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PubMed2002

Mitral valve replacement and remodeling of the left ventricle in dilated cardiomyopathy with mitral regurgitation: initial results.

OBJECTIVE: This study evaluated the effects of a new method of mitral valve replacement on left ventricular (LV) remodeling and heart failure functional class. METHODS: Eight patients (6 men) with severe mitral regurgitation from end-stage dilated cardiomyopathy underwent surgery. Five patients were in functional class (FC) IV, 2 were in FC III and 1 was in FC III/IV. Age ranged from 33 to 63 years. Both the anterior and posterior leaflets of the mitral valve were divided into hemileaflets. The resultant 4 pedicles were displaced under traction toward the left atrium and anchored between the mitral annulus and an implanted valvular prosthesis. The beating heart facilitated ideal chordae tendineae positioning. RESULTS: All patients survived and were discharged from the hospital. After a mean follow-up period of 6.5 months (1-12 m), 5 patients were in FC I; 2 in FC I/II; and 1 in FC II. The preoperative ejection fraction ranged from 19% to 30% (mean: 25.7 +/- 3.4 %), and the postoperative ejection fraction ranged from 21% to 40% (mean: 31.1 +/- 5.8%). Doppler echocardiography showed evidence of LV remodeling in 4 patients, including lateral wall changes and a tendency of the LV cavity to return to its elliptical shape. CONCLUSION: This technique of mitral valve replacement, involving new positioning of the chordae tendineae, allowed LV remodeling and improvement in FC during this brief follow-up period.

Adult↗
PubMed1989

Influence of mitral valve morphology on double-balloon catheter balloon valvuloplasty in patients with mitral stenosis. Analysis of factors predicting immediate and 3-month results.

To determine if mitral valve morphology influences the results of double-balloon catheter balloon valvuloplasty (CBV) for mitral stenosis, two-dimensional echocardiography was performed in 33 patients before CBV. The two-dimensional echocardiographic features of leaflet motion, leaflet thickness, subvalvular disease, and commissural calcium and 14 pre-CBV clinical and hemodynamic variables were then correlated to the immediately post-CBV mitral valve area (MVA). At 3 months after CBV, the two-dimensional echocardiographic features of patients with a 25% or greater decrease in MVA were analyzed to determine whether mitral valve morphology had influenced early results. Leaflet motion had a significant relation with the immediately post-CBV MVA (r = 0.67, y = 4.5x + 0.29, and SEE = 0.45). Leaflet thickness had a weak and negative relation (r = -0.48, y = -0.17x + 2.6, and SEE = 0.53) with the immediately post-CBV MVA. Subvalvular disease and commissural calcium had no significant relation to the immediately post-CBV MVA. When leaflet motion and leaflet thickness were considered as grades of mild, moderate, and severe and assigned a score of 0-2, patients with more severe disease (total score, 3 or 4) had a significant lower MVA immediately after CBV (1.4 +/- 0.4 cm2) than patients with moderate disease (score, 1-2; MVA, 2.0 +/- 0.5 cm2; p less than 0.05) or mild disease (score, 0; MVA, 2.6 +/- 0.6 cm2; p less than 0.05). In 96% of patients with a total score of 0-2, the immediately post-CBV MVA was more than 1.4 cm2, whereas only 29% of patients with a total score of 3-4 had an immediately post-CBV MVA of more than 1.4 cm2. Analysis of all two-dimensional echocardiographic features showed that leaflet motion score had the strongest influence on the post-CBV MVA (p less than 0.001). When all two-dimensional echocardiographic, clinical, and hemodynamic variables were included, leaflet motion, effective balloon dilating area, and cardiac output were the strongest predictors of the immediate post-CB MVA.(ABSTRACT TRUNCATED AT 400 WORDS)

Adult↗
PubMed1998

Evolving experience with cryopreserved mitral valve allografts.

Allograft valves have been used for aortic valve replacement (AVR) for 35 years with excellent results. Early attempts at mitral valve replacement (MVR) with mitral valve allograft were unsuccessful mainly due to technical issues of measurement of appropriate graft size, difficulty of reimplantation, and early dehiscence of the papillary muscle anastomosis. Recently, interest in this procedure has been rekindled by successful laboratory experiments with mitral valve allograft implantation and improved understanding of the mitral valve apparatus from extensive mitral valve repair experience. In this article, we discuss the rationale for allograft use, the historical perspective of allograft use, and technical problems, along with current solutions and clinical outcomes of MVR with mitral valve allograft. Tricuspid valve replacement (TVR) with allograft mitral valve also is briefly discussed.

