Transesophageal echocardiographic evaluation of mitral valve morphology to predict outcome after balloon mitral valvotomy.
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Isolated cleft of the anterior mitral valve leaflet.
Isolated anterior mitral leaflet cleft (not associated with atrio-ventricular septal defect) is a rare cause of congenital mitral regurgitation, and the treatment consists of direct suturing of the cleft. We present a clinical case with this entity.
Adult↗
[Changes in clinical-instrumental parameters in patients with mitral stenosis after balloon catheterization valvuloplasty of the mitral valve].
The results of mitral valvuloplasty using a balloon catheter were presented for 104 patients with mitral stenosis. Instrumental measurements and clinical symptoms were evaluated before the operation, 6 and 12 months after it (62 and 42 patients, respectively). The balloon dilatation has increased mitral orifice from 120.5 +/- 5.8 to 333.88 +/- 7.45 mm2, transmitral diastolic pressure gradient decreased from 22 +/- 1 to 7.91 +/- 0.6 mm Hg. All the patients benefited clinically: cough, blood spitting, lower limb edemas, protodiastolic murmur disappeared, dyspnea noticeably reduced. NYHA functional class I-II was established in 85% of the patients. The highest effect was achieved in patients with isolated mitral stenosis.
Adult↗
Early outcome of mitral valve reconstruction in patients with end-stage cardiomyopathy.
Uncontrollable severe mitral regurgitation is a frequent complication of end-stage cardiomyopathy, significantly contributing to heart failure in these patients, and predicts a poor survival. Although elimination of mitral valve regurgitation could be most beneficial in this group, corrective mitral valve surgery has not been routinely undertaken in these very ill patients because of the presumed prohibitive operative mortality. We studied the early outcome of mitral valve reconstruction in 16 consecutive patients with cardiomyopathy and severe, refractory mitral regurgitation operated on between June 1993 and April 1994. There were 11 men and five women, aged 44 to 78 years (64 +/- 8 years) with left ventricular ejection fractions of 9% to 25% (16% +/- 5%). Preoperatively all patients were in New York Heart Association class IV, had severe mitral regurgitation (graded 0 to 4+ according to color flow Doppler transesophageal echocardiography) and two were listed for transplantation. Operatively, a flexible annuloplasty ring was implanted in all patients. Four patients also had single coronary bypass grafting for incidental coronary disease. In four patients the operation was performed through a right thoracotomy because of prior coronary bypass grafting, and four patients also underwent tricuspid valve reconstruction for severe tricuspid regurgitation. No patient required support with an intraaortic balloon pump. There were no operative or hospital deaths and mean hospital stay was 10 days. There were three late deaths at 2, 6, and 7 months after mitral valve reconstruction, and the 1-year actuarial survival has been 75%. At a mean follow-up of 8 months, all remaining patients are in New York Heart Association class I or II, with a mean postoperative ejection fraction of 25% +/- 10%. There have been no hospitalizations for congestive heart failure, and a decrease in medications required has been noted. For patients with cardiomyopathy and severe mitral regurgitation, mitral valve reconstruction as opposed to replacement can be accomplished with low operative and early mortality. Although longer term follow-up is mandatory, mitral valve reconstruction may allow new strategies for patients with end-stage cardiomyopathy and severe mitral regurgitation, yielding improvement in symptomatic status and survival.
Adult↗
[Congenital anomalies of the mitral valve in the adult: presentation of 3 cases].
Congenital mitral valve anomalies are uncommon and their incidence in adults is very unusual. Transthoracic echocardiography is essential for their diagnosis. In this study two adult patients with parachute mitral valve and one with isolated cleft of mitral valve are described. An echocardiographic exam was decisive in obtaining the diagnosis for each of these patients. Clinical aspects, typical echocardiographic findings and therapeutical approaches of these entities are discussed.
Adolescent↗
Measurement of mitral valve orifice area in infants and children by two-dimensional echocardiography.
