[Long-term follow-up study on valve function and left ventricular function after mitral valve replacement with a tilting disc valve--an echocardiographic study].
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Adolescent↗
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Inaccurate noninvasive mitral valve area calculation during pregnancy.
OBJECTIVE: To compare two different Doppler echocardiographic techniques for the assessment of the transmitral area in pregnant patients with native mitral valve stenosis or prosthetic mitral valves. METHODS: Eight consecutive gravid women with prosthetic mitral valves or obstructive native mitral valve disease were evaluated using both the pressure half-time and the continuity equation Doppler echocardiographic methods. Heart rate, cardiac output, and transmitral valve gradient and area were calculated. These studies were repeated postpartum in five women. Differences between the two methods were assessed by characterizing the absolute differences between the mean and standard deviation and by paired t tests. Linear regression analysis was also applied. RESULTS: For the five women who also had postpartum studies, antepartum data were similar to those of the full set of eight patients. Postpartum heart rate, cardiac output, and transvalvular gradient were lower than antepartum measurements. Calculations using the continuity equation yielded comparable antepartum and postpartum estimates of transmitral areas (1.31 +/- 0.41 versus 1.32 +/- 0.44 cm2, respectively, r = 0.96). These estimates were also consistent with the initial clinical presentation. In contrast, antepartum transmitral valve areas calculated using the pressure half-time technique (2.67 +/- 0.61 cm2) were markedly higher than postpartum (1.94 +/- 0.58 cm2). The correlation between the estimates of antepartum valve area given by the two methods was not statistically significant (r = 0.02). In contrast, there was excellent postpartum correlation of transmitral area between the methods (r = 0.99), despite a significant difference (P < .001) in the transmitral area calculated with each technique. CONCLUSIONS: The results indicate that Doppler echocardiographic estimates of the transvalvular area using the continuity equation technique during pregnancy are valid. In contrast, estimates of area using the pressure half-time technique in pregnant patients are dubious and could result in life-threatening consequences.
Adult↗
A novel approach to calculation of mean mitral valve gradient by Doppler echocardiography.
The Doppler-derived mean mitral valve gradient (DeltaP(M)) based on the simplified Bernoulli equation requires computerized integration of the Doppler signal and evaluation by a technician with the use of special equipment. We have noted empirically that the DeltaP(M) can be derived by the equation DeltaP(M) = (P(P) - P(T)) / 3 + P(T). Peak (P(P)) and trough (P(T)) pressures are derived from the simplified Bernoulli equation (P = 4V(2)). This equation can be used by the experienced observer to calculate the mean mitral valve gradient without specialized equipment. The purpose of this study is to validate the above empirically derived equation in patients with mitral stenosis. We retrospectively reviewed 41 consecutive studies done at our institution from October 1, 1997, through September 30, 1998, in which mean mitral valve gradient was assessed. Each study was reviewed and the DeltaP(M), P(P), and P(T) were measured for 3 beats by using the software package on an HP Sonos 2500. DeltaP(M) was also calculated with our formula. A linear regression model was used to compare the results of the measured versus the calculated DeltaP(M). The following sub-categories were also evaluated: transthoracic studies (TTE), transesophageal studies (TEE), native valve gradients (NV), prosthetic valve gradients (PV), sinus rhythm (SR), and atrial fibrillation (AF). The results of the regression analysis of the entire population of mean versus calculated DeltaP(M) are n = 41, r = 0.99, P <.001, and standard error of the estimate (SEE) = 0.67. The regression results for the subgroups are as follows: TTE: n = 30, r = 0.99, P <.001, SEE = 0.51; TEE: n = 11, r = 0.99, P <.001, SEE = 59; NV: n = 26, r = 0.99, P <.001, SEE = 0.59; PV: n = 15, r = 0.98, P <.001, SEE = 0.84; SR: n = 23, r = 0.99, P <.001, SEE = 0.58; and AF: n = 18, r = 0.98, P <.001, SEE = 0.82. In conclusion, the simple formula that we have derived is an accurate method for calculation of mean mitral valve gradient, and it is accurate over multiple subgroups. Furthermore, the formula allows visual verification of mean mitral gradient without specialized software.
Aged↗
PTFE sutures for mitral valve reconstruction--histological findings in man.
