Mechanism of reduction of mitral regurgitation with vasodilator therapy.

PubMed

Yoran, C; Yellin, E L; Becker, R M; Gabbay, S; Frater, R W; Sonnenblick, E H

1979-04-01

Acute mitral regurgitation was produced in six open chest dogs by excising a portion of the anterior valve leaflet. Electromagnetic flow probes were placed in the left atrium around the mitral anulus and in the ascending aorta to determine phasic left ventricular filling volume, regurgitant volume and stroke volume. The systolic pressure gradient was calculated from simultaneously measured high fidelity left atrial and left ventricular pressures. The effective mitral regurgitant orifice area was calculated from Gorlin's hydraulic equation. Infusion of nitroprusside resulted in a significant reduction in mitral regurgitation. No significant change occurred in the systolic pressure gradient between the left ventricle and the left atrium because both peak left ventricular pressure and left atrial pressure were reduced. The reduction of mitral regurgitation was largely due to reduction in the size of the mitral regurgitant orifice. Reduction of ventricular volume rather than the traditional concept of reduction of impedance of left ventricular ejection may explain the effects of vasodilators in reducing mitral regurgitation.

Noninvasive estimation of cardiac systolic function using continuous-wave Doppler echocardiography in dogs with experimental mitral regurgitation.

PubMed

Asano, K; Masui, Y; Masuda, K; Fujinaga, T

2002-01-01

To evaluate the feasibility of noninvasive estimation of cardiac systolic function using transthoracic continuous-wave Doppler echocardiography in dogs with mitral regurgitation. Seven mongrel dogs with experimental mitral regurgitation were used. Left ventriculography and measurement of pulmonary capillary wedge pressure were performed under inhalational anaesthesia. A micromanometer-tipped catheter was placed into the left ventricle and transthoracic echocardiography was carried out. The peak rate of left ventricular pressure rise (peak dP/dt) was derived simultaneously by continuous-wave Doppler and manometer measurements. The Doppler-derived dP/dt was compared with the catheter-measured peak dP/dt in the dogs. Classification of the severity of mitral regurgitation in the dogs was as follows: 1+, 2 dogs; 2+, 1 dog; 3+, 2 dogs; 4+, 1 dog; and not examined, 1 dog. We were able to derive dP/dt from the transthoracic continuous-wave Doppler echocardiography in all dogs. Doppler-derived dP/dt had a significant correlation with the catheter-measured peak dP/dt (r = 0.90, P < 0.0001). It was demonstrated that transthoracic continuous-wave Doppler echocardiography is a feasible method of noninvasive estimation of cardiac systolic function in dogs with experimental mitral regurgitation and may have clinical usefulness in canine patients with spontaneous mitral regurgitation.

Transcatheter direct mitral valve annuloplasty with the Cardioband system for the treatment of functional mitral regurgitation.

PubMed

Taramasso, Maurizio; Inderbitzin, Devdas T; Guidotti, Andrea; Nietlispach, Fabian; Gaemperli, Oliver; Zuber, Michel; Maisano, Francesco

2016-01-01

Direct mitral valve annuloplasty is a transcatheter mitral valve repair approach that mimics the conventional surgical approach to treat functional mitral regurgitation. The Cardioband system (Valtech Cardio, Inc., Or-Yehuda, Israel) is delivered by a trans-septal approach and the implant is performed on the atrial side of the mitral annulus, under live echo and fluoroscopic guidance using multiple anchor elements. The Cardioband system obtained CE mark approval in October 2015, and initial clinical experiences are promising with regard to feasibility, safety and efficacy. © The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Rare Combination of Pathologies Causing Mitral Stenosis and Mitral Regurgitation: A Case Report.

PubMed

Nair, Anupama K; Chowdhuri, Kuntal Roy; Radhakrishnan, Sitaraman; Iyer, Krishna S; Saxena, Manish

2018-01-01

A supramitral ring is a rare cause of mitral stenosis, while an isolated mitral valve cleft is a rare cause of congenital mitral regurgitation. Fortunately, both the lesions are known to have good outcomes after surgical correction. Although each is known to be associated with a variety of other structural heart defects, their coexistence has not been reported previously. We report a case of a three- and half-year-old boy detected to have a rare combination of supramitral ring producing severe mitral stenosis with a coexisting cleft in the anterior leaflet of mitral valve causing severe mitral regurgitation. The patient underwent successful surgical repair with resolution of both mitral stenosis and regurgitation.