Two-dimensional echocardiograms of the mitral valve orifice area were obtained in 50 normal pediatric subjects, 15 patients with congenital mitral stenosis and 7 patients with tricuspid atresia. The mitral area was measured near the tips of the mitral valve leaflets from a diastolic cross-sectional image of the left ventricle. The cardiac images were recorded on videotape and later transferred to video disc for high resolution contour tracing. Contour analysis was performed by a special purpose microcomputer system for calculation of the enclosed calibrated area. In normal patients, there was an excellent correlation (r = 0.95) between mitral valve area (MVA) (in cm2) and body surface area (BSA) (in m2) described by MVA = 4.83 X BSA - 0.07. Each patient with mitral stenosis had a mitral valve area that measured less than the third percentile predicted from the normal regression formula. In eight patients in whom the Gorlin formula could be applied, there was excellent correlation (r = 0.95) between echocardiographic and hemodynamic measurements of mitral valve area. Each patient with tricuspid atresia had a very large mitral valve area (greater than 99th percentile of normal). It is concluded that noninvasive measurement of mitral valve orifice area can be accurately achieved by two-dimensional echocardiography in pediatric patients with congenital mitral stenosis, allowing serial measurement of their mitral valve area.
Child↗
Emergency surgical treatment of ruptured incompetent mitral valve after percutaneous valvuloplasty.
Of 263 consecutive patients undergoing mitral balloon valvulotomy at the Cardiac Catheterization Unit of Padua University Hospital, six (2.3%) required surgical treatment within 24 hours. The indication for surgery was unstable hemodynamic status due to acute mitral insufficiency caused by the percutaneous balloon valvulotomy. The purpose of this study was to evaluate whether the failure of percutaneous mitral balloon valvulotomy, in this subset of patients, was related to technical problems or was the direct consequence of unfavourable pathologic conditions. Additionally, we evaluated the operative results and clinical outcome of these six patients. The patients were all female with a mean age of 55.7 +/- 14 years (range 38-75 years). Previous surgical commissurotomy was performed in three. The anatomical lesions responsible for the massive regurgitation were tear of the anterior leaflet in two patients and tear of the posterior leaflet in four; rupture of the papillary muscle and/or chordae tendineae were present in five. All patients underwent mitral valve replacement. The elapsed time between the onset of mitral regurgitation and surgery ranged from two to 24 hours (mean 10 +/- 11 hours). There were two hospital deaths (33.3 +/- 21.1%): all surviving patients are alive and clinically well. In conclusion, massive mitral regurgitation following percutaneous mitral dilatation appears to be related to unfavourable pathology of the mitral valve rather than to technical errors. Therefore, careful patient selection is mandatory in order to achieve optimal results. In our experience, adequate and aggressive medical therapy provided sufficient time to prepare for the surgical intervention.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Left ventricular function in mitral valve prolapse: assessment with radionuclide cineangiography.
Abnormalities of left ventricular contraction in patients with mitral valve prolapse have suggested a myocardial factor in this disease. To determine systolic left ventricular function in mitral valve prolapse, technetium-99m gated equilibrium radionuclide cineangiography was performed in 47 patients with this diagnosis. In 39 patients without mitral regurgitation the average ejection fraction was normal at rest (average [+/- standard error of the mean] 57 +/- 3 percent, normal 57 +/- 1 percent, difference not significant) and exceeded the lower limits of normal in all but 1 patient, whose ejection fraction was 41 percent. However, ejection fraction during maximal exercise was lower for the group of patients with mitral prolapse without mitral regurgitation than for normal subjects (average 64 +/- 2 percent, normal 71 +/- 2 percent, p < 0.005). In eight patients with mitral prolapse and mitral regurgitation, the average ejection fraction was normal at rest but was diminished with exercise in comparison with both normal subjects and patients with mitral valve prolapse without mitral regurgitation. Chest pain, arrhythmia and the pattern or extent of mitral valve prolapse on echocardiography were not independently associated with impaired left ventricular functional reserve. We conclude that, although many patients with mitral valve prolapse have normal left ventricular function, there is a subgroup without mitral regurgitation in whom diminished left ventricular functional reserve is suggestive of a cardiomyopathic process.
Adolescent↗
Mini-reoperative mitral valve surgery.