Animals↗
PubMed2005

[Mitral valve disease in elderly patients].

It seems that mitral valve surgery in patients older than 80 years increase against the background of the aging society. Basically, there are not particular differences between elderly patients and younger patients in procedures for diagnosis and operative indication in mitral valve diseases. However, cardiac surgery for patients older than 80 years has been reported to have high mortality rate. Therefore, it is necessary that we should evaluate and treat complications of important organs such as brain/coronary artery/lungs/liver/kidney, adequately. Our mortality rate of the whole mitral valve operations was 2.4% and that of patients older than 75 years was 7.9%. This result compares favorably with those reported from other institutions. However, when we perform mitral valve operations for patients older than 80 years, it is necessary to investigate activities of daily living and quality of life before and after the operation.

Activities of Daily Living↗
PubMed2006

[Systolic anterior motion (SAM): a rare cause of late failure in mitral valve repair].

Systolic anterior motion (SAM) of the mitral valve is a rare complication of mitral valve repair. The treatment of the large majority of cases is purely medical. Nevertheless, an early degradation may require reoperation (revision of the repair or valve replacement). The authors report two cases of post-repair SAM with a poor outcome with medical therapy which required reoperation after several years. In both cases, an excess of bivalvular tissue with respect to the size of the mitral orifice was observed. A second repair was possible (sliding valvuloplasty associated with an oval resection of the anterior leaflet) with satisfactory long-term results. The identification of the risk factors and careful analysis of the lesions in cases of SAM after mitral valve repair may lead to a repeat repair and the avoidance of mitral valve replacement.

Female↗
PubMed2004

Avulsion of the mitral valve leaflet during percutaneous commissurotomy.

Percutaneous mitral valve commissurotomy offers a safe alternative to treat mitral valve stenosis in a select group of patients, and has produced good results. Recently, a new metallic commissurotomy device was made available for clinical use. A rare, life-threatening complication associated with this new technique is described.

Catheterization↗
PubMed2002

Impact of Cox maze procedure on outcome in patients with atrial fibrillation and mitral valve disease.

OBJECTIVE: We sought to determine whether the Cox maze procedure provides additional benefit to patients with atrial fibrillation undergoing mitral valve operations. METHODS: Between May 1992 and August 2000, we performed 258 Cox maze procedures with mitral valve replacement (n = 147) or mitral valve repair (n = 111). We compared the outcomes of these patients with those of 61 control patients with preoperative atrial fibrillation who underwent mitral valve replacement alone during the same interval. The three cohorts were similar in age, sex, and proportion of patients in preoperative New York Heart Association functional class 3 or 4. RESULTS: Although 5-year survivals were similar among the groups (94% for mitral valve replacement alone, 95% for mitral valve replacement plus maze, and 97% for mitral valve repair plus maze), freedoms from atrial fibrillation at 5 years were significantly higher in the mitral valve replacement plus maze group (78%) and the mitral valve repair plus maze group (81%) than in the mitral valve replacement group (6%, P <.0001). Freedoms from stroke at 5 years were 97% for the mitral valve replacement plus maze group, 97% for the mitral valve repair plus maze group, and only 79% for mitral valve replacement group (P <.0001). Multivariable analysis with Cox hazard model revealed that the most significant risk factor for late stroke was the omission of the Cox maze procedure (P =.003). CONCLUSIONS: The addition of the Cox maze procedure to mitral valve repair and replacement was safe and effective for selected patients. Elimination of atrial fibrillation significantly decreased the incidence of late stroke.

Aged↗
PubMed2004

Functional ventricularisation of the left atrium--severe mitral valve prolapse paradoxically resulting in minimal regurgitation.

Mitral valve prolapse is a common condition often associated with mitral regurgitation. Intuitively, one would expect a positive correlation between the severity of mitral valve prolapse and the associated regurgitation. This assumption is overturned by an unusual case of functional ventricularisation of the left atrium due to severe mitral valve prolapse which paradoxically resulted in minimal regurgitation.

Adult↗
PubMed2001

[Risk assessment of mitral valve surgery combined with myocardial revascularization].