Exercise pulmonary hypertension in asymptomatic degenerative mitral regurgitation.

PubMed

Magne, Julien; Lancellotti, Patrizio; Piérard, Luc A

2010-07-06

Current guidelines recommend mitral valve surgery for asymptomatic patients with severe degenerative mitral regurgitation and preserved left ventricular systolic function when exercise pulmonary hypertension (PHT) is present. However, the determinants of exercise PHT have not been evaluated. The aim of this study was to identify the echocardiographic predictors of exercise PHT and the impact on symptoms. Comprehensive resting and exercise transthoracic echocardiography was performed in 78 consecutive patients (age, 61+/-13 years; 56% men) with at least moderate degenerative mitral regurgitation (effective regurgitant orifice area =43+/-20 mm(2); regurgitant volume =71+/-27 mL). Exercise PHT was defined as a systolic pulmonary arterial pressure (SPAP) >60 mm Hg. Exercise PHT was present in 46% patients. In multivariable analysis, exercise effective regurgitant orifice was an independent determinant of exercise SPAP (P<0.0001) and exercise PHT (P=0.002). Resting PHT and exercise PHT were associated with markedly reduced 2-year symptom-free survival (36+/-14% versus 59+/-7%, P=0.04; 35+/-8% versus 75+/-7%, P<0.0001). After adjustment, although the impact of resting PHT was no longer significant, exercise PHT was identified as an independent predictor of the occurrence of symptoms (hazard ratio=3.4; P=0.002). Receiver-operating characteristics curves revealed that exercise PHT (SPAP >56 mm Hg) was more accurate than resting PHT (SPAP >36 mm Hg) in predicting the occurrence of symptoms during follow-up (P=0.032). Exercise PHT is frequent in patients with asymptomatic degenerative mitral regurgitation. Exercise mitral regurgitation severity is a strong independent predictor of both exercise SPAP and exercise PHT. Exercise PHT is associated with markedly low 2-year symptom-free survival, emphasizing the use of exercise echocardiography. An exercise SPAP >56 mm Hg accurately predicts the occurrence of symptoms.

Simple repair approach for mitral regurgitation in Barlow disease.

PubMed

Ben Zekry, Sagit; Spiegelstein, Dan; Sternik, Leonid; Lev, Innon; Kogan, Alexander; Kuperstein, Rafael; Raanani, Ehud

2015-11-01

Mitral valve repair for myxomatous Barlow disease is a challenging procedure requiring complex surgery with less than optimal results. The use of ring-only repair has been previously reported but never analyzed or followed-up. We investigated this simple valve repair approach for patients with Barlow disease and multisegment involvement causing mainly central jet. Of 572 patients who underwent mitral valve repair for mitral regurgitation at our medical center, 24 with Barlow disease (aged 47 ± 14 years; 46% male) underwent ring-only repair. Patients were characterized by severely enlarged mitral valve annulus, multisegment prolapse involving both leaflets, and demonstrated mainly a central wide regurgitant jet. Surgical technique included only the implantation of a large mitral annuloplasty ring. Early and late outcome results were compared with those of the remaining patients who underwent conventional mitral valve repair for degenerative disease (controls). All ring-only patients presented with moderate-severe/severe mitral regurgitation (vena contracta, 0.6 ± 0.1 cm; regurgitation volume, 52 ± 17 mL), with mainly a central jet and almost preserved ejection fraction (59% ± 6%). Cardiopulmonary bypass and crossclamp times were significantly shorter compared with controls (P < .0001). At follow-up (ring-only, 38 ± 36 months and controls, 36 ± 29 months), there were no late deaths in the ring-only group compared with 19 (4%) in the controls. Late follow-up revealed New York Heart Association functional class I or II in 95% of ring-only patients, compared with 90% of controls. Freedom from recurrent moderate or severe mitral regurgitation was 100% and 89% in the ring-only and control groups, respectively. Mitral annuloplasty for Barlow disease patients with multisegment involvement and mainly central regurgitant jet is both simple and reproducible with excellent late outcomes. Copyright © 2015 The American Association for Thoracic Surgery

Papillary Muscle Free Strain in Patients with Severe Degenerative and Functional Mitral Regurgitation.

