocardiographic features the findings on direct inspection, and the types of repair performed were analyzed in 37 incompetent mitral valves. The zone of coaptation of the mitral valve was studied in a series of left ventricular long-axis views obtained with a transesophageal multiplanar echo-transducer from the anterolateral via the central, to the posteromedial segment. Four patterns of leaflet closure were found: normal apart from a dilated annulus (24%), normal apposition but absent coaptation (8%); asymmetrical apposition but intact coaptation (16%); and abnormal apposition and absent coaptation (52%). In addition leaflet motion was described (prolapse, retraction, normal), and the anteroposterior dimension of the mitral annulus was measured. There was a direct relationship between these echocardiographic findings and the types of reconstructive techniques used. The echocardiographic analysis offers a logical approach to the preoperative diagnosis of regurgitant mitral valves, with the possibility to predict the feasibility and the type of mitral repair.

Adult↗
PubMed1997

Right thoracotomy approach to mitral valve surgical procedures.

The right thoracotomy approach to mitral valve surgical procedures allows surgeons to achieve excellent, rapid exposures of mitral annuli; facilitates the excision of diseased mitral valves; avoids injury to previously placed coronary artery bypass grafts; and aids surgeons with the insertion of valve prostheses. This approach is especially appropriate for patients with anatomic deviations (e.g., deep chest cavities, counterclockwise rotations of the heart) and hostile mediastina (i.e., previously opened mediastina with severe adhesions around the heart and posterior side of the sternum). This article discusses mitral valve disease, compares the right thoracotomy approach to median sternotomy, describes perioperative nursing care of patients undergoing mitral valve surgical procedures, and presents a case study.

Female↗
PubMed1979

Indications for surgical replacement of the mitral valve. With particular reference to common and uncommon causes of mitral regurgitation.

Mitral valve replacement is considered when there is severe mitral stenosis, severe mitral insufficiency or a combination of the two. Ordinarily, surgical replacement is considered only for patients who are in functional classes III or IV and do not respond to medical management. Patients with symptomatic mitral stenosis should be treated with mitral commissurotomy whenever possible. Patients selected for commissurotomy should have a pliable valve, no other major valve dysfunction, sinus rhythm, no systemic embolism and good left ventricular function. Early operation is not ordinarily required. Mitral insufficiency may require mitral valve replacement in six rather common settings: rheumatic disease, rupture of mitral chordae tendineae, postinfarction rupture of a papillary muscle, intractable infective endocarditis, floppy mitral valve and malfunction of a prosthetic valve. Rupture of mitral chordae tendineae can usually be recognized from the history, physical examination, echocardiogram and angiocardiogram. Severe left ventricular papillary muscle dysfunction is usually due to cardiac infarction, and occurs within the first 9 days of infarction. When only a papillary muscle tip is ruptured the patient may survive long enough for a mitral valve replacement. In infective endocarditis, operation is more often needed because of congestive heart failure than because of refractory infection. Evidence of mitral stenosis or insufficiency in a patient with a previously implanted prosthetic valve usually indicates an urgent need for study and early operation. Uncommon causes of mitral incompetence that may require valve replacement are endocardial fibroelastosis, Marfan's syndrome, calcified mitral anulus, osteogenesis imperfecta, methysergide-induced heart disease and carcinoid heart disease.

Adult↗
PubMed1996

Effects of increasing flow rate on aortic stenotic indices: evidence from percutaneous transvenous balloon dilatation of the mitral valve in patients with combined aortic and mitral stenosis.