BACKGROUND: Reoperative surgery involving the atrioventricular valves places the patient at risk for cardiac or bypass graft injury upon reoperative sternotomy. Standard right thoracotomy can avoid these problems but is associated with a large incision and possibly more pulmonary complications. METHODS AND RESULTS: An alternative, minimally invasive approach for reoperative atrioventricular valve surgery was studied in 22 patients. Patient age was 66 +/- 10 years. Postoperative mitral regurgitation was 3.4 +/- 0.3 and New York Heart Association (NYHA) Class was III/IV, despite a mean ejection fraction of 44 +/- 14%. These patients had 1-4 prior procedures a mean of 5 years previously. An anterior 5th interspace incision of 5- to 10-cm was performed. A 1-cm segment of 5th rib was removed to facilitate exposure. Cardiopulmonary bypass was performed via ascending aorta or femoral artery cannula and bicaval venous cannulae. Systemic cooling (25 degrees) and fibrillatory arrest was used. Operations performed included mitral valve repair (12), mitral valve replacement (5), prosthetic mitral valve rereplacement (4), repair of perivalvular leak (3), tricuspid valve repair (5), and atrial septal defect closures (7). Mean bypass time was 109 +/- 21 minutes with a mean fibrillatory time of 62 +/- 12 minutes. There was no intraoperative or 30-day mortality. Patients were weaned from ventilation at a mean of 5 hours postoperatively and received 1.3 +/- 1 unit of blood. There were no wound complications or re-explorations for bleeding. At a mean follow-up of 15 +/- 8 months, survivors are NYHA Class I-II. When interviewed, all patients felt their recovery was more rapid and less painful than their original sternotomy. CONCLUSION: This minimally invasive approach to reoperative atrioventricular valve surgery is safe and technically feasible. It has become our preferred approach to the atrioventricular valves in patients with a previous sternotomy.
Aged↗
Mitral valve prolapse in children with secundum--type atrial septal defect (ASD II).
A left ventricular angiocardiogram for evaluation of the mitral valve in patients with uncomplicated secundum type atrial septal defect has been proposed in a recent paper by Victoria et al. (1974). These authors observed 8 children with a ballooning mitral valve and ASD II. They stressed the necessity of performing a left ventricular angiocardiogram in every patient with ASD II. To challange their proposal, the angiocardiograms of 78 children with secundum type ASD were reviewed. Of these 89 angios 34 were performed using the left ventricle (LV) as injection site while 55 times the injection was made in other parts of the heart, e.g. left atrium, pulm. art., right ventricle, right atrium. All 34 LV angios, but only 12 of the others allowed an evaluation of function and morphology of the mitral valve. Of the 46 angiocardiograms 27 (58.7%) revealed an intact, normally closing and opening mitral valve. In the remaining 19 (41.3%) various grades of ballooning or mild prolapsing of one or two leaflets of the mitral valve could be detected. The "scallops" were minimal in 12, moderate in 4 and pronounced in 3 cases. A mild regurgitation was seen in 1 patient only. No patient had the pronounced ballooning observed by Victoria et al. On auscultation only 1 case had the apical murmur of mitral regurgitation. The ECG of our 19 "positive" cases did not show signs of left atrial or left ventricular hypertrophy. A left axis deviation was found in 1 patient. During surgery no structural abnormality of the mitral valve was noted. Postoperative reevaluation of the mitral valve (including left ventricular contrast injection) in 10 cases revealed no change of mitral valve appearance in 8, a decrease of the ballooning in one, and an increase in another patient. It is concluded that prolapses of the mitral valve are seldom of such a degree as to cause dysfunction in children with secundum type ASD. The indications for performing a left ventricular injection of contrast material are the clinical signs of mitral valve regurgitation and/or left axis deviation in the ECG.
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Temporal resolution of mitral regurgitation in patients with mitral valve prolapse: a phonocardiographic and Doppler echocardiographic study.
To assess the timing and duration of mitral regurgitation in mitral valve prolapse, 20 patients with a mid-systolic click or late systolic murmur, or both (Group 1) and 16 patients with a pansystolic murmur with late systolic accentuation (Group 2) were studied with phonocardiography and echocardiography including various Doppler techniques. The subjects' ages ranged from 15 to 73 years. Mitral valve prolapse with mitral regurgitation was observed in 15 of 20 patients in Group 1 and in all 16 patients in Group 2. M-mode Doppler color echocardiography demonstrated a mitral regurgitant signal throughout systole and isovolumic relaxation in all but 1 of these 31 patients regardless of the pattern of the systolic murmur. The regurgitant signal was recorded after the click in only one patient with mitral valve prolapse in Group 1. Two of the five patients in Group 1 without two-dimensional echocardiographic findings of mitral valve prolapse had the early systolic signal of mitral regurgitation. The timing and duration of the mitral regurgitant signal detected in patients in Group 1 with pulsed or continuous wave Doppler ultrasound varied with the site of the sample volume or beam direction. In the patients in Group 2, however, the signal was demonstrated throughout systole and isovolumic relaxation by both Doppler methods. Compared with M-mode Doppler color echocardiography, therefore, pulsed and continuous wave Doppler methods were less sensitive and thus inadequate to investigate the timing and duration of mitral regurgitation in mitral valve prolapse, especially in patients with a mid-systolic click or a late systolic murmur, or both, who had mild or eccentric mitral regurgitant jets.(ABSTRACT TRUNCATED AT 250 WORDS)
Adolescent↗
Percutaneous mitral valve repair: a feasibility study in an ovine model of acute ischemic mitral regurgitation.