PubMed

Kılıcgedik, Alev; Kahveci, Gokhan; Gurbuz, Ahmet Seyfeddin; Karabay, Can Yucel; Guler, Ahmet; Efe, Suleyman Cagan; Aung, Soe Moe; Arslantas, Ugur; Demir, Serdar; Izgi, Ibrahim Akin; Kirma, Cevat

2017-04-01

The role of papillary muscle function in severe mitral regurgitation with preserved and reduced left ventricular ejection fraction and the method of choice to evaluate PM have still been the subjects of controversy. To evaluate and compare papillary muscle function in and between patients with severe degenerative and functional mitral regurgitation by using the free strain method. 64 patients with severe mitral regurgitation - 39 patients with degenerative mitral regurgitation (DMR group) and 25 patients with severe functional mitral regurgitation (FMR group) - and 30 control subjects (control group) were included in the study. Papillary muscle function was evaluated through the free strain method from apical four chamber images of the anterolateral papillary muscle (APM) and from apical three chamber images of the posteromedial papillary muscle (PPM). Global left ventricular longitudinal and circumferential strains were evaluated by applying 2D speckle tracking imaging. Global left ventricular longitudinal strain (DMR group, -17 [-14.2/-20]; FMR group, -9 [-7/-10.7]; control group, -20 [-18/-21] p < 0.001), global left ventricular circumferential strain (DMR group, -20 [-14.5/-22.7]; FMR group, -10 [-7/-12]; control group, -23 [-21/-27.5] p < 0.001) and papillary musle strains (PPMS; DMR group, -30.5 [-24/-46.7]; FMR group, -18 [-12/-30]; control group; -43 [-34.5/-39.5] p < 0.001; APMS; DMR group, (-35 [-23.5/-43]; FMR group, -20 [-13.5/-26]; control group, -40 [-32.5/-48] p < 0.001) were significantly different among all groups. APMS and PPMS were highly correlated with LVEF (p < 0.001, p < 0.001; respectively), GLS (p < 0.001, p < 0.001; respectively) and GCS (p < 0.001, p < 0.00; respectively) of LV among all groups. No correlation was found between papillary muscle strains and effective orifice area (EOA) in both groups of severe mitral regurgitation. Measuring papillary muscle longitudinal strain by the free strain method is practical and applicable

Mitral-valve repair versus replacement for severe ischemic mitral regurgitation.

PubMed

Acker, Michael A; Parides, Michael K; Perrault, Louis P; Moskowitz, Alan J; Gelijns, Annetine C; Voisine, Pierre; Smith, Peter K; Hung, Judy W; Blackstone, Eugene H; Puskas, John D; Argenziano, Michael; Gammie, James S; Mack, Michael; Ascheim, Deborah D; Bagiella, Emilia; Moquete, Ellen G; Ferguson, T Bruce; Horvath, Keith A; Geller, Nancy L; Miller, Marissa A; Woo, Y Joseph; D'Alessandro, David A; Ailawadi, Gorav; Dagenais, Francois; Gardner, Timothy J; O'Gara, Patrick T; Michler, Robert E; Kron, Irving L

