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PubMed2000

Mitral valve surgery utilizing homografts: early results.

BACKGROUND AND AIM OF THE STUDY: Mitral valve repair is superior to prosthetic valve replacement due to preservation of the subvalvular apparatus. We used cryopreserved homografts for mitral valve replacement in selected cases, in whom valve repair would not have been successful. METHODS: Cryopreserved homografts were used in 10 patients (four males, six females; mean age 47 +/- 8 years; range: 27-65 years), for either complete (n = 7) or partial (n = 3) mitral valve replacement. Surgery was indicated due to acute endocarditis (n = 3), stenosis (n = 4) or combined mitral valve disease (n = 3). Transesophageal echocardiography (TEE) was performed to determine correct homograft size; these values were compared with intraoperative measurements of valvular dimensions. The function of the implanted grafts was examined intraoperatively by TEE. Follow up included clinical examination, electrocardiography and echocardiography. RESULTS: All patients survived surgery. Intraoperative TEE revealed mild insufficiency (grade I) in six cases and no insufficiency in four. The papillary muscle-mitral annulus distance was the most reliable preoperative echocardiographic parameter to determine the required homograft. Mean pressure gradients were 3.2 +/- 0.7 mmHg for complete and 2.4 +/- 0.5 mmHg for partial homograft replacement. Sinus rhythm was present in all cases at discharge. Mean follow up was 24 months (range: 6-36 months). At six-month and one-year follow up, the pressure gradients had risen slightly to 3.4 +/- 0.6 mmHg (complete) and 2.8 +/- 0.6 mmHg (partial). To date, four patients had competent grafts, and six presented with an insufficiency (grade I). All patients had normal left ventricular function (EF 65 +/- 6%) at their last follow up; there were no signs of endocarditis during the follow up period. CONCLUSION: Mitral homografts for valve replacement or repair are recommended in selected cases in whom conservative reconstruction techniques are not possible. The avoidance of long-term anticoagulation therapy and preservation of left ventricular geometry are clear advantages to other mitral valve prostheses.

Adult↗
PubMed2000

Limited right anterolateral thoracotomy for mitral valve surgery.

OBJECTIVE: There has been great enthusiasm in recent years to perform mitral valve surgery through small multiple incisions with the use of the Port Access technique. The procedure is costly, involves a relatively long training curve and leaves the patient with multiple scars in the chest and groin. We used a mini-thoracotomy technique for mitral valve patients and compared our results with the conventional technique. METHODS: We randomized 100 consecutive patients presenting to our practice for mitral valve surgery between two groups. The first group (test group) consisted of 50 patients in which mitral valve surgery was performed via mini-right anterolateral thoracotomy approach. The control group (50 patients) underwent classical mitral valve surgery through median sternotomy. Standard aortic and bicaval cannulation with antegrade blood cardioplegia was adopted in both groups. RESULTS: There was no statistical difference between the two groups preoperatively regarding their age, pathology, LV function and male/female ratio. Most of the patients had valve replacement except four in the test group and three in the control group. The incision in the test group was 12-15 cm long in the right submammary groove. Direct aortic cannulation, clamping and cardioplegia administration was achieved in all patients easily. The mean bypass time was slightly longer in the test group (64+/-12 min) when compared with the test group (59+/-11 min). The cross-clamp time was lower in the test group (27+/-8 min) when compared with the control group (31+/-9 min). There was no hospital mortality in both groups and there was one morbidity in the form of sternal infection in the control group. The mean hospital stay was similar for both groups (7+/-2 days). CONCLUSION: The cosmetic appearance in the test group was excellent and the patients' wounds were scarcely apparent in the female patients. The study demonstrates the efficacy and safety of this older technique, with excellent cosmetic results and no additional cost or risk to the patients.

Adolescent↗
PubMed1999

Predictive factors for persistence of atrial fibrillation after mitral valve operation.

