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PubMed1997

Can the maze procedure be combined safely with mitral valve repair?

BACKGROUND AND AIMS OF THE STUDY: The safety of combining mitral valve repair with the maze procedure for chronic atrial fibrillation in the surgical management of patients with mitral valve disease is not well elucidated. We present our operative results regarding mortality and morbidity after such combined surgery. As a comparison, our operative results after mitral valve repair in patients without chronic atrial fibrillation are presented. METHODS: Between April 1993 and December 1994, 39 patients with chronic atrial fibrillation underwent mitral valve repair and concomitant maze procedure (group 1) at the Iwate Medical University. During the same period, 36 patients with sinus rhythm and one patient with DDD pacemaker underwent mitral valve repair (group 2). In order to evaluate the operative risk, morbidity, and mortality of adding the maze procedure to mitral valve repair, total cardiopulmonary bypass time, aortic cross-clamp time, intraoperative blood loss, intubation period, and duration of ICU stay were compared between the groups. RESULTS: Total cardiopulmonary bypass time and aortic cross-clamp time in group 1 were longer than in group 2 (174.0 +/- 38.8 min versus 150.1 +/- 54.4 min; p = 0.032, 122.5 +/- 30.7 min versus 95.8 +/- 38.2 min; p = 0.0012). However, the duration of ICU stay, intubation period, and intraoperative blood loss were not different between the groups. There were no hospital deaths in either group. Four patients in group 1, and two patients in group 2 required re-exploration for bleeding (p = NS). Two patients in group 1, and none in group 2 required pacemaker implantation postoperatively (p = NS). Two patients in group 2, and none in group 2 had minor cerebral infarction (p = NS). At hospital discharge, 28 patients in group 1 (72%) and 35 patients (97%) in group 2 were in sinus rhythm. CONCLUSIONS: The maze procedure can be combined with mitral valve repair without adding undue operative risk to patients. Those patients with chronic atrial fibrillation undergoing mitral valve repair may be advised for the possibility of concomitant maze procedure.

Aged↗
PubMed1985

[Doppler sonographic determination of the degree of severity of mitral valve stenoses].

Using combined two-dimensional echocardiography and Doppler technique in 30 patients with pure mitral valve stenosis or combined valve disease with prevailing mitral stenosis, the mitral valve area and diastolic pressure gradient were determined, and compared to the invasively recorded values obtained during heart catheterization. Four patients were examined by Doppler ultrasound before and after mitral valve replacement. The determination of the mitral valve area was performed 1) invasively by means of the formula derived by Gorlin (and measured between 0.5 and 2.9 cm2), 2) by means of planimetry by integration of the two-dimensional echo in the short-axis view (between 0.7 and 2.8 cm2), and 3) by Doppler ultrasound based on the formula 220/t1/2, whereby the pressure half-time was obtained by dividing maximum flow velocity by square root 2. Here, the mitral valve area was between 0.5 and 2.8 cm2. The correlation between values obtained invasively and by means of Doppler ultrasound was good (r = 0.86), and compared well to the correlation between two-dimensional echocardiography and heart catheterization (r = 0.88). The best correlation of r = 0.89 was found between the mitral valve areas obtained by Doppler ultrasound and two-dimensional echocardiography. The diastolic pressure gradient was calculated by means of the formula derived from the Bernoulli equation, which is: delta P = 4Vmax2, whereby Vmax equals the maximum transmitral flow velocity. The invasively measured pressure gradients were between 2 and 30 mm Hg, the values obtained by Doppler ultrasound were between 6 and 29 mm Hg.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1993

Echocardiographic restenosis after successful balloon dilatation of the mitral valve with the Inoue balloon: experience of a United Kingdom centre.