2014-01-02

Ischemic mitral regurgitation is associated with a substantial risk of death. Practice guidelines recommend surgery for patients with a severe form of this condition but acknowledge that the supporting evidence for repair or replacement is limited. We randomly assigned 251 patients with severe ischemic mitral regurgitation to undergo either mitral-valve repair or chordal-sparing replacement in order to evaluate efficacy and safety. The primary end point was the left ventricular end-systolic volume index (LVESVI) at 12 months, as assessed with the use of a Wilcoxon rank-sum test in which deaths were categorized below the lowest LVESVI rank. At 12 months, the mean LVESVI among surviving patients was 54.6±25.0 ml per square meter of body-surface area in the repair group and 60.7±31.5 ml per square meter in the replacement group (mean change from baseline, -6.6 and -6.8 ml per square meter, respectively). The rate of death was 14.3% in the repair group and 17.6% in the replacement group (hazard ratio with repair, 0.79; 95% confidence interval, 0.42 to 1.47; P=0.45 by the log-rank test). There was no significant between-group difference in LVESVI after adjustment for death (z score, 1.33; P=0.18). The rate of moderate or severe recurrence of mitral regurgitation at 12 months was higher in the repair group than in the replacement group (32.6% vs. 2.3%, P<0.001). There were no significant between-group differences in the rate of a composite of major adverse cardiac or cerebrovascular events, in functional status, or in quality of life at 12 months. We observed no significant difference in left ventricular reverse remodeling or survival at 12 months between patients who underwent mitral-valve repair and those who underwent mitral-valve replacement. Replacement provided a more durable correction of mitral regurgitation, but there was no significant between-group difference in clinical outcomes. (Funded by the National Institutes of Health and the Canadian Institutes of

Long-term outcomes of tricuspid annuloplasty for functional tricuspid regurgitation associated with degenerative mitral regurgitation: suture annuloplasty versus ring annuloplasty using a flexible band.

PubMed

Murashita, Takashi; Okada, Yukikatsu; Kanemitsu, Hideo; Fukunaga, Naoto; Konishi, Yasunobu; Nakamura, Ken; Koyama, Tadaaki

2014-01-01

We investigated the long-term outcomes of suture/ring tricuspid valve annuloplasty for functional tricuspid regurgitation associated with degenerative mitral regurgitation. We retrospectively reviewed patients who underwent flexible ring tricuspid valve annuloplasty (n = 120) or suture tricuspid valve annuloplasty (n = 42) for functional tricuspid regurgitation concomitant with surgery for degenerative mitral regurgitation (mean follow-up duration, 5.3 ± 5.1 years). The mean age of patients was 62.5 ± 13.1 years. Thirty-day mortality was zero in the suture group, and 0.8% in the ring group. Tricuspid regurgitation grade at discharge was lower in the ring group ( p = 0.002). No difference was observed between survival and freedom from major cardiac/cerebrovascular adverse events between the groups. However, freedom from ≥moderate tricuspid regurgitation was higher in the ring group (Log-rank p = 0.003). From univariate analysis, the risk factors for ≥moderate TR were suture annuloplasty and preoperative tricuspid regurgitation grade. No reoperation for recurrent tricuspid regurgitation occurred in either group because symptoms experienced by patients with recurrent tricuspid regurgitation were relatively insignificant. Concomitant tricuspid annuloplasty using flexible bands offered improved durability than suture annuloplasty for preventing postoperative tricuspid regurgitation progression.

Quantification of mitral regurgitation using proximal isovelocity surface area method in dogs.

PubMed

Choi, Hojung; Lee, Kichang; Lee, Heechun; Lee, Youngwon; Chang, Dongwoo; Eom, Kidong; Youn, Hwayoung; Choi, Mincheol; Yoon, Junghee

2004-06-01

The present study was performed to determine the accuracy and reproducibility of calculating the mitral regurgitant orifice area with the proximal isovelocity surface area (PISA) method in dogs with experimental mitral regurgitation and in canine patients with chronic mitral insufficiency and to evaluate the effect of general anesthesia on mitral regurgitation. Eight adult, Beagle dogs for experimental mitral regurgitation and 11 small breed dogs with spontaneous mitral regurgitation were used. In 8 Beagle dogs, mild mitral regurgitation was created by disrupting mitral chordae or leaflets. Effective regurgitant orifice (ERO) area was measured by the PISA method and compared with the measurements simultaneously obtained by quantitative Doppler echocardiography 4 weeks after creation of mitral regurgitation. The same procedure was performed in 11 patients with isolated mitral regurgitation and in 8 Beagle dogs under two different protocols of general anesthesia. ERO and regurgitant stroke volume (RSV) by the PISA method correlated well with values by the quantitative Doppler technique with a small error in experimental dogs (r = 0.914 and r = 0.839) and 11 patients (r = 0.990 and r = 0.996). The isoflurane anesthetic echocardiography demonstrated a significant decrease of RSV, and there was no significant change in fractional shortening (FS), ERO area, LV end-diastolic and LV end-systolic volume. ERO area showed increasing tendency after ketamine-xylazine administration, but not statistically significant. RSV, LV end-systolic and LV end-diastolic volume increased significantly (p < 0.01), whereas FS significantly decreased (p < 0.01). The PISA method is accurate and reproducible in experimental mitral regurgitation model and in a clinical setting. ERO area is considered and preferred as a hemodynamic-nondependent factor than other traditional measurements.