INTRODUCTION AND OBJECTIVES: Patients with combined mitral valve operation and coronary artery surgery represent a high risk group. The aim of this retrospective study was to evaluate which factors affect early and late postoperative results in this particular group of considered high risk patients. PATIENTS AND METHOD. Between 1984 and 1997, 264 patients (mean age: 63 +/- 7.3 years) underwent mitral valve surgery (199 patients; 75% mitral valve replacement, 25% mitral valve repair) in combination with coronary revascularization (mean 2.4 +/- 1.3 grafts). Follow-up comprised a mean of 69 +/- 42 months and was 98.3% complete. RESULTS: Early mortality was 10.6% (28/264). Ischemic mitral regurgitation operated on in emergent status, moderate to severe reduced left ventricular function and advanced age (> 60 years) were independently associated with early hospital mortality (p < 0.05). Ischemic etiology of mitral valve disease (emergency and elective operations), severity of mitral regurgitation and New York Heart Association (NYHA) functional class IV were related to early hospital mortality, only with univariate statistics. Actuarial survival was 86, 69 and 48% at 1, 5 and 10 years, respectively. The preoperative NYHA functional class was the only variable independently related to late survival. Eighty-five percent of the surviving patients were in NYHA functional class I and II. CONCLUSIONS: Mitral valve operation combined with coronary artery bypass grafting is associated with a high early hospital mortality. Independent risk factors of early mortality are emergency operation of ischemic mitral valve disease, reduced left ventricular function and advanced age. Long term survival is independently influenced only by preoperative NYHA functional class IV.

Adult↗
PubMed1986

Results of mitral valve reconstruction.

To evaluate the early results of mitral valve reconstruction for mitral insufficiency, 117 consecutive cases were analyzed. Sixty-four (57.7%) of the patients were men, and the mean age was 60 +/- 13 years (range 18 to 85). Eighty-nine (76%) of the patients were in NYHA functional class III or IV preoperatively. The cause of the mitral disease was degenerative in 94 (80%) and rheumatic in 13 (11%) patients. Isolated mitral valve repair was performed in 56 patients (47.9%); the remainder underwent associated procedures that included myocardial revascularization in 38 (32.5%). Ninety-nine (85%) underwent a ring annuloplasty but in only seven (6%) was this the only repair technique. Resection of the posterior leaflet was performed in 41 (35%). There were five operative deaths (4.3%); one (1.8%) occurred after isolated repair and four (6.5%) after repair with associated procedures. All deaths occurred in patients greater than 65 years of age who were in NYHA functional class III or IV. Mean follow-up was 13.5 months (range 1 to 62). Two year actuarial survival was 90.6%. Three patients required reoperation (incidence of 2.5% per patient-year). Two patients sustained embolic events (incidence of 1.6% per patient-year). There were no anticoagulant-related complications. After surgery, 100 survivors (96.2%) were in NYHA functional class I or II.

Adolescent↗
PubMed2005

Experimental stenting of the posterior mitral leaflet to correct prolapse in mitral valve insufficiency.

OBJECTIVE: This study investigated the use of a new concept of mitral valve reconstruction using a novel device to stent the posterior mitral leaflet in combination with semicircular annuloplasty. Modern mitral valve repair is an accepted modality and a routine procedure for treatment of degenerative mitral valve insufficiency. One of the most common mechanisms of mitral valve insufficiency is leaflet prolapse. In the majority of cases the posterior leaflet is dysfunctional and therapeutic reconstruction of the PII flail leaflet segment involves quadrangular resection which is usually combined to mitral annulo-plasty with a ring. A new time-saving concept of mitral valve reconstruction by stenting the posterior mitral leaflet in combination with semicircular annuloplasty is presented. METHODS: The new mitral valve reconstruction device (Shelhigh MitroFast, Shelhigh, Inc., Union, NJ, USA) was implanted in four adult sheep. It is constructed as an annuloplasty ring in combination with a posterior leaflet stent. The device has the shape of a closed posterior leaflet and forms a "buttress" against which the anterior leaflet can coapt. RESULTS: Every implantation of a MitroFast device could be performed in less than 30 minutes. After implantation of the device, all animals could be successfully weaned from CPB. Invasively measured left atrial pressure was below 12 mm Hg in all animals. After chest closure, transoesophageal echocardiography revealed a competent mitral valve in all animals, without any inflow restriction in three animals, and suspected mild stenosis in one animal. CONCLUSIONS: In this experimental model, implantation of the newly designed annuloplasty ring with stenting the posterior mitral leaflet avoids extensive and time-consuming reconstructive surgery on a flail posterior leaflet. Implantation of the device resulted in favorable short-term hemodynamic effects. Implantation technique of the device is simple, the potential for minimal invasive implantation of a conceptual similar device will be further investigated.

Animals↗
PubMed1999

Surgery for mitral valve disease in the pediatric age group.