Annuloplasty is the cornerstone of surgical mitral valve repair. A percutaneous transvenous catheter-based approach for mitral valve repair was tested by placing a novel annuloplasty device in the coronary sinus of sheep with acute ischemic mitral regurgitation. Mitral regurgitation was reduced from 3-4+ to 0-1+ in all animals (P < 0.03). The annuloplasty functioned by reducing septal-lateral mitral annular diameter (30 +/- 2.1 mm preinsertion vs. 24 +/- 1.7 mm postinsertion; P < 0.03). These preliminary experiments demonstrate that percutaneous mitral annuloplasty is feasible. Further study is necessary to demonstrate long-term safety and efficacy of this novel approach.
Animals↗
Coexistence of mitral valve prolapse in a consecutive group of 528 patients with hypertrophic cardiomyopathy assessed with echocardiography.
Hypertrophic cardiomyopathy and mitral valve prolapse are both conditions that may be genetically transmitted and incur a risk for sudden cardiac death. Although the small left ventricular cavity and distorted geometry characteristic of hypertrophic cardiomyopathy might suggest a predisposition to mitral valve prolapse, the frequency with which these two entities coexist and the potential clinical significance of such an association are not known. To further define the relation of hypertrophic cardiomyopathy and mitral valve prolapse, 528 consecutive patients with hypertrophic cardiomyopathy were studied by echocardiography. Patients ranged in age from 1 to 86 years (mean 45); 335 (63%) were male. Unequivocal echocardiographic evidence of systolic mitral valve prolapse into the left atrium was identified in only 16 (3%) of the 528 patients. The mitral valve excised at operation from three of the patients had morphologic characteristics of a floppy mitral valve, which was judged to be responsible for the echocardiographic findings. Occurrence of clinically evident atrial fibrillation was common in patients with hypertrophic cardiomyopathy and mitral valve prolapse (9 [56%] of 16). Hence, in a large group of patients with hypertrophic cardiomyopathy, the association of echocardiographically documented mitral valve prolapse was uncommon. The coexistence of mitral valve prolapse in patients with hypertrophic cardiomyopathy appears to predispose such patients to atrial fibrillation.
Adolescent↗
The conditions of mitral valve closure.
Due to inertia of the mitral blood flow the closure of the mitral valve is delayed for a certain time after the atrioventricular pressure cross over. This delay is investigated by means of dimensional analysis. A nondimensional number occurring in this analysis is taken from a reported dog experiment and the analysis is then used to determine the conditions of mitral valve closure in man, both during rest and during exercise. The results show that rather high ventricular pressures are obtained during exercise before the mitral valve closes.
Animals↗
Left ventricular pannus causing inflow obstruction late after mitral valve replacement for endocardial fibroelastosis.
A case of mitral stenosis following mitral valve replacement in a patient with endocardial fibroelastosis is reported. A 14-year-old boy presented with cardiac failure. He had been diagnosed as having endocardial fibroelastosis at the age of 7 months and had undergone resection of endocardial fibrous tissue in the left ventricle at that time. Five years later his mitral valve was resected owing to mitral stenosis, with Bjork-Shiley valve replacement. Cross-sectional echocardiography on this admission showed restrictive left ventricular inflow due to a thickened immobile prosthetic valve with severely dyskinetic left ventricle (ejection fraction 8%). The electrocardiogram showed atrioventricular reentry tachycardia. Despite direct current cardioversion and continual amiodarone infusion he suffered a cardiac arrest and died 12 days after admission. Postmortem examination showed left ventricular endocardial fibroelastosis with severe inflow obstruction due to the formation of a complete fibrous ring of pannus/fibrosis around the prosthetic margin on the ventricular aspect of the left ventricle. This complication has not previously been described in children after mitral valve replacement.