Percutaneous Transvenous Mitral Annuloplasty (PTMA) with the Viking device reduces pacing-induced mitral regurgitation.

PubMed

Kimblad, Per Ola; Harnek, Jan; Roijer, Anders; Meurling, Carl; Brandt, Johan; Solem, Jan Otto

2005-11-01

The new percutaneous mitral annuloplasty Viking device was evaluated in surviving sheep with pacing-induced mitral regurgitation. Twenty sheep were subjected to rapid ventricular pacing for one to three months, leading to cardiomyopathy and mitral regurgitation. Device implantation could be successfully performed in 11 of these animals after pacemaker treatment for 64+/-7 days. The device-related procedure time was 12+/-2 min. The mean follow-up time was 58+/-8 days after implantation of the device. Mitral annulus septo-lateral diameter was significantly reduced after insertion of the device, from 35+/-1 mm before implantation to 30+/-1 mm at the final follow up intracardiac echocardiography (P = 0.0097). The degree of mitral regurgitation (on a scale from 0 to 4) was 2.6+/-0.2 before device implantation and decreased to 0.8+/-0.2 after treatment (P = 0.0039), and the vena contracta was reduced from 7+/-0.4 mm to 3+/-0.8 mm (P = 0.0019). Angiography showed no signs of impairment of the coronary arteries. No thrombosis was observed. These results indicate that the septo-lateral diameter of the mitral annulus, and the degree of experimentally induced mitral regurgitation, can be significantly reduced with a percutaneous catheter technique in surviving sheep.

Mechanisms of valve competency after mitral valve annuloplasty for ischaemic mitral regurgitation using the Geoform ring: insights from three-dimensional echocardiography.

PubMed

Armen, Todd A; Vandse, Rashmi; Crestanello, Juan A; Raman, Subha V; Bickle, Katherine M; Nathan, Nadia S

2009-01-01

Left ventricular remodelling leads to functional mitral regurgitation resulting from annular dilatation, leaflet tethering, tenting, and decreased leaflet coaptation. Mitral valve annuloplasty restores valve competency, improving the patient's functional status and ventricular function. This study was designed to evaluate the mechanisms underlying mitral valve competency after the implantation of a Geoform annuloplasty ring using three-dimensional (3D) echocardiography. Seven patients (mean age of 65 years) with ischaemic mitral regurgitation underwent mitral valve annuloplasty with the Geoform ring and coronary artery bypass surgery. Pre- and post-operative 3D echocardiograms were performed. Following mitral annuloplasty, mitral regurgitation decreased from 3.4+/-0.2 to 0.9+/-0.3 (P-value<0.0001), mitral valve tenting volume from 13+/-1.7 to 3.2+/-0.3 mL (P-value<0.001), annulus area from 12.6+/-1.0 to 3.3+/-0.2 cm2 (P-value<0.0001), valve circumference from 13+/-0.5 to 7.3+/-0.3 cm (P-value<0.0001), septolateral distance from 2.1+/-0.1 to 1.4+/-0.06 cm (P-value<0.01) and intercommissural distance from 3.4+/-0.1 to 2.7+/-0.03 cm (P-value<0.03). There was significant decrease in the septolateral distance at the level of A2-P2 with respect to other regions. These geometric changes were associated with the improvement in the NYHA class from 3.1+/-0.3 to 1.3+/-0.3 (P-value<0.002). The mitral valve annuloplasty with the Geoform ring restores leaflet coaptation and eliminates mitral regurgitation by effectively modifying the mitral annular geometry.

Quantification of mitral and tricuspid regurgitation by the proximal flow convergence method using two-dimensional colour Doppler and colour Doppler M-mode: influence of the mechanism of regurgitation.