OBJECTIVES: To investigate the effects of transvalvar flow rate on aortic valve resistance and valve area after percutaneous transvenous balloon dilatation of the mitral valve in a homogeneous group of patients with rheumatic heart disease. DESIGN: Retrospective analysis of 12 patients with combined aortic and mitral stenosis who had undergone balloon dilatation of the mitral valve over a period of 9 years. SETTING: Tertiary referral centre. PATIENTS: Twelve (8 women, 4 men; mean (SD) age 37 (9) of 227 consecutive patients with critical mitral stenosis undergoing transvenous balloon dilation of the mitral valve in the centre also had aortic stenosis, defined as a transaortic pressure gradient of more than 25 mm Hg measured at a catheterisation study before valvuloplasty. INTERVENTIONS: Echocardiographic variables (mitral valve area measured by the pressure half-time method and planimetry, and the aortic valve area derived from the continuity equation) and haemodynamic measurements (cardiac output, left ventricular mean systolic pressure, aortic mean pressure, transaortic valve pressure gradient, mitral valve and aortic valve areas derived from the Gorlin formula, and aortic valve resistance) were assessed before and after transvenous balloon dilatation of the mitral valve. Follow up catheterisation to measure haemodynamic variables was performed one week after mitral valvuloplasty. RESULTS: Mean transaortic flow rate increased 33% after mitral valvuloplasty (from 198 (68) to 254 (41) ml/s, P = 0.002). Aortic valve areas derived from the Gorlin formula were significantly increased from 0.57 (0.12) to 0.73 (0.14) cm2 (P = 0.006) after mitral valvuloplasty. However, aortic valve area and valve resistance derived from the continuity equation were independent of the increase in flow rate after mitral valvuloplasty (from 1.29 (0.35) to 1.30 (0.29) cm2 and from 317 (65) to 259 (75) dyn.s.cm-5, both P = NS). CONCLUSION: The Gorlin-derived aortic valve area tends to be flow-dependent, and continuity equation-derived aortic valve area and catheterisation-derived valve resistance seem to be less flow-dependent. In patients with combined mitral and aortic stenosis, these flow-independent indices are important for decision-making.

Adult↗
PubMed2000

Echocardiographic markers for mitral valve surgery to preserve left ventricular performance in mitral regurgitation.

BACKGROUND: The timing of mitral valve (MV) surgery to preserve left ventricular (LV) contractility in patients with mitral regurgitation (MR) has been defined by complex cardiac catheterization techniques. Whether noninvasive methods can identify patients with MR, a normal LV ejection fraction, and early LV contractile impairment is unknown. We hypothesized that echocardiographic measures would separate patients with MR and a normal LV ejection fraction into those with and without contractile dysfunction and, thus, prospectively predict the response of LV size and performance to MV surgery. METHODS AND RESULTS: We studied 27 patients with micromanometer LV pressures and radionuclide angiography to obtain a determination of LV volumes and ejection fraction and calculate chamber elastance, a measure of LV contractility, before MV surgery. Echocardiographic studies were performed before MV surgery and repeated at 3 and 12 months after surgery. Age, New York Heart Association class, LV plus maximum pressure per unit change in time, LV systolic and end-diastolic pressures, and echocardiographic posterior wall thickness and radius to wall thickness ratio did not identify preoperative LV contractile dysfunction. However, other echocardiographic measures were related to LV contractility, including LV end-diastolic dimension (r = -0.50, P <.005), LV end-systolic dimension (r = -0.60, P <.0001), and LV fractional shortening (r = 0.50, P =.005). From analysis of receiver operator characteristic curves, an LV end-systolic dimension of >/=40 mm was identified as most predictive for separating patients with MR before surgery into those with and without LV contractile dysfunction (sensitivity of 82% and specificity of 100%). The patients with MR and impaired preoperative LV contractility showed a dramatic deterioration in LV fractional shortening at 3 months after MV surgery (P =.01), which recovered to within the normal range for fractional shortening at 12 months (P =.02) from a progressive reduction in LV end-systolic dimension. This response in LV size and performance temporally differed from that in the patients with MR and normal contractility (2-way analysis of variance P <.0001). However, at 12 months after MV surgery, LV end-diastolic dimension, end-systolic dimension, and fractional shortening were normal in both groups of patients with MR. CONCLUSION: We conclude that echocardiographic measures, particularly an end-systolic dimension of >/=40 mm, may be useful for identifying patients with MR before surgery with early, occult LV contractile dysfunction in whom MV surgery may be recommended to preserve LV systolic performance.

Adult↗
PubMed1992

Mitral valve prolapse: etiology, clinical presentation and neuroendocrine function.

