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PubMed2005

Midterm results of mitral valve repair with artificial chordae in children.

OBJECTIVE: We have used artificial chordal replacement with expanded polytetrafluoroethylene sutures for mitral valve repair in children and reported favorable early clinical results. In this article we evaluate the midterm results of mitral valve repair with expanded polytetrafluoroethylene sutures in 39 children. METHODS: From April 1995 through September 2003, mitral valve repair with chordal replacement using expanded polytetrafluoroethylene sutures was performed in 39 patients. In all patients the preoperative grade of mitral regurgitation was moderate or more because of prolapse of the anterior mitral leaflet. The mean age and body weight at the time of the operation were 4.7 +/- 5.3 years (range, 1 month to 17.8 years) and 14.4 +/- 12.2 kg (range, 3.9-54.4 kg), respectively. The number of expanded polytetrafluoroethylene sutures ranged from 1 to 3 (mean, 1.4). The mean follow-up period and body weight at the latest follow-up were 5.0 +/- 2.3 years (range, 1.1-8.5 years) and 25.7 +/- 16.4 kg (range, 6.9-73 kg), respectively. RESULTS: There were no operative or late deaths. Only one patient required mitral valve replacement, which occurred 17 days after repair. Two patients underwent redo mitral valve repair 2 and 5 years after initial repair, respectively. The actuarial freedom from reoperation at 5 and 8 years was 94.8% and 89.5%, respectively. At the latest follow-up, trivial or less mitral regurgitation was observed in 33 (84.6%) patients. CONCLUSIONS: Mitral valve repair with expanded polytetrafluoroethylene sutures in children demonstrated favorable midterm outcome. The procedure is safe and effective, with potential for patients' growth.

Adolescent↗
PubMed1998

[Mitral valve tissue characterization using acoustic microscopy].

Mitral valve hardness in the rough and clear zones was evaluated by measuring the propagation velocity (m/sec) of ultrasound through the valve, based on the hypothesis that harder tissues will have larger ultrasonic velocity values passing through the tissue. Mitral valve specimens were obtained from 16 normal subjects (age, 15-72 years) at autopsy. An acoustic microscope, operating at 450 MHz, was used to measure the ultrasonic velocity through the three layers of the valve: the atrialis; the spongiosa; and the fibrosa. Furthermore, the mean ultrasonic velocity through the three layers was measured. These measurements were conducted in the rough and clear zones of the valve. In the rough zone, the ultrasonic velocities were 1,634 +/- 71 in the atrialis, 1,574 +/- 37 in the spongiosa, and 1,726 +/- 97 m/sec in the fibrosa. In the clear zone, the ultrasonic velocities were 1,691 +/- 117 in the atrialis, 1,575 +/- 44 in the spongiosa, and 1,909 +/- 131 m/sec in the fibrosa. There were significant differences between velocities in the three layers in both the rough and clear zones. Furthermore, the mean ultrasonic velocity in the three layers in the clear zone (1,887 +/- 138 m/sec) was higher than that in the rough zone (1,642 +/- 53 m/sec; p < 0.001). These findings show that fibrosa, which is rich in collagen fibers, is harder than atrialis, which is rich in elastic fibers, and the spongiosa, which is poor in connective tissues, is the softest. The higher mean ultrasonic velocity in the clear zone than in the rough zone indicates that the clear zone is harder than the rough zone, although the clear zone is thinner than the rough zone.

Adolescent↗
PubMed1987

Repair of tricuspid valve insufficiency in patients undergoing double (aortic and mitral) valve replacement. Perioperative mortality and long-term (1 to 20 years) follow-up in 109 patients.

Between 1965 and 1984, 109 patients underwent simultaneous aortic and mitral valve replacement and tricuspid valve repair at the Mayo Clinic, with a perioperative mortality of 21%. The only variable predictive of perioperative mortality on multiple regression analysis was New York Heart Association class IV disability. The median follow-up was 5.6 years (range 1 to 20 years). Cumulative 5-, 10-, and 15-year survival rates in patients discharged from the hospital were 70% +/- 5%, 42% +/- 6%, and 33% +/- 7%. Multivariate analysis identified advanced age and class IV disability as significant predictors of poor survival. Five-year survival rates were similar in patients undergoing operation between 1965 and 1974 and after 1975, despite an increase in age and in the severity of preoperative symptoms in the recent group. Late mortality was due to sudden death in 38% of the patients, heart failure in 21%, reoperation in 5%, endocarditis in 2%, and thromboembolism and bleeding in 4%. Late complications included systemic emboli in 22% (embolism rate 4.5 events/100 patient-years), bleeding in 17%, reoperation in 14%, myocardial infarction in 8%, permanent pacemaker implantation in 5%, and infective endocarditis in 3%. Of 43% of the patients still alive, 79% are in class I or II.