PubMed

Grossmann, G; Giesler, M; Stein, M; Kochs, M; Höher, M; Hombach, V

1998-10-30

In patients with mitral (n=77: organic=49, functional=28) and tricuspid regurgitation (n=55: functional=54) quantified by angiography, the temporal variation of the proximal flow convergence region throughout systole was assessed by colour Doppler M-Mode, and peak and mean radius of the proximal isovelocity surface area for 28 cm/s blood flow velocity were measured. Additionally, the peak radius derived from two-dimensional colour Doppler was obtained. About 50% of the patients with mitral and tricuspid regurgitation showed a typical temporal variation of the flow convergence region related to the mechanism of regurgitation. The different proximal isovelocity surface area radii were similarly correlated to the angiographic grade in mitral and tricuspid regurgitation (rank correlation coefficients 0.55-0.89) and they differentiated mild to moderate (grade < or =II) from severe (grade > or =III) mitral and tricuspid regurgitation with comparable accuracy (82-96%). However, moderate mitral regurgitation due to leaflet prolapse in two patients was correctly classified by the mean M-mode radius and overestimated by both peak radii. Only half of the patients showed a typical variation of the flow convergence region related to the mechanism of regurgitation. The different proximal isovelocity surface area radii were suitable to quantify mitral and tricuspid regurgitation in most patients. However, in mitral regurgitation due to leaflet prolapse the use of the mean M-mode radius may avoid overestimation.

Initial experience of percutaneous treatment of mitral regurgitation with MitraClip® therapy in Spain.

PubMed

Carrasco-Chinchilla, Fernando; Arzamendi, Dabit; Romero, Miguel; Gimeno de Carlos, Federico; Alonso-Briales, Juan Horacio; Li, Chi-Hion; Mesa, Maria Dolores; Arnold, Roman; Serrador Frutos, Ana María; Pan, Manuel; Roig, Eulalia; Rodríguez-Bailón, Isabel; de la Fuente Galán, Luis; Hernández, José María; Serra, Antonio; Suárez de Lezo, José

2014-12-01

Symptomatic mitral regurgitation has an unfavorable prognosis unless treated by surgery. However, the European registry of valvular heart disease reports that 49% of patients with this condition do not undergo surgery. Percutaneous treatment of mitral regurgitation with MitraClip® has been proved a safe, efficient adjunct to medical treatment in patients with this profile. The objective of the present study is to describe initial experience of MitraClip® therapy in Spain. Retrospective observational study including all patients treated between November 2011 and July 2013 at the 4 Spanish hospitals recording the highest numbers of implantations. A total of 62 patients (77.4% men) were treated, mainly for restrictive functional mitral regurgitation (85.4%) of grade III (37%) or grade IV (63%), mean (standard deviation) ejection fraction 36% (14%), and New York Heart Association functional class III (37%) or IV (63%). Device implantation was successful in 98% of the patients. At 1 year, 81.2% had mitral regurgitation ≤ 2 and 90.9% were in New York Heart Association functional class ≤ II. One periprocedural death occurred (sepsis at 20 days post-implantation) and another 3 patients died during follow-up (mean, 9.1 months). Two patients needed a second implantation due to partial dehiscence of the first device and 2 others underwent heart transplantation. In Spain, MitraClip® therapy has principally been aimed at patients with functional mitral regurgitation, significant systolic ventricular dysfunction, and high surgical risk. It is considered a safe alternative treatment, which can reduce mitral regurgitation and improve functional capacity. Copyright © 2014 Sociedad Española de Cardiología. Published by Elsevier Espana. All rights reserved.

Electrical conduction disturbance effects on dynamic changes of functional mitral regurgitation.