OBJECTIVES: (a) To assess the echocardiographic incidence of restenosis after successful balloon dilatation of the mitral valve at a mid-term follow up of one year among a population of predominantly United Kingdom patients. (b) To identify any factors, assessed before or during dilatation, which may predict the development of restenosis. DESIGN: Successful dilatation of the mitral valve was defined as an increase in mitral valve area of > 25% and a final valve area of at least 1.5 cm2. Echocardiographic restenosis was defined at follow up as a loss of 50% of initial gain and a valve area of less than 1.5 cm2. Mitral valve area was assessed by transthoracic echocardiography before, during, 48 hours after, and one year after successful balloon dilatation of the mitral valve. Echo score before dilatation (an assessment of valvar and subvalvar calcification, thickening, and mobility), age, rhythm, echocardiographic mitral valve area before and after dilatation, left atrial pressure before and after dilatation, and end diastolic mitral valve gradient before and after dilatation were compared in those patients with and without echocardiographic restenosis at one year. SETTING: A regional cardiothoracic centre in the United Kingdom that performs 20-30 balloon dilatations of mitral valves each year. PATIENTS: 39 patients, with symptomatic dominant mitral stenosis, who had undergone successful balloon dilatation of the mitral valve, and in whom echocardiographic assessment of mitral valve area was available at one year. 92% of patients were citizens of the United Kingdom. INTERVENTIONS: Balloon dilatation of the mitral valve by the Inoue technique. MAIN OUTCOME MEASURES: Mitral valve area and patient symptom class (New York Heart Association) one year after successful dilatation of the mitral valve. RESULTS: The incidence of echocardiographic restenosis was eight of 39 patients (21%). Of the eight patients with restenosis four underwent mitral valve replacement, two had repeat dilatation of the mitral valve, and two remained on medical treatment. With univariant analysis, factors associated with restenosis were increased age, higher echo score before dilatation, and a lower mitral valve area immediately after the operation. The only independent risk factor for restenosis, shown by multivariant analysis, was a high echo score before dilatation. There was no significant fall in mitral valve area at one year in those patients without restenosis. Most (28/31) of these patients had echocardiographic evidence of splitting of at least one commissure after dilatation compared with only two of eight patients who developed restenosis. Of 10 patients with an echo score before dilatation > or = 10 only two had an initially successful operation and no restenosis at one year. CONCLUSIONS: The echocardiographic incidence of restenosis after dilatation of the mitral valve by the Inoue technique in patients of the United Kingdom is 21%. The principal factor associated with restenosis is a high echo score before dilatation. Increases in mitral valve area are maintained in those patients without restenosis and it is likely that the mechanism of initial increase in valve area is different in the two groups, being commissural splitting in those patients who do not get restenosis and valve stretching in those that do. In patients with an echo score > or = 10 dilatation of the mitral valve should be considered only as a palliative procedure.

Adult↗
PubMed1976

Association of ostium secundum atrial septal defects with mitral valve prolapse.

Severe prolapse of the mitral valve leaflets was seen at left ventricular angiography in 16 of 92 patients with a secundum type atrial septal defect studied prospectively from 1970 to 1974. The patients were aged 15 to 69 years; angioplasty or mitral valve replacement was carried out in nine. In 9 of 122 patients aged 15 to 55 years who were operated on for closure of a secundum type atrial septal defect between 1956 and 1969, mitral regurgitation due to prolapse but with intact chordae tendineae was seen at operation. In three of these patients chordal rupture was seen at a second operation 2 to 6 years later. The outlook in the syndrome of mitral valve prolapse may be less benign than is usually believed.

Adolescent↗
PubMed1996

Rationale of the Cox maze procedure for atrial fibrillation during redo mitral valve operations.