Aortic Valve↗
PubMed1985

Echocardiographic aortic to mitral valve opening area ratio for determining the presence and severity of mitral regurgitation.

A simple and accurate noninvasive method to quantify the degree of mitral regurgitation (MR) is lacking. Therefore, the ratio of the aortic (AVO) to mitral valve opening area (MVO) from 2-dimensionally guided M-mode echocardiographic tracings was examined as an estimate for the presence and severity of MR. Seventy-two patients who had undergone catheterization were studied: 49 with idiopathic dilated cardiomyopathy, 7 with coronary artery disease and 16 with organic MR. Twenty-eight patients had no MR (group I), 23 had mild/moderate MR (group II) and 21 had severe MR (group III). The AVO/MVO ratio was 0.86 +/- 0.2 in group I, 0.53 +/- 0.1 in group II and 0.31 +/- 0.1 in group III (p less than 0.001). An AVO/MVO ratio of 0.65 or less predicted MR with a sensitivity of 98% and a specificity of 86%. Furthermore, a strong relation was found between the ratio and the angiographic severity of MR. Thus, the AVO/MVO ratio is a simple echocardiographic parameter for detecting the presence and severity of MR.

Aged↗
PubMed2002

Qualitative and quantitative evaluation of mitral valve morphology by intraoperative volume-rendered three-dimensional echocardiography.

BACKGROUND AND AIM OF THE STUDY: Two-dimensional echocardiography (2DE) performed to evaluate mitral valve anatomy during valve repair has certain limitations and pitfalls. The study aim was to assess the feasibility, accuracy and incremental value of three-dimensional echocardiography (3DE), coupled with 2DE in evaluating mitral valve structure, before and after repair and pericardial posterior annuloplasty. METHODS: The site and extent of mitral valve prolapse, systolic and diastolic changes of mitral annular area were evaluated using 2D and 3D transesophageal echocardiography (TEE), both pre- and postoperatively in 34 patients before and after mitral valve repair and pericardial posterior annuloplasty. RESULTS: Concordance between 2DE and surgery in evaluating prolapsing mitral valve scallops was 76% for the anterior leaflet and 75% for the posterior leaflet; for 3DE and surgery, concordance was 87% and 93% respectively. There was a significant reduction in maximal and minimal annular area after surgery, with a statistically significant difference between systolic-diastolic changes. CONCLUSION: 3DE, coupled with 2DE, is feasible and accurate in delineating the extent and location of prolapsing scallops of the mitral valve. The combined approach is also valuable in planning mitral valve surgery and evaluating the mitral valve annulus in vivo.

Adult↗
PubMed1997

Corridor procedure--surgical option for treatment of chronic atrial fibrillation in patients undergoing mitral valve replacement.

The aim of this study was to determine the effectiveness of the 'corridor' procedure when added to mitral valve replacement in restoring and maintaining sinus rhythm in patients with chronic atrial fibrillation resulting from rheumatic mitral valve disease. Twenty-two patients with rheumatic mitral valve disease and chronic atrial fibrillation with fast, irregular ventricular response were divided into two groups. In the first group (n = 12), mitral valve replacement was combined with sinus node-AV node isolation ('corridor'): in the second, control group (n = 10), mitral valve replacement was performed through the left atriotomy. The effectiveness of the 'corridor' procedure on heart rhythm was analysed by: (i) 24-h Holter monitoring performed before and during 72 h after surgery, at hospital discharge, and 2 months later; and (ii) postoperative electrophysiological studies using temporary epicardial wires on each isolated atrial compartment. Immediately after surgery and in the following 2 months, heart rate variability analysis showed significantly lower hourly ventricular rates and rate variations in the 'corridor' group compared with those of the control group (P < 0.01). A significant difference was also found when comparing postoperative to preoperative findings in the corridor group (P < 0.05). In the control group, however, no significant differences (P > 0.05) were found concerning pre- and postoperative ventricular rate variations. At hospital discharge, nine of 12 patients with 'corridor' procedure were in sinus rhythm. Control patients remained in atrial fibrillation with irregular ventricular rate. The 'corridor' procedure, when added to mitral valve replacement, prolonged surgery, but led to restoration and long-term maintenance of sinus rhythm in 75% of patients with chronic atrial fibrillation and rheumatic mitral valve disease.