BACKGROUND: The majority of patients operated on for mitral valve disease with chronic atrial fibrillation (AF) do not recover sinus rhythm with conventional postoperative treatment. The maze procedure may be used in these circumstances. To define the precise indications for the maze procedure, it would be necessary to identify those patients based on preoperative factors. METHODS: A retrospective study was undertaken on 100 consecutive patients operated on for mitral valve disease in chronic AF. The return to sinus rhythm was analyzed with relation to age, gender, AF duration, left atrial size, left ventricular ejection fraction, lesion type, valve procedure, associated procedures, and reoperation. RESULTS: At late follow-up (more than 1 year) 26 (26%) patients presented sinus rhythm and 74 (74%) remained in AF. Statistical single parametric analysis demonstrated that mitral stenosis was a risk factor for maintaining AF, whereas regurgitation was more associated to sinus rhythm recovery. There was no relation with the other parameters with return to sinus rhythm. It should be noted, however, that 96% of this series had AF for more than 6 months preoperatively. CONCLUSIONS: The majority of patients with mitral valve disease remain in AF and this may justify the association of maze procedure. Pure regurgitation may be a single predictor for return to sinus rhythm after mitral valve operation in chronic AF.

Adolescent↗
PubMed2003

The evolution of mitral valve surgery: 1902-2002.

The evolution of the surgical therapy of mitral valve disease emanates from original statements by British cardiologists in 1902 and anecdotal individual surgical cases in 1923 and 1925. Considerable amounts of experimental investigation during these years and after World War II in 1948 finally resulted in the widespread use of closed mitral commissurotomy, a successful therapy for noncalcified mitral stenosis. The history of mitral valve surgery then rapidly progressed with a variety of prosthetic and bioprosthetic valve devices, ultimately, to a considerable number of successful valve repair operations with prosthetic ring annuloplasty. The authors conclude with a discussion of the current status of minimally invasive mitral valve surgery, both by direct vision and robotic assistance. The entire evolution of thought and technique of mitral valve surgery is summarized in this paper from 1902-2002.

Adult↗
PubMed1999

Mitral valve repair in children using Carpentier's techniques.

Controversy remains regarding whether valve repair is preferable to valve replacement in children suffering from rheumatic mitral valve disease. To answer this question, 130 children aged 3 to 15 years (mean age, 11.8 +/- 2.8 years) undergoing surgery between January 1992 and December 1997 using Carpentier's techniques were reviewed. There were 111 cases of rheumatic valve diseases (85%), 17 cases of congenital mitral valve malformations (13%), one case of Barlow's syndrome (1%), and one case of bacterial endocarditis (1%). Valve dysfunction was classified into three types according to Carpentier's classification. There were 14 type II (leaflet prolapse), 78 type III (restricted leaflet motion), and 38 associated type II (anterior leaflet) and III (posterior leaflet) cases. There was one early (in-hospital) death (0.7%); the remaining 129 children were examined every 6 months. At the last examination, 99.2% of the patients were still alive, 96.8% were free of reoperation, and 89% showed no sign of significant residual stenosis or insufficiency on echocardiography. There have been no thromboembolisms. We conclude that mitral valve repair using Carpentier's techniques is the preferred procedure in the surgical treatment of mitral valve incompetence in children, even in those with rheumatic valvular disease. Copyright 1999 by W.B. Saunders Company

Journal Article↗
PubMed1987

Echocardiographic mitral valve prolapse in ballet dancers: a function of leanness.

To determine the prevalence of mitral valve prolapse in ballet dancers by echocardiography and to establish which anthropometric measurements best predict the presence of mitral valve prolapse, we compared 44 professional dancers (22 men and 22 women) with 52 controls (24 men and 28 women). Forty-eight percent (21 of 44) of dancers had echocardiographic mitral valve prolapse compared with 10% (5 of 52) of controls (p less than 0.01). The dancers weighed less than the controls and had significantly smaller bony diameters and body circumferences. However, only ponderal index was predictive of mitral valve prolapse in both dancers and controls. Thus, echocardiographic mitral valve prolapse is associated with low body weight relative to height and neither to ballet dancing nor to a distinct body habitus. Echocardiographic mitral valve prolapse may represent a normal variant in the majority of asymptomatic, thin subjects without auscultatory findings.

Adult↗
PubMed1999

Allograft mitral valve replacement.