A case of mitral valve reconstruction with replacement of the chordae tendineae by polytetrafluoroethylene (PTFE) sutures is described in a 52-year-old man. 21 days after operation mitral valve insufficiency due to rupture of a natural chorda led to reoperation with mitral valve replacement. The cardiac valve tissue was examined both macroscopically and microscopically. It showed a proliferation of fibroblasts. However, there was no endothelial cell layer detectable. To the best of our knowledge our case is the first report of the histological changes in human cardiac valvular tissue after implantation of PTFE sutures.
Chordae Tendineae↗
Decreasing incidence of systolic anterior motion after mitral valve reconstruction.
BACKGROUND: With the widespread application of mitral valve reconstructive techniques, systolic anterior motion (SAM) of the anterior mitral leaflet causing left ventricular outflow tract obstruction has been recognized by several groups. SAM occurred in 9.1% of the first 441 patients operated on for mitral valve reconstruction at our institution. Fortunately, SAM subsided with medical therapy within 1 year for a majority of patients as reported in May 1993. Some surgeons, however, have considered abandoning repair for prosthetic replacement after SAM was detected on intraoperative echocardiogram. METHODS AND RESULTS: Since June 1991, a triangular anterior leaflet resection has been cautiously evaluated in patients with extensive anterior leaflet tissue. This has been performed in 23 of 119 patients. CONCLUSIONS: The frequency of SAM in the 119 study patients has decreased from 9.1% to 3.4%.
Female↗
Superior left atrial approach to the mitral valve: incidence of postoperative arrhythmia.
BACKGROUND AND AIM OF THE STUDY: The superior left atrial approach to mitral surgery involves exposure of the mitral valve through a longitudinal, craniocaudally orientated incision in the roof of the left atrium. The study aim was to evaluate the incidence of postoperative arrhythmias following this procedure. METHODS: Fifty-nine patients underwent either mitral valve repair (n = 20), mitral valve replacement (n = 26) or an associated procedure (n = 13), including aortic valve replacement, coronary artery bypass grafting and atrial septal defect closure. Eight patients had undergone previous surgery on the mitral valve. Patients were classified according to their preoperative rhythm: sinus rhythm (SR), paroxysmal or chronic atrial fibrillation (AF), or permanent pacing. Changes in cardiac rhythm were evaluated postoperatively, after four weeks, and at late follow up (mean 23.8 months). RESULTS: Preoperatively, 24 patients had shown SR, 10 had paroxysmal AF, 24 had chronic AF, and one patient had permanent pacing. At the time of discharge, SR was recorded in 18 patients who had SR preoperatively, in seven who had paroxysmal AF preoperatively, and in one patient who had chronic AF preoperatively. At follow up, SR was seen in 19 patients with preoperative SR, in seven with paroxysmal AF preoperatively, and in two with chronic AF preoperatively. Four patients received permanent pacemakers postoperatively due to total heart block or bradycardia. CONCLUSION: The superior left atrial approach to mitral valve surgery appears to be safe as it maintains the sinus rhythm in a high proportion of patients postoperatively. In addition, it is not normally prone to technical complications.
Aged↗
Technique and outcome of mitral valve replacement in dogs.
Eight dogs with naturally occurring severe mitral regurgitation underwent mitral valve replacement with a mechanical valve prosthesis during cardiopulmonary bypass. Dogs received warfarin orally after surgery to maintain a prothrombin time-based international normalized ratio from 2.5 to 3.5. Seven dogs survived surgery. Left ventricular diastolic volume index decreased significantly from 206 +/- 91 mL/m2 before surgery to 121 +/- 47 mL/m2 after surgery. Left atrium-to-aorta ratio decreased significantly from 2.66 +/- 0.4 before surgery to 1.73 +/- 0.65 after surgery. Left ventricular systolic volume index was not significantly different after surgery (56 +/- 36 mL/m2), compared with before surgery (40 +/- 32 mL/m2). Median survival after surgery was 4.5 months (range, 0.75 months to 5.25 years). Six dogs died of confirmed or suspected thrombosis of the valve prosthesis. Dogs with severe mitral regurgitation tolerated mitral valve replacement well, but a high incidence of prosthetic valve thrombosis limited long-term outcome.
Animals↗
Exercise and anxiety neurosis: comparison of patients with and without mitral valve prolapse.