Adult↗
PubMed1991

Functional tricuspid regurgitation following replacement of the mitral valve.

In this series, the effect of replacement of the mitral valve was examined in 86/900 (9.6%) patients who had developed moderate functional tricuspid regurgitation, secondary to rheumatic mitral valvar disease. These patients were subdivided according to the severity of pulmonary hypertension and impairment of right ventricular function. Forty-six patients presented with severe pulmonary hypertension and 40 patients had moderate pulmonary hypertension (mean main pulmonary arterial pressure: 78 +/- 14 mmHg vs 41 +/- 6 mmHg; P less than 0.05). The latter had more advanced disease, greater impairment of right ventricular function and dilatation of the right heart chambers. Functional tricuspid regurgitation regressed in 38/42 survivors with severe pulmonary hypertension and persisted or progressed significantly in 22/34 survivors with impaired right ventricular function despite successful replacement of the mitral valve. The latter underwent replacement of the tricuspid valve (n = 16) or tricuspid annuloplasty (n = 6), at a mean interval of 44 +/- 4.4 months after replacement of the mitral valve, which resulted in 8/22 (23.5%) early deaths. Functional tricuspid regurgitation is more likely to persist in patients with advanced right ventricular failure. Tricuspid valvar competence should be restored in these patients at initial replacement of the mitral valve.

Adult↗
PubMed1986

[Mitral valve abnormalities in the hypoplastic right heart syndrome: echocardiographic observations].

Two-dimensional echocardiographic examinations were performed for 86 patients with the hypoplastic right heart syndrome (55 cases of tricuspid atresia, 9 of pure pulmonary stenosis and 22 of pure pulmonary atresia). Prolapse of the anterior mitral leaflet was detected in 14 patients (16.3%). Four of these 14 patients had mitral regurgitation. Among the patients with mitral valve prolapse, ruptured chordae tendineae of the mitral valve were detected in two, and elongation of the chordae in one. There were no significant relationships between the incidence of mitral valve prolapse and sex, age, type of tricuspid atresia, previous palliative surgery, or PaO2. However, one patient with pure pulmonary stenosis, who had had mitral valve prolapse without mitral regurgitation, developed mitral regurgitation several months after undergoing a Blalock-Taussig shunt operation. The mechanism responsible for mitral valve prolapse in the hypoplastic right heart syndrome is not clear. Multiple factors, such as long-standing left ventricular volume overload, hypoxic myocardial damage, and anatomical chordal abnormalities may cause mitral valve prolapse. The presence of a mitral valve abnormality has an important bearing on the natural history as well as the surgical procedure of choice. The need for careful echocardiographic examinations to detect mitral valve abnormalities in the hypoplastic right heart syndrome is thus underscored.

Adolescent↗
PubMedDate not supplied

Accessory mitral valve tissue: an increasingly recognized cause of left ventricular outflow tract obstruction.

Subvalvar left ventricular outflow tract obstruction (LVOTO) may be secondary to congenital abnormalities of the mitral valve, including abnormal attachments of the anterior leaflet of the mitral valve, parachute mitral valve, and accessory valve tissue. Successful correction of LVOTO due to accessory mitral valve tissue is reported in a 44-year-old man. Twenty-five patients with LVOTO due to accessory mitral valve tissue have been previously reported; however, only a few have been recognized preoperatively. A high index of suspicion is necessary for preoperative and intra-operative recognition and correction of the abnormality.

Adult↗
PubMed1984

Bioprosthetic valve replacement in children--long-term follow-up of 135 isolated mitral valve implantations.

From August 1976 to January 1980, 135 patients, age 20 years or younger (mean 13.7 +/- 3.46 years), received 37 Hancock, 4 Angell-Shiley and 94 Carpentier-Edwards prostheses as a mitral valve substitute. Only patients who had isolated mitral valve replacement were included in this study. All patients were in NYHA class III and IV and 22 had acute rheumatic valvulitis. Approximately half of the patients had mitral regurgitation. Early mortality was 4.4% (6 patients). The cumulative follow up period was 356 patient-years. Thirty-eight patients died late (10.7% per patient year), of which 26 (7.3% per patient year) died of valve related causes. Sixty-four patients (18% per patient year) had mitral valve replacement for a degenerated bioprosthesis. Eleven patients with degenerating prostheses died without surgery and 5 await reoperation. Hence, structural valve failure occurred in 80 instances (22.5% per patient year). Actuarial survival at 7 years was 50%. Complication-free valve survival was 15%. Only 7 patients (5.2%) remain with their original prostheses, free from degeneration. Our experience confirms that bioprostheses have a prohibitive failure rate in children. Degenerating valves should be replaced early rather than late.