OBJECTIVES: We reviewed a 20-year experience with the surgical treatment of mitral valve disease in the pediatric age group at our institution with 2 objectives: to clarify the long-term results over the last 2 decades and to evaluate the recent advances in mitral valve operation in children. METHODS: Since December 1978, 56 patients have undergone a total of 36 mitral valve repairs and 30 mitral valve replacements. Associated cardiac anomalies were present in 46 patients (82%), and concurrent repair of associated lesions was performed in 37 patients (66%). The age of the patients ranged from 3 months to 15 years (mean, 3.6 years) at mitral valve repair, and ranged from 2 months to 16 years (mean, 5.7 years) at mitral valve replacement. Mean follow-up period was 92.0 months (range, 1-235 months). RESULTS: There were 2 hospital deaths and 2 late deaths in patients who underwent mitral valve repair. Reoperation was performed in 4 patients. Three of these patients underwent mitral valve replacement because of residual mitral incompetence. No hospital deaths occurred in patients who underwent mitral valve replacement. Two late deaths occurred after mitral valve replacement. Six patients had a total of 10 episodes of prosthetic valve thrombosis. Thrombolytic therapy with urokinase was successful in all episodes without serious complications. Five patients required reoperations 49 to 141 months (mean, 78.4 months) after the initial valve replacement for relative prosthetic valve obstruction as the result of somatic growth. A valve 2 or 3 sizes larger than the original prostheses was inserted without death. Actuarial survival and freedom from cardiac events at 10 years after the operation were 87.2% and 72.7% in children who underwent mitral valve repair, and 90.3% and 67.3% for those children who underwent mitral valve replacement. CONCLUSIONS: The current risk of mitral valve operation in the pediatric age group is low, and the long-term results are satisfactory, irrespective of severe deformation of the mitral valve apparatus and associated complex cardiac anomalies.

Actuarial Analysis↗
PubMed1982

Idiopathic mitral valve prolapse-analysis by real-time two-dimensional echocardiography.

Mitral valve prolapse is diagnosed in real-time two-dimensional echocardiograms when there are discrepancies in the coaptation zone of the anterior mitral leaflet and the posterior mitral leaflet. Out of the 100 cases of mitral valve prolapse diagnosed in this way, 65 had prolapsed anterior mitral leaflets, 28 prolapsed posterior mitral leaflets and 7 prolapses of both the anterior and posterior mitral leaflets. In addition to the cases with mitral valve prolapse 23 cases of ruptured chordae tendineae of the mitral valve, including 15 cases which had undergone surgery, were investigated. The frequent site of mitral valve prolapse was the posteromedial commissure in the anterior leaflet and the posteromedial and anterolateral commissures in the posterior leaflet. These sites coincide with those where rupture of the chordae tendineae of the mitral valve was apt to occur. An investigation of the relation between age and mitral valve prolapse showed that the number of cases of prolapsed anterior leaflet did not increase with age, but there was an age-related increase in the number of cases of prolapsed posterior leaflets. It was also found that the degree of the prolapse progressed with age. Many of the cases of ruptured chordae tendineae of the mitral valve were in their forties or fifties, and there appeared to be some relation between the progress of the prolapse and age. Mitral regurgitant murmurs were recorded on phonocardiograms, and the severer the degree, the wider the range of the prolapse. Mitral regurgitation was more likely to occur in cases of prolapsed posterior leaflets than in those with prolapsed anterior leaflets, even if the degree and the range of the prolapse were mild.

Adolescent↗
PubMed1994

[A case of aortic and mitral regurgitation with two aneurysms in the mitral valve].

A 59-year-old male was found to have two aneurysms in the mitral valve, mitral regurgitation, and aortic regurgitation by the echocardiographic examination. The patient had a previous history of infectious endocarditis by streptococcus at the age of 24. Under the diagnosis of mitral aneurysms developed after infectious endocarditis, surgery was undertaken. A 5 x 8 mm sized perforation in the right coronary cusp and two aneurysms in the anterior mitral leaflet, 22 mm and 17 mm in size, were found intraoperatively. Both the mitral and aortic valves were replaced. Patients with a history of infectious endocarditis have to be followed up for a long period of time. Transesophageal echocardiogram is useful in those patients. Considering high prevalence of aortic valvular diseases in those with a mitral aneurysm after infectious endocarditis, aortic valves should be carefully evaluated.

Aneurysm, Infected↗
PubMed1992

Stress/strain characteristics of porcine mitral valve tissue: parallel versus perpendicular collagen orientation.