It has been hypothesized that mitral valve prolapse may account for a substantial number of patients who have symptoms of chronic anxiety neurosis. In a previous investigation, this hypothesis was confirmed in eight of 21 patients who had anxiety neurosis. In the present investigation, we reevaluated the hypothesis that persons with anxiety neurosis have impaired exercise ability by exercising 20 of the anxiety neurotics according to a standard treadmill exercise protocol. Compared with the control group, the anxiety neurotics required less exercise to achieve an equivalent heart rate and therefore their estimated maximum oxygen consumption was less, thus confirming the hypothesis. However, this difference was due entirely to the anxiety neurotics with mitral valve prolapse, and those without prolapse did not differ significantly from the controls. This suggests that impaired exercise tolerance in anxiety neurotics may be attributable to a subgroup of these patients with mitral valve prolapse.
Adult↗
Approach to the mitral valve through a right thoracotomy in potentially hazardous reoperation.
BACKGROUND: Repeat sternotomy for mitral valve surgery may be hazardous in some patients. A right thoracotomy avoids the densely scarred area beneath the sternum and provides adequate in-line exposure of the mitral valve. METHODS: Between 1994 and 1997, five patients were reoperated for a mitral valve or prosthesis dysfunction through a right thoracotomy. Indications were three second redo-mitral valve surgeries and two first redo, once in a patient with an aortic prosthesis and once in a patient with patent aortocoronary grafts. The operation was performed without clamping the ascending aorta in moderate hypothermic (four patients) or normothermia (one patient). RESULTS: Exposure of the mitral valve for replacement (four patients) or for repair of a paraprosthetic leak (one patient) was optimal in all patients. Resumption of cardiac function occurred rapidly after repair without specific support. Postoperative course was uncomplicated. Blood loss ranged from 300 to 700 mL. Patients were discharged from 7 to 12 days postoperatively. They are in New York Heart Association (NYHA) functional Class I (four patients) and II (one patient), from 3 to 42 months postoperatively. CONCLUSION: Right thoracotomy provides a direct "in the line of vision" access to the mitral valve. Because complete de-airing of the heart is difficult and respiratory function depressed after a right thoracotomy, this approach seems suitable when technical difficulties are expected in sternal reopening.
Adult↗
Allogeneous transplantation of the mitral valve. An open question.
To overcome the disadvantages of mechanical valves and bioprostheses, especially in the mitral position, transplantation of an allogeneous mitral valve was performed in 3 patients. One transplant had to be removed 8 weeks postoperatively, most probably due to maladjustment of the anterior leaflet during surgery. The histology of this specimen showed not clear signs of rejection. In 2 patients, echocardiography showed a normal motion pattern of the mitral valves 6 months postoperatively. Regurgitation was less than 10% of the total stroke volume as calculated by videodensitometry. Both patients were in excellent clinical condition. Mitral valve transplantation can be performed with excellent short-term results. Further studies including immunologic monitoring are necessary to evaluate the long-term behavior of the transplant.
Adult↗
Mitral valve reconstruction: long-term results of 120 cases.
Between January 1977 and December 1992, 120 patients underwent mitral valve reconstruction for pure mitral valve regurgitation (n = 88), or associated with mitral stenosis (n = 32). The mean age was 57.6 years. Some 89 patients were in New York Heart Association (NYHA) class III and IV; 61% were in atrial fibrillation. Four mechanisms of mitral regurgitation were assessed: dilatation of the annulus (group I: n = 10); increased amplitude of valve motion (group II: n = 62); restriction of valve motion (group III: n = 23), and mixed lesions (group IV: n = 25). Mitral valve repair was carried out using techniques described by Carpentier. Ring annuloplasty was performed in all patients. There were two operative deaths, and six late deaths. Mean patient follow-up was 41 (range 2-142) months. The actuarial survival rate, excluding hospital deaths, was 91.7% at 5 years and 89.1% at 8 years. Actuarial freedom from reoperation at 8 years was 95(2)%. Freedom from all thromboembolic complications was 89.1% at 8 years. Most survivors had improved to NYHA class I or II and postoperative Doppler echocardiography revealed satisfactory mitral valve competence in 83 patients. Mitral valve reconstruction for mitral regurgitation using Carpentier techniques provides excellent long-term functional results and should be considered as the procedure of choice in patients referred for mitral regurgitation.
Adolescent↗
On the frequency of early systolic clicks in mitral valve prolapse.