Adolescent↗
PubMed1990

[Hemodynamic evaluation of the effectiveness of preservation of subvalvular structures in mitral valve prosthesis].

The article deals with the clinical evaluation of the results of mitral valve prosthetics with preservation of the subvalvular structures in 40 patients and comparative evaluation of the hemodynamic indices after prosthetics with preservation of the subvalvular structures of the posterior cusp and after routine mitral valve prosthetics. The authors show good clinical results in patients after valvar-preserving prosthetics of the mitral valve and essential improvement of left-ventricular contractile activity after such an operation. Comparative analysis showed that the total ejection fraction increased by 10.8 +/- 4.5% in the main group and reduced by 11.4 +/- 2.6% (p less than 0.01) in the control group. Left-ventricular end diastolic pressure did not change in the main group but increased significantly (p less than 0.05) in the control group. A conclusion is drawn that preservation of the subvalvular structures in mitral valve prosthetics is expedient even in patients with an initially grave condition because the method makes it possible to normalize intracardiac hemodynamics more rapidly in the postoperative period and essentially improve the contractility of the left ventricle.

Heart Valve Prosthesis↗
PubMed1986

[Ventricular arrhythmias in mitral valve disease: incidence, severity and relations to hemodynamic parameters].

The incidence and severity of ventricular arrhythmias was analyzed in 42 patients with pure or predominant mitral valve stenosis (age: 51 +/- 9 years; NYHA class: 2.7 +/- 0.5) and 23 patients with pure or predominant mitral valve regurgitation (age: 55 +/- 11 years; NYHA class: 2.7 +/- 0.6) employing 24 h ambulatory monitoring. Coronary artery disease was excluded by angiography in all patients. Ten patients (14%) had no ventricular premature beats (VPB), 5 patients (7%) greater than 1,000 VPB/24 h, 31 patients (44%) multiform VPB, 19 patients (27%) repetitive VPB and 7 patients (10%) ventricular tachycardia. There was no difference in VPB between patients with mitral valve stenosis and mitral valve regurgitation. The incidence and severity of ventricular arrhythmias was significantly higher (p less than 0.001) in patients with mitral valve disease compared to the VPB of 50 normals without identifiable heart disease. This was still valid, if only patients with normal left ventricular ejection fraction greater than 55% (n = 60) were compared (p less than 0.01). The occurrence of frequent and complex ventricular arrhythmias was not determined by age, NYHA class, pulmonary artery pressure, pulmonary artery resistance, size of the left atrium, mitral valve area, degree of mitral regurgitation or cardiac index. However, a significant inverse correlation was found between incidence and severity of VPB and left ventricular ejection fraction. A reduced right ventricular ejection fraction, on the other hand, barely affected the occurrence of complex ventricular arrhythmias. Thus frequent and complex ventricular arrhythmias may be a sign of reduced left ventricular function in patients with mitral valve disease.

Adult↗
PubMed1977

Mitral valve prolapse in patients with coronary artery disease. Echocardiographic-angiographic correlation.

Echocardiography was performed in 25 consecutive patients with angina pectoris and angiographically demonstrable coronary artery disease. Left ventricular echograms detected late or pansystolic mitral valve bowing suggesting of mitral valve proplapse in 6/25 (24%). Left ventricular angiography showed prolapse of the posterior mitral leaflet in 15/25 (60%), including 5 detected by echocardiography. Significant triple vessel coronary disease was present in 11 of 15 patients with prolapsed mitralvalve. In each of the latter a greater than 90 per cent obstructive lesion was noted in at least one coronary artery: right coronary artery, 9 subjects (82%); left circumflex coronary artery, 5 patients (33%); and left anterior descending coronary artery, 4 patients (27%). Of 15 subjects with angiographic evidence of mitral valve prolapse, 13 had left ventricular asynergy-inferior or inferoposterior in 8 subjects (62%) and anterior or anteroapical in 5 subjects (38%). Eleven subjects had vectorcardiographic evidence of transmural myocardial infarction-inferior or inferoposterior in 9 (82%) and anteroseptal in 2 (18%). A single subject with mitral valve prolapse had mild mitral regurgitation. It is concluded that: (1) coexisting prolapse of the posterior mitral valve leaflet and coronary artery disease is usually associated with triple vessel obstructive lesions, (2) severe right coronary disease, inferior left ventricular wall asynergy, and inferior myocardial infarction are important angiographic and vectorcardiographic correlates, and (3) echocardiography will detect such mitral valve prolapse in only one-third of affected cases.