Adolescent↗
Endocarditis after mitral valve repair.
BACKGROUND: Native valve endocarditis is frequently managed with antibiotics alone, but prosthetic valve endocarditis usually requires an early operation. What is the best treatment of endocarditis after mitral valve repair? METHODS: From 1986 to 2000, 22 patients were treated for endocarditis affecting a previously repaired mitral valve. Causes of mitral valve dysfunction that led to repair were degenerative (11 patients), ischemic (5 patients), endocarditic (3 patients), rheumatic (2 patients), and functional (1 patient). Endocarditis was active in 21 patients and healed in 1. Interval from initial mitral valve repair to onset of endocarditis ranged from 1 week to 10.3 years (median, 6 months). Pathology included leaflet vegetation (15), annuloplasty vegetation (4), leaflet perforation (5), and abscess (3). Mean follow-up was 3.9 +/- 3.3 years. RESULTS: Fifteen patients underwent repeat mitral valve operations with freedom from mitral valve reoperation of 65%, 41%, and 26% at 30 days, 1 year, and 5 years after onset of endocarditis. After a high early hazard, risk of reoperation fell to 10.8% per year. Seven patients, all with a leaflet vegetation, were treated with antibiotics alone. Antibiotics eradicated infection in all; however all had mitral regurgitation 2+ to 4+. Survival was 96%, 74%, and 68% at 30 days, 1 year, and 5 years. Endocarditis recurred in 1 patient (92% free of event). CONCLUSIONS: Most patients that have endocarditis develop after mitral valve repair require reoperation. However if infection is limited to a leaflet, early reoperation may be unnecessary because antibiotics alone can eradicate infection.
Adolescent↗
Double-orifice mitral valve: report of two cases.
Two cases of double-orifice mitral valve are reported. The first case was associated with coarctation of the aorta and a large perimembranous ventricular septal defect, and the second case had an associated large patent ductus arteriosus. A bridge-type defect created two equal-sized openings in the mitral valve in case 1. In case 2, a small accessary opening was located in the posteromedial leaflet of the mitral valve. Double-orifice mitral valve is a rare anomaly associated with coarctation of the aorta, ventricular septal defect, and patent ductus arteriosus. The morphology of a double-orifice mitral valve can be clearly delineated by 2-D echocardiography.
Aortic Coarctation↗
Cardiac autotransplantation for mitral valve replacement.
We present an unusual case of a 69-year-old patient with severe mitral valve regurgitation and extensive coronary artery disease who required mitral valve replacement and myocardial revascularization. With the patient on cardiopulmonary bypass, distal vein grafting was performed first. This procedure was followed by a transatrial transseptal approach to the mitral valve, but visualization of valve structures was extremely difficult. Following the partial excision of the posterior leaflet and the placement of a few pledgeted annular sutures on which traction was applied, access to the mitral annulus remained impossible. There appeared no option but to explant the heart and perform the mitral valve replacement ex vivo. Cardiac explantation was performed by transecting the aorta and pulmonary artery and completing the already extended right and left atriotomies. Cold blood cardioplegic solution was administered intermittently into the coronary sinus during the period when the heart was ex vivo. A porcine bioprosthesis was easily seated into the mitral annulus. Cardiac reimplantation consisted of repair of the previously divided atria, and end-to-end anastomoses of both the aorta and the pulmonary artery. While rewarming was taking place, the 3 proximal vein graft anastomoses were performed. Temporary and permanent epicardial pacing leads were placed. Total ischemic time was 299 minutes, and the period on cardiopulmonary bypass was 359 minutes. The heart sustained good hemodynamics, and after full functional recovery, the patient was discharged home and remained well for 7 years. In view of this experience, a questionnaire was mailed to >3000 cardiothoracic surgeons, and responses were obtained from 1120. Inadequate mitral valve exposure had been experienced by 70%. To provide increased exposure, 50% had extended the initial atrial incision both horizontally and perpendicular to the atrial groove, 17% had divided the superior vena cava, 1% had divided the inferior vena cava, and 1% had divided both cavae. Furthermore, 4% of surgeons reported being forced to abandon the operation in 71 patients because of inadequate exposure. Three hundred twenty perioperative deaths were directly attributed to an incomplete surgical procedure. Explantation of the heart, with mitral valve replacement being performed ex vivo followed by reimplantation, should be considered when access to the mitral valve proves impossible with more standard techniques.
Aged↗