OBJECTIVE: The frequency of reoperation for mitral valve diseases with chronic atrial fibrillation has increased steadily. This study examined the rationale for using the Cox maze operation for atrial fibrillation during redo mitral valve operations. METHODS: Between June 1992 and July 1995, we performed the maze procedure in 42 patients as a concomitant operation with redo mitral valve surgery (maze group). Associated procedures were tricuspid valve surgery in 27 patients and aortic valve surgery in 15 patients. The mean age at operation was 57.3 +/- 9.7 years, and the mean interval from the previous operation was 14.3 +/- 10.5 years. The mean follow-up period after the maze procedure was 25.5 +/- 10.8 months. Atrial fibrillation was present at the time of the previous operation in 29 patients (69%). RESULTS: Neither hospital death nor late death occurred. Sinus rhythm was regained in 28 patients (67%), and an atrial A-wave was detected in 21 patients (50%) by pulsed Doppler study. Patients in whom sinus rhythm was restored had a shorter history of atrial fibrillation (9.0 +/- 6.0 years vs 15.9 +/- 4.6 years, p = 0.0009), a larger f-wave on lead V1 of the electrocardiogram (0.18 +/- 0.10 mV vs 0.10 +/- 0.08 mV, p = 0.017), and a smaller cardiothoracic ratio (63% +/- 8% vs 67% +/- 5%, p = 0.049) than patients with persistent atrial fibrillation. During the same period, 54 patients underwent mitral valve reoperation without the maze procedure (control group). The aortic crossclamp and cardiopulmonary bypass times were slightly longer (p = 0.048 and p = 0.012) in the maze group (133 +/- 28 minutes and 221 +/- 43 minutes) than in the control group (126 +/- 65 minutes and 197 +/- 78 minutes). There was no significant difference in the amount of chest tube drainage or transfusion between the two groups (890 +/- 510 ml and 2120 +/- 1600 ml, respectively, in the maze group and 840 +/- 480 ml and 2140 +/- 1760 ml, respectively, in the control group). It was not necessary to reopen the chest for bleeding significantly more often in one group than in the other (14% in the maze group and 7% in the control group), and it was possible to operate without transfusion with the same frequency in the two groups (17% in the maze group and 20% in the control group). CONCLUSION: These results suggest that the maze procedure should be considered in selected patients who have a high possibility of regaining sinus rhythm during redo mitral valve operations.

Adult↗
PubMed1988

Mitral valve prolapse (Barlow's syndrome) and retinal emboli.

Mitral valve prolapse (M.V.P.) is a noninflammatory degeneration of the mitral valve leaflets which results in a billowing of the redundant valve tissue toward the left atrium during the systolic phase. Mitral valve prolapse can be diagnosed by echocardiography or by auscultation where a characteristic mid-systolic click and late systolic murmur can be heard. Ophthalmic complications of MVP include chronic external progressive ophthalmoplegia and an association with keratoconus. In this case we present a case of a young woman who presented with sudden recurrent decrease in vision secondary to retinal arterioli emboli associated with the mitral valve prolapse syndrome.

Adult↗
PubMed1979

Noninvasive assessment of hemodynamic effects of mitral valve commissurotomy during rest and exercise in patients with mitral stenosis.

Noninvasive radionuclide angiocardiography (RNA) provides simple and accurate assessment of parameters of cardiac function during rest and during maximal exercise. Left ventricular function was assessed by RNA in nine patients with isolated mitral stenosis before and approximately 6 months after mitral commissurotomy. Before operation, the mean mitral valve gradient was 14.0 +/- 2.8 mm Hg, and the mean mitral valve area was 1.20 +/- 0.3 cm2. Each patient was evaluated at rest and during maximal exercise on an isokinetic bicycle ergometer before and after commissurotomy. Heart rate, ejection fraction, end-diastolic volume, stroke volume, pulmonary transit time, cardiac output, and diastolic ventricular filling rate were determined by the radionuclide technique. Before operation, patients with mitral stenosis had characteristic changes from rest to exercise which supported restriction to diastolic ventricular filling as the primary limitation in generating a cardiac output during exercise. The stroke volume was unchanged from rest to exercise. Thus the cardiac output during exercise was heart rate dependent. However, after commissurotomy the stroke volume increased from rest to exercise. Therefore, cardiac output during exercise was achieved by heart rate and an augmented stroke volume. Moreover, the pulmonary transit time was reduced during rest and exercise after operation. The maximum ventricular ejection and filling rates were markedly increased during rest and exercise after commissurotomy. These differences in hemodynamic parameters at rest and during exercise document the mechanics of increased exercise tolerance in patients with mitral stenosis after mitral commissurotomy.

Adult↗
PubMedDate not supplied

An approach to the surgery of mitral valve disease in children.