Mitral valve tissue was analyzed in uniaxial tension testing. Rectangular strips were excised from fresh, whole, porcine mitral valve leaflets, with the long axis in the following orientation: perpendicular to the annulus (posterior [PPERP] and anterior [APERP]), parallel to the annulus (posterior [PPAR] and anterior [CAPAR]), and parallel to the annulus and involving chordal insertions (anterior [MAPAR]). Basal and marginal chordae were also tested. These samples were tested in uniaxial tension (INSTRON Model 1000) at deformation rates of 5 and 10 mm/min, the load applied along the long axis of the strip. The specimens were preconditioned by cyclically loading from 0 to 4.0 g for five cycles, and then applying a final 50-g load. Whole excised porcine mitral valves were previously examined by small angle light scattering, polarized light microscopy, and routine histologic examination in order to ascertain the collagen fiber orientation throughout the valve. Groups tested in uniaxial tension with collagen fibers parallel to the applied stress are significantly stiffer than those with perpendicular fibers (p less than 0.001). Collagen fiber density is greater in the chordae than in the leaflets, and a corresponding increase in stiffness is demonstrated. This indicates that the mitral valve tissue behaves as a classic fiber reinforced composite, i.e., increasing mechanical stiffness (modulus) is related to density and direction of fibers. This information can be applied to the design of biosynthetic valve substitutes with a similar fiber reinforced composite structure.

Animals↗
PubMed1975

Diagnosis and evaluation of mitral valve disease using transseptal Doppler ultrasound catheterization.

In 33 patients with confirmed mitral valve disease, the mitral valve flow velocity traces were recorded by means of a directional Doppler ultrasonic velocimeter using the transseptal route, and correlated with the clinical and haemodynamic data. In all cases, characteristic anomalies of the mitral flow velocity patterns were noted and could be related to the type of lesion, stenosis, regurgitation, or a combination of these. Furthermore, specific patterns of the flow velocity traces were shown to correlate satisfactorily with the degree of severity of the disease. The authors propose a pathophysiological interpretation of the anomalies of the velocity patterns, based on turbulence for stenosis and backward flow wave for regurgitation. They conclude that the transseptal directional Doppler catheterization provides a new reliable method for establishing the diagnosis and grading the severity of mitral valve disease using pattern recognition, and, moreover, offers a new approach to the understanding of mitral haemodynamic disturbances on a beat-to-beat basis.

Adult↗
PubMed1990

Experimental balloon valvuloplasty of fibrotic and calcific mitral valves.

This study evaluated the mechanism of valvular area expansion during single- and double-balloon valvuloplasty in fibrotic and calcific mitral valves. Special interest was focused on the morphological features of the valves treated. Mitral valves that appeared unsuitable for commissurotomy were excised in toto at the time of mitral valve replacement in 15 patients. The excised valves were mounted in a fluid-filled chamber with a window for photographic evaluation. The chamber was perfused continuously to ensure maximal valvular opening. The valve was photographed, and the orifice area was measured before and after balloon expansion. In addition, the specimens were examined macroscopically and radiographically with regard to calcium content and degree and localization of fibrosis. These data were correlated with splitting of commissures and with rupture of leaflets. Nine valves were fibrotic, and six were calcific. Dilatation was performed first with a single-balloon catheter (diameter, 2 cm) and then with a double-balloon catheter (diameter, 2 and 1.5 cm). After dilatation with one balloon, the average mitral valve area increased from 0.79 to 1.09 cm2, and with two balloons, average area increased to 1.59 cm2. The single-balloon technique caused commissural splitting in nine valves, stretching in three, partial leaflet rupture in one, and no change in two. After the double-balloon technique, commissural splitting occurred in 12 valves and three leaflets were ruptured where severe fibrosis and calcification were mainly located within the commissures. As a rule, after dilatation with the single-balloon technique, the remaining stenosis was still severe, and after dilatation with the double-balloon technique, the remaining stenosis was moderate.(ABSTRACT TRUNCATED AT 250 WORDS)

Calcinosis↗
PubMed1992

Long-term results of the Ivalon baffle mitral valve repair.

In the evolution of mitral valve surgery, Ivalon sponge was sutured to the posterior leaflet of the mitral valve to obtain competency. Between August 1959 and October 1962, 18 patients had this procedure. All patients were discharged home. Three patients were lost to follow-up 5 to 10 years after operation. Valve replacement was necessary in 7 patients 10.4 +/- 8.5 years after repair. Bacterial endocarditis causing late death occurred in 5 patients within 4 years. Five embolic episodes occurred. The estimated probability of survival and need for valve replacement at 28 years were 29.2% +/- 12.3% and 12.4% +/- 6.7%, respectively.

Adolescent↗