PubMed

Fukuda, Shota; Grimm, Richard; Song, Jong-Min; Kihara, Takashi; Daimon, Masao; Agler, Deborah A; Wilkoff, Bruce L; Natale, Andrea; Thomas, James D; Shiota, Takahiro

2005-12-20

The aim of this study was to investigate the relationship between dynamics of functional mitral regurgitation (MR) and the degree of electrical conduction disturbance, and to evaluate the impact of cardiac resynchronization therapy (CRT) on MR severity and its phasic pattern. Mechanisms of phasic changes of functional MR, which may be determined by annulus dilation and tethering of the leaflet, remain unclear. Transthoracic two-dimensional echocardiography was performed in 60 patients with functional MR. A biventricular pacemaker was implanted in 19 patients. The mitral annulus area (MAA) and the tenting area (TA) were measured from apical views. The MR volume and fraction were assessed by the quantitative pulsed Doppler method. Instantaneous regurgitation flow rate was measured by proximal flow convergence method. A dynamic change in MR flow rate was evaluated by frame-by-frame analysis throughout systole. A phasic pattern with two peaks at early- and late-systole and decrease in mid-systole was noticed in 57 patients. The early-systolic peak of MR was larger than the late-systolic peak (128.4 +/- 64.3 ml/s vs. 73.9 +/- 55.1 ml/s, p < 0.001). The ratio of flow rate at these two peaks correlated with QRS duration (r = 0.55, p < 0.001). Early-systolic flow rate reduced after CRT (143.9 +/- 60.8 ml/s to 90.7 +/- 54.1 ml/s, p < 0.05), but late-systolic flow rate did not (61.5 +/- 55.0 ml/s to 51.2 +/- 40.9 ml/s, p = NS). A similar pattern was observed for TA, whereas MAA did not change after CRT. Biphasic pattern was found in functional MR, and the ratio of flow rate at two peaks correlated with QRS duration. The CRT decreased regurgitation flow volume by reducing early-systolic MR but not late-systolic MR, resulting in the change in phasic pattern of functional MR.

Relationship between mitral annulus function and mitral regurgitation severity and left atrial remodelling in patients with primary mitral regurgitation.

PubMed

Mihaila, Sorina; Muraru, Denisa; Miglioranza, Marcelo Haertel; Piasentini, Eleonora; Aruta, Patrizia; Cucchini, Umberto; Iliceto, Sabino; Vinereanu, Dragos; Badano, Luigi P

2016-08-01

To explore the relationship between the mitral annular (MA) remodelling and dysfunction, mitral regurgitation (MR) severity, left ventricular (LV) and atrial (LA) size and function in patients with organic MR (OMR). A total of 52 patients (57 ± 15 years, 31 men) with mild to severe OMR and 52 controls underwent 3D transthoracic echocardiography acquisitions of the mitral valve (MV), LA, and LV. MA geometry and dynamics, LV and LA volumes, LV ejection fraction (LVEF) and emptying fractions (LAEF) were assessed using dedicated software packages. LA and LV myocardial deformations were assessed using 2D speckle-tracking echocardiography. OMR patients presented larger and more spherical MA than controls during the entire systole (P < 0.001). Although the MA non-planarity at early-systole was similar between OMR and controls (157 ± 13° vs. 153 ± 12°, P = NS), the MA became flatter from mid- to end-systole (153 ± 12 vs. 146 ± 10° and 157 ± 12 vs. 147 ± 8°, P < 0.01) in OMR. MA area fractional change was lower in patients with OMR (22 ± 5% vs. 28 ± 5%, P < 0.001), and correlated with the MR orifice and volume (r = -0.52 and r = -0.55). MA fractional area change correlated with LA minimum and maximum volumes (r = 0.77 and r = 0.70), total and active LAEF (r = 0.72 and r = 0.76), and LA negative strain and strain rate (r = 0.52 and r = 0.57), but not with the LVEF or LV global longitudinal strain. In a multivariate regression model using LAEF and LVEF, solely active LAEF correlated with the MA fractional area change (β = 0.51, P = 0.005). In patients with OMR, MA reduced function correlates with the MR severity and the LA size and function, but not with the LV function. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2016. For permissions please email: journals.permissions@oup.com.

Probe for production and measurement of acute mitral regurgitant flow in dog.