Isolated mitral valve surgery was carried out in 182 children under the age of 16 years. Closed valvulotomy was performed in 72, annuloplasty or reconstruction in 10 and valve replacement in 100 of the children. Preoperative atrial fibrillation implied severe disease. Acute rheumatic carditis was not a contraindication to operation. Two patients died after closed mitral commissurotomy and the results were unsatisfactory in nine children with valve calcification and in 12 with a small jet of incompetence. Restenosis occurred in 10 patients during a review period of five years. The long-term results of annuloplasty were disappointing, and this procedure is not recommended for children with mitral incompetence. Ten of the 100 patients who underwent mitral valve replacement died in hospital and there were two late deaths. Seventy-seven patients are completely well and 11 have grade II disability. Severe mitral valve disease in children is associated with high morbidity and mortality, unless normal hemodynamics are restored. Since the results of operation are so satisfactory, we believe that the natural history of this condition is most favorably altered by surgical treatment.

Adolescent↗
PubMedDate not supplied

Pulmonary parenchymal manifestations of mitral valve disease.

Pulmonary parenchymal manifestations of mitral valve disease are the result of either pulmonary venous hypertension in mitral stenosis or abnormal regurgitant flow into pulmonary veins in mitral insufficiency. Typical radiographic findings in mitral stenosis include pulmonary vascular cephalization; interstitial, perivascular, and occasionally alveolar pulmonary edema; diffuse alveolar hemorrhage; hemosiderosis; and pulmonary ossification. Signs of interstitial pulmonary edema are frequently visible and include septal lines. Radiographic findings in diffuse alveolar hemorrhage consist of diffuse, confluent acinar or ground-glass areas of increased opacity, often sparing the peripheral parenchyma and creating the so-called window frame effect. Hemosiderosis is characterized by small, ill-defined nodules or by coarse reticular areas of increased opacity with a bias for the middle and lower lung regions. Ossification manifests as densely calcified, 1-5-mm nodules, mainly in the middle and lower lungs, with a tendency for confluence and the occasional presence of trabeculae. Imaging findings in mitral regurgitation depend on the acuteness of the disease. The most common parenchymal manifestations of acute mitral regurgitation are symmetric alveolar and interstitial pulmonary edema with indistinct, engorged pulmonary vessels and cephalized blood flow. Familiarity with these manifestations can expedite diagnosis, particularly in rare cases of unsuspected mitral valve disease.

Humans↗
PubMed2000

Evaluation of collagenase-induced mitral valve regurgitation in dogs.

OBJECTIVE: To investigate the hemodynamic changes induced by injecting collagenase into the mitral valve to induce mitral valve regurgitation (MVR) in dogs. ANIMALS: 9 healthy Beagles. PROCEDURE: Dogs were randomly assigned to 3 groups: control (saline [0.9% NaCl] solution; n = 3), single collagenase injection (C1; 3), and 2 collagenase injections (C2; 3). Open-heart surgery was performed, and saline or collagenase solutions were injected into the mitral valve. Before and weekly for 11 weeks after surgery, radiography, echocardiography, and phonocardiography were performed. Mean pulmonary arterial pressure and mean pulmonary arterial wedge pressure (mPAWP) were measured before and 11 weeks after surgery. Postmortem examinations were performed after dogs were euthanatized. RESULTS: No changes were detected in the control group during the 11-week follow-up period. A systolic murmur and MVR developed 1 week after surgery in groups C1 and C2. The murmur changed from a protosystolic to a pansystolic murmur, and left atrial diameter and the left atrial-to-aortic root diameter ratio increased with time. Mean pulmonary arterial pressure and mPAWP were greater 11 weeks after surgery in groups C1 and C2, compared with presurgery values. During necropsy, tissue loss was detected in the mitral valve at the site of collagenase injection. Degree of regurgitation corresponded to lesion size. CONCLUSIONS AND CLINICAL RELEVANCE: Injection of collagenase into the mitral valve of healthy dogs induced MVR, and dogs with MVR developed progressive hemodynamic changes without acute overload. Collagenase-induced MVR may be an appropriate model for evaluation of prognostic markers of idiopathic MVR in dogs.