Based on our experience and the experience of others, the following classification of patients with mitral valve prolapse has been proposed. Mitral valve prolapse - Anatomic includes patients with a wide spectrum of mitral valve abnormalities from mild to severe. Symptoms, physical findings and laboratory abnormalities in these patients are directly related to mitral valve dysfunction and progressive mitral regurgitation. Complications related to abnormal mitral valve include infective endocarditis, thromboembolic events, cardiac arrhythmias, progressive mitral regurgitation, rupture of chordae tendineae and congestive heart failure. Individuals with thick mitral leaflets and mitral systolic murmur are at higher risk of developing complications. The term mitral valve prolapse syndrome refers to the occurrence of symptoms such as palpitation, chest pain, fatigue, poor exercise tolerance, dyspnea, orthostatic phenomena and syncope or presyncope in patients with mitral valve prolapse which cannot be explained on the basis of mitral valve abnormality alone. The pathogenesis of these symptoms in patients with mitral valve prolapse syndrome appears to be related to metabolic neuroendocrine abnormalities. Preventing infective endocarditis is a major consideration in patients with mitral valve prolapse. Significant mitral regurgitation with the development of congestive heart failure often requires mitral valve surgery. The most important therapeutic approach in patients with mitral valve prolapse syndrome is to explain the mechanisms of symptoms and to reassure the patient.

Autonomic Nervous System↗
PubMed1989

Transesophageal Doppler color flow imaging in the detection of native and Björk-Shiley mitral valve regurgitation.

Regurgitant blood flow of mitral valves was studied by transesophageal Doppler color flow echocardiographic imaging in 11 healthy volunteers (Group 1), 25 cardiac patients with a native mitral valve (Group 2), 10 patients with a normally functioning Björk-Shiley mitral prosthesis without clinical evidence of mitral regurgitation (Group 3) and 10 patients with angiographic or surgical evidence of Björk-Shiley mitral valve regurgitation (Group 4). Holosystolic regurgitant color jets were classified as type I or type II. The data were compared with results obtained with precordial techniques, i.e., continuous wave and Doppler color flow echocardiographic imaging (Groups 1 to 4) and left ventricular angiography or surgery (Groups 2 and 4). In Group 1, transesophageal Doppler color flow imaging revealed no mitral regurgitant flow in 7 of the 11 patients and a type I jet in 4 patients that was detected in only 1 patient by precordial techniques. In Group 2, angiography showed no mitral regurgitation in 20 patients and documented mitral regurgitation in 5. Transesophageal Doppler color flow imaging detected in 4 of the 20 patients a type I jet that was not visualized with precordial techniques in 2 patients. Type II jets were detected by the transesophageal technique in all five patients with proven mitral regurgitation and were also visualized with precordial echocardiography. All patients in Group 3 showed two identical type I jets that were not detected with precordial echocardiography.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1992

Comparison of cardiac findings in patients with mitral valve prolapse who die suddenly to those who have congestive heart failure from mitral regurgitation and to those with fatal noncardiac conditions.

Sudden death occurs in a small but important subset of patients with mitral valve prolapse (MVP). Clinical criteria for identifying patients at risk for sudden death have been elusive. To determine if certain morphologic characteristics were present in hearts from patients with sudden cardiac death and MVP, autopsy hearts from persons with sudden death and isolated MVP who were previously asymptomatic or had a history of cardiac arrhythmias (n = 27) were compared with (1) hearts from patients with congestive heart failure (CHF) and mitral regurgitation (MR) secondary to MVP (n = 14), and (2) hearts from persons dying from non-cardiac causes in which MVP was an incidental finding (n = 19). Patients who died suddenly were younger than both patients with MR/CHF and incidental cases (37 +/- 10 vs 65 +/- 16 and 58 +/- 21 years, respectively, p less than 0.001). Mitral valve annular circumference, anterior and posterior mitral valve leaflet lengths, posterior mitral valve thickness, and presence and extent of endocardial plaque were greater in hearts from patients with sudden death than hearts from those with incidental MVP. Hearts from patients with MR/CHF weighed significantly more, had greater left and right atrial cavity sizes and left ventricular cavity diameter than hearts from both sudden death and incidental cases.