Adult↗
PubMed1995

Mitral valve procedures in ischemic regurgitation.

A restrictive definition of ischemic mitral regurgitation (IMR) has allowed us to select a more uniform cohort of 41 patients having undergone mitral valve surgery for IMR between January 1993 and March 1995. Thirty-six patients (88%) presented with chronic and five with acute IMR. All patients had at least one significant stenosis in the circumflex area. Left ventricular ejection fraction averaged 35%. Transesophageal echocardiography (TEE) revealed a > or = 3+ MR in 30 patients and an intermittent, fluctuating or grade 2+ MR in 11 (27%). Annulus dilatation was found in all cases, and it was the only mechanism in 10 (24.4%). Leaflet restrictive motion was clearly seen in 17 cases (41.5%) and leaflet prolapse in 14 (34%). In doubtful cases, an intra-operative dynamic testing using TEE, and associating a loading test and an afterload test, led to the indication of a valve procedure in 11/19 patients (58%). An average of three distal coronary anastomoses per patient were constructed. Mitral valve replacement (MVR) was unavoidable in four patients (9.8%); at least the posterior leaflet subvalvular apparatus was preserved in all. Repair of the mitral valve (Mvrep) was achieved in 37 cases (90%). Ring annuloplasty alone was performed in 27 cases (73%). In the remaining 10 cases, leaflet prolapse was corrected by various artifices such as flip-over technique, quadrangular resection, papillary muscle plication or commissuroplasty. At the 10th postoperative day, a residual MR was found in 4/34 cases (11.8%), only after isolated ring annuloplasty. The four patients who have died in the ICU after MVrep belonged to the same group of isolated ring annuloplasty; this mortality of 4/27 (14.8%) illustrates the mediocre prognosis of marked annulus dilatation and impaired LV function with restrictive leaflet motion. Overall, the hospital mortality (14.6%) more reflected the mode of presentation of the patients than the type of operative technique: when a short and definitive procedure is required by a precarious general condition, one should not hesitate to prefer a rapid MVR to a complicated repair. At 4.5 months, there was no significant improvement in LV dimensions. At six months, 80.5% of the patients survived, with 88% of them being in NYHA class I or II.

Adult↗
PubMed1984

[Function of the right ventricle in mitral valve defects before and after surgical correction].

To ascertain whether surgical correction of mitral valve lesions can lead to postoperative improvement of right ventricular function, investigations were carried out in 17 patients with mitral valve disease, clinical severity grade III and IV, before and at an average of 18 months postoperatively. Six subjects without heart disease served as controls. Preoperatively, all patients underwent catheterization and cineangiographic evaluation of both the right and left ventricles. The right ventricular ejection fraction (RV-EF) was also determined from the radionuclide ventriculogram before and after the surgical intervention (closed mitral commissurotomy in five patients and mitral valve replacement in twelve). The patients were studied at rest and during bicycle ergometry in the supine position. As compared with control subjects, before surgery at rest, patients with mitral valve disease had significantly higher values for mean left atrial pressure (22 +/- 7 vs 8 +/- 2 mm Hg), mean pulmonary artery pressure (39 +/- 17 vs 17 +/- 5 mmHg), pulmonary arteriolar resistance (361 +/- 260, increased 5-fold, vs 69 +/- 27 dyn . s . cm-5) and right ventricular systolic pressure (55 +/- 20 vs 24 +/- 6 mmHg) while the values for right ventricular end-diastolic pressure, mean right atrial pressure, left ventricular end-diastolic pressure and left ventricular systolic pressure did not differ (Table 1).(ABSTRACT TRUNCATED AT 250 WORDS)

Cardiac Catheterization↗
PubMed1986

Double mitral valve orifice.

A two-day-old baby with a type-I truncus arteriosus and double mitral valve orifice is reported. The double mitral valve orifice and additional lesions of each subdivision of the mitral valve were clearly shown by two-dimensional echocardiography. The medial orifice had a cleft leaflet and the lateral one a parachute-like disposition of the tension apparatus. This is the first report of double mitral valve orifice associated with truncus arteriosus, and the first in which anomalies of the subdivisions of the mitral valve were detected by two-dimensional echocardiography.

Echocardiography↗