Allograft valves have been used in cardiac valve replacement for over 40 years. Early failures of allograft mitral valve replacement (AMVR) were attributed to inadequate allograft preservation or unsuccessful implantation techniques. Due to an improved understanding of mitral valve function gained from experience in mitral valve reconstruction, improved imaging techniques for preoperative assessment, and improved methods of allograft preservation, there has been a resurgence of interest in AMVR. The use of bioprosthetic valves in children and young adults is characterized by reduced durability and early valve failure. With the use of mechanical valves, there is a significant long-term risk of morbidity and mortality resulting from thrombosis or hemorrhagic complications from anticoagulation. Additionally, anticoagulation is often difficult to manage in children. The advantages of using allograft mitral valves include the avoidance of anticoagulation and the preservation of the subvalvar apparatus and its role in ventricular function. At our institution, successful early results with AMVR have been obtained in eight children and young adults with previous atrioventricular septal defects, previous placement of mitral valve prostheses, rheumatic valvular disease, and bacterial endocarditis. Our early results and those of others are encouraging for the continued use of AMVR in children and young adults. Long-term follow-up will be necessary to assess the durability and function of these allograft mitral valves. Copyright 1999 by W.B. Saunders Company

Journal Article↗
PubMed1986

Esophageal disorders in patients with chest pain and mitral valve prolapse.

The origin of chest discomfort in patients with mitral valve prolapse is controversial. We performed esophageal manometry in 18 patients with mitral valve prolapse, chest pain, and no significant coronary artery disease at cardiac catheterization. Fourteen of the 18 had esophageal disorders: five had diffuse esophageal spasm and two had hypertensive lower esophageal sphincter-motility disorders associated with chest pain syndromes; five mitral valve prolapse patients had hypotensive lower esophageal sphincters, a finding that increases the probability of symptomatic gastroesophageal reflux; and two had nonspecific motor abnormalities. Esophageal disorders may provide an explanation for chest discomfort experienced by certain patients with mitral valve prolapse.

Adult↗
PubMed1992

Mitral valve repair using Carpentier techniques in patients more than 70 years old. Early and late results.

BACKGROUND: Mitral valve incompetence in elderly patients raises the problem of whether to replace or to repair the mitral valve. The purpose of this study is to review our experience with mitral valve repair in patients > 70 years old. METHODS AND RESULTS: Between 1986 and 1991, 79 consecutive patients > 70 years old underwent mitral valve repair by Carpentier techniques. The most frequent cause was degenerative valve disease (65 of 79). Preoperative echocardiography showed that 6% of the patients had type I, 88% type II, and 5% type III mitral valve dysfunction. Anatomic lesions encountered at surgery confirmed the preoperative echocardiographic findings, with 88% of the patients with a leaflet prolapse either of the posterior leaflet (56%) or of both the anterior and posterior leaflets (32%). Multiple surgical procedures were required in each patient. Posterior leaflet resection was the most common technique used (76%). Prosthetic ring annuloplasty was used in 96% of patients. Associated procedures were performed in 21.5% of cases. Three patients died, for an operative mortality of 3.8%. One patient (1.3%) required reoperation for residual mitral insufficiency. Nonfatal complications related to the patients' preoperative condition were noted in more than half of the patients. Echocardiography obtained before discharge revealed absent or minimal mitral insufficiency in 91% of patients and mild mitral insufficiency (2+/4+) in 9%. Follow-up was available for 74 of 76 patients (97.3%) and ranged from 3 months to 6 years (mean, 22 months). Two patients (2.6%) were lost to follow-up. Sixty patients (89%) were in New York Heart Association functional class I or II. Seven patients died and one required reoperation. Actuarial analysis of the results showed overall survival at 5 years 81 +/- 11%; freedom from thromboembolism, hemorrhage, and reoperation 97 +/- 5%, 97 +/- 5%, and 98 +/- 4%, respectively. Color-coded echo Doppler studies obtained in 67 patients at the time of follow-up showed absent or minimal MI (91%) (n = 61), and mild MI in 9% (n = 6). CONCLUSIONS: These data suggest that mitral valve repair using Carpentier techniques should now be considered as the procedure of choice in patients of any age referred for mitral insufficiency.

Actuarial Analysis↗
PubMed2000

Congenital Heart Surgery Nomenclature and Database Project: mitral valve disease.