Age Factors↗
PubMed1977

Mitral valve aneurysm after infective endocarditis in the billowing mitral leaflet syndrome.

Mitral valve aneurysm is an uncommon complication of infective endocarditis. This report describes a patient with severe regurgitation due to perforations in a mitral aneurysm who required mitral valve replacement 9 years after a staphylococcal infection was superimposed on a billowing mitral leaflet. The unusual auscultatory signs and angiographic appearance could have led to diagnosis of the aneurysm.

Adult↗
PubMed2005

Surgical treatment of ischemic mitral valve regurgitation.

In cases of old myocardial infarction, the presence of mitral valve regurgitation is one of the predicting factors of long-term prognosis. The mechanism of ischemic mitral regurgitation consists of mitral annular dilatation, left ventricular (LV) dilatation followed by tethering of the mitral valve, etc. Since long-term prognosis of the patients in whom the degree of mitral valve regurgitation is 2+ or more is typically poor, the mitral valve procedure should be considered at the time of coronary artery bypass grafting (CABG) or more. In this type of surgery, the treatment essentially involves the use of an artificial ring implantation as the basic technique. In the chronic stage, a significant degree of mitral regurgitation persists in approximately 20% of the cases if they have been treated by ring annuloplasty alone. Additional surgical procedures that reduce or eradicate the tethering are essential for the control of the regurgitation completely in cases with strong tethering. We recently employed two new surgical techniques, namely, cutting the secondary chordae to the anterior mitral valve leaflet and the anterior and posterior papillary muscle reapproximation. The surgical results of the acute phase appear to be promising; however, the long-term results of such new methods are yet to be determined. If the mitral valve regurgitation cannot be controlled even by various operative techniques of mitral valve repair, mitral valve replacement should be considered. This is because the long-term survival rate of the suboptimal repair surgical patients is lower when compared with that of mitral valve replacement patients.

Cardiac Surgical Procedures↗
PubMed1982

Two-dimensional echocardiographic estimation of the size of the mitral valve annulus.

The diameter of the mitral annulus as measured on the long axis by two-dimensional echocardiogram was found to correlate well with the size of the sewing ring used to replace the mitral valve in 35 consecutive patients. The size of the prosthesis which was used could be predicted within 1 mm of error in 83% of the mitral stenosis (MS) patients and in 76% of the mitral regurgitation (MR) patients in the study. Preoperative echocardiographic estimation of the size of the mitral valve annulus and prediction of the sewing ring size of the prosthetic valve used could reduce the incidence of valve prosthesis-patient mismatch.

Adult↗
PubMed2003

[Trends and results of mitral valve surgery].

BACKGROUND: Retrospective study of 303 patients with mitral valve surgery operated in the last 7 years is evaluated. A mitral valve replacement was done in 271 patients (89.4%), mitral valve reconstruction in 32 patients (10.6%). Only the replacement of mitral valve was done in 70 patients (23.1%), replacement in combination with some other intervention, most frequently the revascularization was done in 27 patients. METHODS AND RESULTS: The total mortality in mitral valve replacements was 7.7% with the prevalence of combined surgery, including the acute cases. Mortality for patients with prosthetics was 8.6% during 1996 to 98, and only 6.5% in the following years. From patients with the mitral reconstruction four has died (12.5%), all were acute or emergent cases with combined surgery. The average length of hospitalisation was 7.5 days. Postoperative Q-IM occurred in one patient (0.41%), revision for bleeding was necessary in 16 patients (5.3%), neurological complications developed in 14 patients (4.6%). CONCLUSIONS: Results of early mitral replacements are comparable or in some combined surgeries better to the results given in the literature or in the international register. In the aetiology of disease, a comparative decrease of rheumatic origin and an increase of ischaemic and degenerative disorders become apparent. The paper demonstrates improving results in this field of cardiosurgery, shows the new trends in the development of surgical treatment of the mitral valve and it also stresses the necessity of early indication to the surgery.

Adult↗