Animals↗
PubMed1996

Minimally invasive mitral valve operations.

A technique for mitral valve operations is described in which exposure is performed through a small right parasternal incision. Via a transseptal approach, excellent exposure to the mitral valve is obtained, allowing surgical correction of the diseased valve.

Cardiopulmonary Bypass↗
PubMed2005

Recurrence of cerebrovascular thromboembolic event in a woman with accessory mitral valve during puerperium period.

Accessory mitral valve tissue is an extremely rare congenital cardiac anomaly. Most of the cases reported in the literature were associated with left ventricular outflow tract obstruction. In this report, a second cerebrovascular event is presented in the same patient two years after an operation in which septal myectomy was performed but accessory mitral valve tissue was not excised.

Adult↗
PubMed1995

Partial mitral homograft: a new technique for mitral valve repair.

Partial mitral homograft was used in 22 patients with localized lesions contraindicating a conventional valve repair. The etiologies of valve disease were: calcified rheumatic stenosis (n=14) and acute bacterial endocarditis (n=8). One patient died three months after surgery from cancer. Another patient required reoperation for residual stenosis 14 months postoperatively. All other patients had an excellent functional result with 19 patients in sinus rhythm. In this series, partial homograft replacement of the mitral valve significantly extended the possibilities of reconstructive surgery.

Adolescent↗
PubMedDate not supplied

[Mitral valve replacement by mechanical disk valve. A surgical alternative].

From July to December 1993, 10 patients underwent mitral valve replacement with mechanical disc valve and running suture, preserving the posterior mitral valve apparatus. There were 6 men and 4 women, with a mean age of 44.2 years (25 to 63 years old). Three patients were in functional class II of the NYHA, 5 in functional class III and 2 in functional class IV. Eight patients were operated on for simple mitral valve replacement, of which, 2 underwent the first replacement 4 the second replacement and 2 the third replacement. One patient underwent double valve replacement (mitral and aortic valves) plus "bicuspidization" of the tricuspid valve and one patient underwent myocardial revascularization with two grafts of reverse saphenous vein besides mitral valve replacement. We used cardiopulmonary bypass in all patients with moderate hypothermia at 28 degrees and cardiac protection with cold cardioplegia at 4 degrees with potassium. One to 2 dosis of cardioplegia were required. Aortic cross clamping time was 37 minutes and 64 minutes of cardiopulmonary bypass in the patients operated on of simple mitral valve replacement. Supported by these preliminary results, we conclude that this surgical alternative is effective and safe with less ischemic and cardiopulmonary bypass time, preserve the posterior mitral apparatus and avoid disc jamming by the residual leaflet or tendinous chordae.

Adult↗
PubMed2003

Long-term results after Starr-Edwards mitral valve replacement in children aged 5 years or younger.

BACKGROUND: Mitral valve replacement with prosthetic valves in infants and children requires consideration of multiple variables. When we examined our late follow-up, the effect of the growth of the patient relative to the size of the prosthesis placed was the most important variable predicting late successful results. We reviewed our experience with mitral valve replacement using the Starr-Edwards ball valve in children aged 5 years or younger, focusing on the effect of valve prosthesis-patient mismatch on the long-term results in the growing patient. METHODS: From August 1974 to June 1986, 8 patients aged 5 years or younger underwent mitral valve replacements using the Starr-Edwards prosthesis size OM in 3 patients and 1M in 5 patients. Model 6320 was used in 1 patient and Model 6120 in the remaining 7 patients. RESULTS: Follow-up was 100% from 15 to 27 years (mean, 20 years). No valve-related complications of thromboembolism, anticoagulant-related hemorrhage, or prosthetic valve endocarditis were seen. All patients normally developed to adult size. The range of the valve area index of the 3 patients who received the smaller Starr-Edwards valve (size OM) was 0.97 to 1.24 cm2/m2. Although this size valve was adequate for patient growth to adolescence, in each case valve replacement with a larger valve was required. CONCLUSIONS: Our long-term review of Starr-Edwards ball valve mitral valve replacement in children aged 5 years or younger shows that the Starr-Edwards ball valve (Models 6320 [1 patient] and 6120 [7 patients]) showed excellent durability, no thromboembolism, and no anticoagulant-related complications. Size OM valves required replacement for hemodynamic reasons because of patient growth; larger size 1M valves remained hemodynamically satisfactory in spite of patient growth.