The extant nomenclature for mitral valve disease is reviewed for the purpose of establishing a unified reporting system. The subject was debated and reviewed by members of the STS-Congenital Heart Surgery Database Committee and representatives from the European Association for Cardiothoracic Surgery. All efforts were made to include all relevant nomenclature categories using synonyms where appropriate. Mitral valve disease has been subdivided into stenotic and regurgitant lesions. Lesions have been characterized further by etiology and by anatomic location: supravalvar, valvar, and subvalvar. A comprehensive database set is presented which is based on a hierarchical scheme. Data are entered at various levels of complexity and detail which can be determined by the clinician. These data can lay the foundation for comprehensive risk stratification analyses. A minimum database set is also presented which will allow for data sharing and would lend itself to basic interpretation of trends. Outcome tables relating diagnoses, procedures, and various risk factors are presented.

Databases, Factual↗
PubMed1995

Transesophageal echocardiography for the diagnosis and management of nonobstructive thrombosis of mechanical mitral valve prosthesis.

BACKGROUND: Diagnosis of a mechanical mitral valve prosthesis thrombosis is currently made with transthoracic Doppler echocardiography and occasionally with fluoroscopy. However, identifying a thrombus on a valve prosthesis may be difficult, especially if the thrombus is nonobstructive. To prospectively define the role of transesophageal echocardiography for identification of nonobstructive thrombi, we studied a series of patients in whom the prosthetic valve was considered to function normally on clinical examination and transthoracic echocardiography. METHODS AND RESULTS: One hundred fourteen consecutive patients with mechanical mitral valve prosthesis were investigated by both transthoracic echocardiography and transesophageal echocardiography. These examinations were performed for recent systemic emboli (15 patients), fever of unknown etiology (11 patients), routine postoperative evaluation (56 patients), and other reasons (32 patients). Based on transthoracic echo diagnosis, all prostheses were considered normal. Yet, in 20 patients transesophageal echocardiography revealed the presence of a 2- to 15-mm-long mobile thrombus localized on the atrial surface of the prosthesis. When compared with the remaining 94 patients with no visible thrombi, there was no significant difference between the two groups in terms of incidence of atrial fibrillation (65% versus 52%), left atrial size (48 +/- 9 versus 51 +/- 13 mm), left ventricular end-diastolic diameter (49 +/- 10 versus 51 +/- 13 mm) and fractional shortening (28 +/- 9% versus 31 +/- 10%), presence of spontaneous contrast to the left atrium (40% versus 41%), transprosthetic mean pressure gradient (4.0 +/- 1.4 versus 3.9 +/- 1.5 mm Hg), or the type of prosthesis used. After we discovered a nonobstructive thrombosis, patients were treated with heparin (n = 9) or oral anticoagulation (n = 11). The presence of a localized thrombus was confirmed in 3 patients who were operated on. In the present study, evolution appeared to depend on thrombus size: of 14 patients exhibiting a small (< 5 mm) thrombus, 10 had an uneventful course, whereas 5 of 6 patients with a large (> or = 5 mm) thrombus developed complications or died. CONCLUSIONS: Transesophageal echocardiography appears to be a reliable method to diagnose thrombi on a mechanical mitral valve prosthesis, even when transthoracic Doppler echocardiographic parameters appear to be normal. Transesophageal echo assessment of thrombus size may be helpful in deciding whether a patient with mitral prosthesis should be treated by anticoagulation, thrombolysis, or valve rereplacement.

Adult↗
PubMed1976

Granulomatous mitral valve obstruction.

Acquired non-rheumatic valvular mitral valve obstruction is extremely rare. A case of mitral valve obstruction is described which resulted from a granulomatous mass replacing the valve cusps. The problems in diagnosis and probable aetiology are discussed.

Adult↗
PubMed2000

Mitral valve replacement using bileaflet mechanical prosthetic valve in the first year of life.