Phonocardiography was performed in 74 patients with mitral valve prolapse. 24 patients had early systolic clicks (less than 80 msec from S1). Four of them had associated systolic murmurs. 30 patients had mid or late systolic clicks (greater than 80 msec from S1). A systolic murmur followed the click in 13 of these patients. Both an early and mid/late systolic click were noted in three patients. 17 patients did not have systolic murmurs. Seven patients had 'silent' mitral valve prolapse. In summary, early systolic clicks are common in mitral valve prolapse. In many instances the early click is not accompanied by a murmur. Echocardiography is recommended in patients with chest pain or arrhythmia of uncertain etiology, even if characteristic signs of mitral valve prolapse are absent.
Adolescent↗
Minimally invasive mitral valve surgery.
BACKGROUND: To reduce surgical trauma and the drawbacks associated with sternotomy, we performed robotically controlled, video-assisted mitral valve surgery, using either the port-access or the transthoracic clamp technique. METHODS AND RESULTS: Between September 1997 and September 2000, 221 patients (78 males, 143 females) underwent mitral valve surgery through a small right minithoracotomy using the port-access endovascular cardiopulmonary bypass system. Mitral valve exposure was facilitated with an endoscope attached to a voice-controlled robotic arm (AESOP 3000) allowing stabilization and voice-activated camera positioning. Twenty-six patients underwent mitral valve repair and 195 had valve replacement. In 197 patients, mitral valve surgery was the primary operation, while 24 were redo cases. Skin-to-skin mean operating time was 3.5 +/- 1.2 hours and aortic cross-clamp time was 58 +/- 16 min, mean intensive care unit stay was 22 +/- 7 hours and hospital stay 6.4 +/- 1.2 days. There was no re-exploration for bleeding. There was no late death or re-operation on mean follow-up of 16.4 +/- 12.2 months. Patients showed improvement in their NYHA functional class from 2.6 +/- 0.5 to 1.4 +/- 0.8 postoperatively. Outcomes were compared with those of our previous 220 patients who underwent mitral valve surgery with the median sternotomy approach. CONCLUSIONS: The use of video and robotic assistance in port-access mitral valve surgery not only minimizes the length of the incision, but also gives full visualization of the entire mitral valve apparatus. This approach provides comparable results with the sternotomy approach, as well as marked advantages of reduced intensive care unit stay. ,ower blood transfusion requirement, better cosmesis and earlier hospital discharge.
Adult↗
[Atrio-ventricular pressure difference associated with mitral valve motion].
Pressure difference (PD) across the mitral valve was analyzed by a computer-aided catheter system in dogs. Positive PD (PPD) was consistently traced in the initial phase of rapid filling. While heart rate (HR) was below 100 beat/min, a negative PD (NPD) followed the above PPD. In the period between the NPD and the 2nd PPD due to atrial contraction, PD was kept at zero, while LA and LV pressures were gradually elevated by pulmonary venous return. As HR exceeded 100, 2 positive peaks of PD merged into M-shaped or mono-peaked PD. Through higher inflow resistance produced by artificial mitral stenosis, PPD peak decayed without NPD. In mitral regurgitation with an acute volume overload, all of the PD amplitudes were exaggerated. Thus the quick reversal of PD suggested the effect in blood filling process across the mitral valve.
Animals↗
A complex mitral valve reconstruction: a case report.
Several techniques are currently in use for mitral valve reconstruction. We report a mitral repair case in which the use of a combination of different surgical techniques resulted in the necessary correction. A 47-year-old woman underwent surgical intervention to treat severe mitral valve insufficiency due to A1/A2/A3 and P2 prolapsed valve tissue. A combination of quadrangular resection, sliding leaflet, single chordal transposition, "flip-over" leaflet, and ring annuloplasty techniques were applied, and postsurgical correct valve function was documented by results of a left ventricular saline filling test and transesophageal echocardiography control. Complex mitral valve repairing techniques can be combined to reestablish valvular function.
Female↗
[A case of the double mitral valve orifices].