Adolescent↗
PubMed2000

Association between idiopathic mitral valve prolapse and panic disorder.

AIM: To evaluate the association between idiopathic mitral valve prolapse and panic disorder. METHODS: The study comprised 50 patients with idiopathic mitral valve prolapse, 50 patients with panic disorder, and 50 healthy controls. All subjects underwent echocardiographic evaluation. If idiopathic mitral valve prolapse was present, the level of prolapse was measured. To reach psychiatric diagnosis, the Structured Clinical Interview for DSM-IV Axis I Disorders, clinician version, was administered to all subjects. For psychometric evaluation, all subjects completed the Symptom Check List, Beck Depression Inventory, and State and Trait Anxiety Inventory. RESULTS: The prevalence of panic disorder was 16% in patients with idiopathic mitral valve prolapse, and 2% in healthy controls (p=0.03). The average scores on all psychometric scales were the highest in the panic disorder group, whereas average scores in idiopathic mitral valve prolapse group were significantly higher than in the control group (p<0.001). Idiopathic mitral valve prolapse and panic disorder groups displayed similar features of panic attack symptoms. Panic disorder cases with idiopathic mitral valve prolapse and those without it did not significantly differ in terms of psychometric evaluations and clinical symptoms. CONCLUSION: The possibility of comorbidity of panic disorder and idiopathic mitral valve prolapse should be taken into account in the approach to the patients diagnosed with either of the disorders.

Adolescent↗
PubMed2004

[Usefulness of transthoracic freehand three-dimensional echocardiography for the evaluation of mitral valve prolapse].

BACKGROUND: Two-dimensional (2D) echocardiography is routinely used in evaluating patients with mitral valve prolapse but requires a systematic examination for accurate assessment of the involved lesion of mitral valve prolapse, because the sonographer is required to mentally reconstruct two-dimensional images into three dimensions. Recently, freehand three-dimensional (3D) echocardiography has been introduced in the clinical setting for three-dimensional visualization of the mitral valve apparatus. OBJECTIVES: To evaluate the accuracy of the freehand 3D echocardiography system in assessing the involved lesion in patients with mitral valve prolapse. METHODS: This study consisted of 25 consecutive patients (15 men, 10 women, mean age 55 +/- 17 years) with mitral valve prolapse who were scheduled for 3D echocardiography. Mitral valve was reconstructed in the view from the left atrium (surgeon's view) by 3D echocardiography. The location of the involved lesion in mitral valve was classified as the medial, middle and lateral portions of the anterior leaflet, and the medial, middle and lateral scallops of the posterior leaflet, respectively. The results by 3D echocardiography were compared with those of 2D echocardiography as the clinical standard. RESULTS: An adequate three-dimensional display of the entire mitral valve for analysis of the involved lesion could be reconstructed in all 25 patients (feasibility 100%). The sensitivity of 3D echocardiography for detecting the lesions at the medial, middle and lateral portions of the anterior leaflet was 80%, 100% and 75%, and the medial, middle and lateral scallops of the posterior leaflet was 100%, 100% and 0%, respectively. The specificities were 100% at all locations in the mitral valve. CONCLUSIONS: These results indicate that freehand 3D echocardiography is useful for assessment of the involved lesion of the mitral valve in patients with mitral valve prolapse.

Aged↗
PubMed1985

Mitral valve alternans.

An echogram showing mitral valve alternans was recorded in a patient with advanced cardiomyopathy and pulsus alternans induced by premature ventricular depolarizations. Decreased left ventricular emptying by the weak beat was followed by blunting of the subsequent mitral valve E point, a finding compatible with a significant elevation of left ventricular pressure in early diastole. Both alternating systolic (contractile state) and diastolic (pressure and dimension) variables seemed to participate in the alternans phenomenon in this patient.

Arrhythmias, Cardiac↗