OBJECTIVE: The operative management and long term outcome of mitral valve replacement in infancy remain a therapeutic challenge. The selection of a prosthetic valve for this particular age group might affect the clinical outcome. Here we present our experience of mitral valve replacement in 6 infants using small bileaflet mechanical prosthetic valves. METHODS: Between January 1994 and August 1997, 6 infants (their age ranged from 3 months to 11 months, and their body weight from 2978 g to 7403 g) underwent mitral valve replacement using a mechanical valve prosthesis (16 mm CarboMedics prosthetic valve in 5, and 17 mm St. Jude Medical prosthetic valve Hemodynamic Plus in 1). The preoperative morphological features of the mitral valve were stenosis in 1, regurgitation in 3, and a combination of these in 2. The prosthesis was fixed at the annulus in 3, and at the supra-annular position in 3. Anticoagulation was performed using warfarin. RESULTS: There was no operative mortality. Postoperative catheterization revealed an acceptable wedge pressure in the pulmonary arteries, ranging from 10 to 12 mmHg. During the mean follow-up period of 36 months, late death due to residual pulmonary hypertension occurred in 1 patient at 10 months after surgery. Excluding this patient, all remaining patients are doing well with no need for repeated operation with no thromboembolic complication. The actuarial survival rate and the reoperation free rate at 70 months are 83 +/- 15% and 100%, respectively. CONCLUSION: Mitral valve replacement using a small size bileaflet mechanical prosthetic valves in infancy can be performed with low operative mortality and with satisfactory mid-term results.

Follow-Up Studies↗
PubMed2000

Mitral valve repair and septal myectomy for hypertrophic obstructive cardiomyopathy.

Combined mitral valve repair using the sliding leaflet technique and septal myectomy were employed to successfully treat left ventricular outflow tract (LVOT) obstruction and mitral regurgitation due to hypertrophic obstructive cardiomyopathy (HOCM). A 46-year-old man was diagnosed with HOCM along with congestive heart failure and was treated medically. These symptoms, however, were resistant to medical treatments with a beta-blocker, a Ca-antagonist, and disopyramide, and he was referred to our hospital for surgery. Doppler echocardiography demonstrated an LVOT obstruction at rest with a peak pressure gradient of 138 mmHg. The interventricular septum thickness was 14 mm. Mitral regurgitation of 3+ with severe SAM was also observed. Temporary dual chamber pacing was tried without significant improvement. Following these examinations, the patient underwent surgery. A transaortic septal myotomy-myectomy was performed first, and the mitral valve was then approached through the left atrium. Mitral valve repair was performed with the sliding leaflet technique to reduce the height of the posterior leaflet from 2 cm to 1 cm. Postpump transesophageal echocardiography revealed no MR and a peak LVOT gradient of 15 mmHg. The patient recovered well except for a residual mild SAM, and MR2+. We therefore concluded that this surgical approach might provide results which are superior to those of myectomy alone.

Cardiomyopathy, Hypertrophic↗
PubMed1978

Loss of apical left ventricular contraction after closed mitral valve surgery.

28 patients with advanced mitral valve restenosis were studied by cardiac catherization on an average of 7.2 years after previous closed mitral valvotomy, performed using the Tubbs dilator technique. Loss of left ventricular apical contraction was noted in 17 of 31 left ventricular cineangiograms. In the other regions, only 2 cases of local anterior wall akinesia and 1 of posterobasal akinesia was observed. The extent of akinesia was rather small: from 4 to 21%, a mean of 10.1% of the left ventricular circumference. Though ejection fractions remained 21% smaller in those with regional left ventricular dysfunction than in those with normal contraction (p less than 0.005), no other clinical haemodynamic consequences were found. The mechanical trauma caused by insertion of the dilator seems to result frequently in focal contraction abnormalities of the left ventricle, but these are of minor degree.

Adult↗
PubMed2004

Selecting patients with mitral regurgitation and left ventricular dysfunction for isolated mitral valve surgery.