In 1996 student course of gross anatomy dissection at Iwate Medical University School of Medicine, a case of the double mitral valve orifices was found in a heart of a 73-year-old male cadaver who died of acute pneumonia. No other congenital anomalies were detected in this heart. There was no prior history of heart disease. The left atrioventricular ostium was an oval with a long axis of 4 cm and a short axis of 2.5 cm. There were double mitral valve orifices, main and accessory (Fig. 1). The main orifice situated left ventrally with a long axis of 2.5 cm and a short axis of 1.7 cm, had a larger cleft. The accessory orifice situated right dorsally with a long axis of 2.5 cm and a short axis of 1.2 cm, had a smaller cleft. There was a bridge-like valvular leaflet between the two clefts (Fig. 1). Disregarding small incisions, both the main and the accessory mitral valves had two cusps, anterior and posterior. The anterior and posterior cusps of the main and accessory valves were continuous and considered to be homologous with the anterior and posterior cusps of the normal mitral valve. In other wards, this double mitral valve orifices was appeared to be formed by bridging the cleft between the anterior and posterior cusps of the normal mitral valve. The valvular cusps of the main or the accessory mitral valve had proper chordae tendineae and papillary muscles. The papillary muscles were classified into four groups, anterior (A), anterolateral (AL), posterior (P) and posterolateral (PL) according to Taniya (1974). The anterior papillary muscles group had a base at the anterior wall of the left ventricle, the anterolateral papillary muscles group had at the whole lateral wall, the posterior papillary muscles group had at the boundary between the interventricular septum and the posterior wall, and the posterolateral papillary muscles group had at the posterior part of the lateral wall (Fig. 3). The anterior and anterolateral papillary muscles groups, and the posterior and posterolateral papillary muscles groups of Taniya (1974) constituted the anterior and the posterior papillary muscles respectively in the general use of the anatomical term. The chordae tendineae attached to the cusps of the main orifice arose from the anterior, anterolateral and posterior papillary muscles groups (Fig. 2a). And those attached to the cusps of the accessory orifice arose from the posterolateral papillary muscles group (Fig. 2b). The chordae tendineae were also classified into three types after Taniya (1974). The A type chordae tendineae were thick and attached to the base of the cusps, the type B were moderately thick and attached to the midway between the base and the margin of the cusps, and the C type were thin and attached to the margin of the cusps. The main mitral valve had 6 type A, 8 type B and 40 type C chordae. The accessory mitral valve had 0, 6 and 30 chordae respectively (Fig. 2). This case of the double mitral valve orifices is considered to be included in the central type of Cascos et al. (1967) and the bridge type of Elfenbein et al. (1967). A morphogenetic mechanism of this type of the double mitral valve orifices is explained by an abnormal adhesion between the dorsal endocardial cushion and the left lateral endocardial cushion like mass in early developmental stage according to Wimsatt and Lewis (1948). But a possibility of an abnormal orifice in the posterior cusp which is produced in the process of formation of cusps, chordae tendineae and papillary muscles in later stage, still remains to be discussed.
Aged↗
[Relationship between rheumatic disease and mitral valve prolapse: an etiopathogenetic connection or the result of a semiologic confusion?].
The term mitral valve prolapse is used to describe either one of the pathophysiological mechanisms of mitral regurgitation or a distinct biological condition with a defined inherited basis, with or without mitral incompetence. In the former case, association with rheumatic fever is implied by the definition itself; in the latter it's questionable (rheumatic fever could act as an environmental factor in the expression of a genetically determined mitral valve prolapse). Three hundred and twenty patients with mitral valve prolapse, diagnosed as a primary one, were studied in order to assess the prevalence of a well-documented history of rheumatic fever: this resulted higher versus a control population (5.6% vs 0.9%-p < 0.01). The retrospective nature of the study does not allow a definite conclusion. Familial as well as long-term follow-up studies are necessary to better define the association between rheumatic fever and mitral valve prolapse; a potentially different prognosis, mainly accounting to the development of a clinically relevant mitral regurgitation in patients with mitral valve prolapse and previous rheumatic fever, has to be searched.
Adult↗
Ventricular function following mitral valve surgery: assessment using radionuclide ventriculography.
The effects of mitral valve replacement or commissurotomy on cardiac function were studied using radionuclide ventriculography in 13 patients with chronic mitral stenosis and in 8 with chronic mitral regurgitation, before and after mitral valve surgery. The stenosis resulted from rheumatic heart disease in all instances while regurgitation was due to mitral valve prolapse in three patients and rheumatic heart disease in five. Fourteen patients had a Carpentier-Edwards valve inserted and 4 a Lillehei-Kaster disc valve. Three patients with mitral stenosis had an open commissurotomy. All patients underwent supine-rest and symptom-limited exercise radionuclide ventriculography shortly before and 6 to 12 months after operation. The data obtained showed that left ventricular function remained unchanged postoperatively in patients with mitral stenosis but deteriorated in those with mitral regurgitation. Right ventricular function improved postoperatively in those with mitral stenosis but remained unchanged in patients who had regurgitation.
Adult↗