BACKGROUND: American College of Cardiology/American Heart Association (ACC/AHA) Guidelines state that patients with an ejection fraction (EF) of 30% or less should not undergo mitral valve replacement for mitral regurgitation (MR). We sought to establish, using a national cardiac surgery database, whether patients with left ventricular dysfunction may safely undergo mitral valve surgery for MR, and if so, which ones. METHODS: We queried the Society of Thoracic Surgeons (STS) National Database to identify patients who had isolated mitral valve replacement or repair for MR between 1998 and 2001. Mortality and morbidity outcomes were compared by EF category (< or = 30% vs > 30%), and observed mortality compared by EF group, stratified by predicted risk for mortality. A classification and regression tree (CART) model was then used to determine which patient characteristics contributed most to designate the high-risk patient. RESULTS: Of the 14,582 patients who had mitral valve surgery, 727 had an EF of 30% or less and 13,855 had an EF of more than 30%. Observed mortality rates were higher for patients with an EF of 30% or less (5.4% vs 3.1%). However, for low-risk to medium-risk patients, mortality rates remained fairly constant across levels of EF. Mortality is notably increased in the high-risk patients (predicted risk > 10%). A classification tree identifies three key characteristics for high risk: age more than 75 years, renal failure, and emergent or salvage procedure. CONCLUSIONS: When the predicted mortality risk is less than 10%, EF has minimal impact on operative mortality for mitral regurgitation. In contrast to the ACC/AHA Guidelines, our data show that operative risk for mitral valve surgery is not prohibitive for most patients with ventricular dysfunction.

Aged↗
PubMed1999

Randomized trial of partial versus complete chordal preservation methods of mitral valve replacement: A preliminary report.

BACKGROUND: The merits of retaining the subvalvular apparatus during mitral valve replacement for chronic mitral regurgitation have been demonstrated in numerous clinical and laboratory investigations. In this preliminary report, we analyzed the early effects of complete versus partial chordal preservation on left ventricular mechanics. METHODS AND RESULTS: Fifty patients undergoing isolated surgical correction of mitral insufficiency were prospectively randomized to either total or partial chordal-sparing mitral valve replacement. Of the first 19 patients studied, 8 had preservation of the posterior leaflet only, and 11 had complete preservation of all chordal structures. A comparison group consisted of 6 patients who had primary mitral valve repair. Echocardiography was performed preoperatively and at discharge from the hospital to determine dimensions, wall stress, and ejection fraction. Preservation of the posterior leaflet only resulted in a reduction in end-diastolic volume, an increase in end-systolic volume (P=0.058), a rising trend in end-systolic stress, a decrease in long-axis fractional shortening, and a fall in ejection fraction from 0.68+/-0.16 to 0. 46+/-0.19 (P=0.001). Although patients who had preservation of all chordal structures also had decreased end-diastolic volume, long-axis fractional shortening, and ejection fraction (0.60+/-0.13 to 0.52+/-0.07, P=0.01), end-systolic stress fell and end-systolic volume decreased instead of increased. Compared with the posterior leaflet preservation group, those in the group with completely preserved chordal structures had a larger decline in end-diastolic volume and smaller decreases in long-axis fractional shortening and ejection fraction. Changes in end-systolic volume and stress were also statistically different between the 2 cohorts. No differences were detected between the group with total preserved chordal structures and the mitral repair group in any of the measured parameters. CONCLUSIONS: Compared with posterior chordal preservation only, complete retention of the subvalvular apparatus during mitral valve replacement resulted in improved ejection performance and smaller chamber volumes due to reduced systolic wall stress. These hemodynamic advantages are comparable to those observed with primary mitral reconstruction.

Aged↗
PubMed1987

Surgical techniques for treatment of bacterial endocarditis of the mitral valve.

Bacterial endocarditis of the mitral valve appears to be much less common than bacterial endocarditis of the aortic valve. One of the main etiologic factors is the presence of degenerative lesions of the mitral apparatus, ballooning or mitral floppy valve. The surgical anatomy of the lesions is described: vegetations, perforations, rupture of chordae tendinae, abscess of the mitral ring observed in the isolated mitral endocarditis, mitral-aortic dislocation, abscesses and aneurysms of the mitral-aortic fibrosa and jet lesions on the anterior mitral leaflet. In the isolated primitive mitral infective lesions, all the technical skills are directed toward the prevention of the perivalvular leakage of the prostheses. Special procedures are described for the management of the abscesses of the mitral ring. In patients with mitral-aortic lesions, the main problem is treatment of the dislocation of the annuli or aneurysms of the mitral-aortic fibrosa. Despite technical advances, the surgical prognosis of the mitral endocarditis remains severe. In a personal series, the authors recorded a mortality of 12% in isolated mitral cases and 42% in the combined mitral-aortic patients. Early surgical treatment remains the most significant factor in decreasing the fatality of such lesions.

Aortic Valve↗