PubMed

Kléber, A G; Simon, R; Rutishauser, W

1976-02-01

A probe for production and measurement of acute mitral regurgitation in dogs is described. It consists of a tube that is introduced into the mitral valve through the left atrial appendage. Regurgitant flow through the tube is measured by an electromagnetic device. Variation of flow and zero flow are achieved by narrowing or occluding the tube with a rubber cuff. In animals weighing 30-50 kg, the probe does not produce significant mitral stenosis and the mitral leaflets fit closely around the probe during ventricular systole. The instantaneous relationship between mitral regurgitant flow (MRF) and the gradient between left ventricular and left atrial pressure shows a marked delay of MRF at the beginning and end of regurgitation. This delay can be attributed to some extent to electrical phase lag and to the small movement of the probe relative to the mitral valve during the cardiac cycle. Measurement of regurgitant stroke volume is affected by this movement only to a small extent.

Left ventricular remodeling in preclinical experimental mitral regurgitation of dogs.

PubMed

Dillon, A Ray; Dell'Italia, Louis J; Tillson, Michael; Killingsworth, Cheryl; Denney, Thomas; Hathcock, John; Botzman, Logan

2012-03-01

Dogs with experimental mitral regurgitation (MR) provide insights into the left ventricular remodeling in preclinical MR. The early preclinical left ventricular (LV) changes after mitral regurgitation represent progressive dysfunctional remodeling, in that no compensatory response returns the functional stroke volume (SV) to normal even as total SV increases. The gradual disease progression leads to mitral annulus stretch and enlargement of the regurgitant orifice, further increasing the regurgitant volume. Remodeling with loss of collagen weave and extracellular matrix (ECM) is accompanied by stretching and hypertrophy of the cross-sectional area and length of the cardiomyocyte. Isolated ventricular cardiomyocytes demonstrate dysfunction based on decreased cell shortening and reduced intracellular calcium transients before chamber enlargement or decreases in contractility in the whole heart can be clinically appreciated. The genetic response to increased end-diastolic pressure is down-regulation of genes associated with support of the collagen and ECM and up-regulation of genes associated with matrix remodeling. Experiments have not demonstrated any beneficial effects on remodeling from treatments that decrease afterload via blocking the renin-angiotensin system (RAS). Beta-1 receptor blockade and chymase inhibition have altered the progression of the LV remodeling and have supported cardiomyocyte function. The geometry of the LV during the remodeling provides insight into the importance of regional differences in responses to wall stress. Copyright © 2012 Elsevier B.V. All rights reserved.

Assessment of mitral regurgitation in dogs: comparison of results of echocardiography with magnetic resonance imaging.

PubMed

Sargent, J; Connolly, D J; Watts, V; Mõtsküla, P; Volk, H A; Lamb, C R; Fuentes, V Luis

2015-11-01

Echocardiography is used routinely to assess mitral regurgitation severity, but echocardiographic measures of mitral regurgitation in dogs have not been compared with other quantitative methods. The study aim was to compare echocardiographic measures of mitral regurgitation with cardiac magnetic resonance imaging-derived mitral regurgitant fraction in small-breed dogs. Dogs with myxomatous mitral valve disease scheduled for magnetic resonance imaging assessment of neurological disease were recruited. Correlations were tested between cardiac magnetic resonance imaging-derived mitral regurgitant fraction and the following echocardiographic measures: vena contracta/aortic diameter, transmitral E-wave velocity, amplitude of mitral prolapse/aortic diameter, diastolic left ventricular diameter:aortic diameter, left atrium:aortic diameter, mitral regurgitation jet area ratio and regurgitant fraction calculated using the proximal isovelocity surface area method. Measurement of cardiac magnetic resonance imaging-derived mitral regurgitant fraction was attempted in 21 dogs. Twelve consecutive, complete studies were obtained and 10 dogs were included in the final analysis: vena contracta/aortic diameter (r = 0 · 89, p = 0 · 001) and E-wave velocity (r = 0 · 86, p = 0 · 001) had the strongest correlations with cardiac magnetic resonance imaging-derived mitral regurgitant fraction. E velocity had superior repeatability and could be measured in all dogs. The presence of multiple jets precluded vena contracta/aortic diameter measurement in one dog. Measurement of cardiac magnetic resonance imaging-derived mitral regurgitant fraction is feasible but technically demanding. The echocardiographic measures that correlated most closely with cardiac magnetic resonance imaging-derived mitral regurgitant fraction were vena contracta/aortic diameter and E-wave velocity. © 2015 British Small Animal Veterinary Association.

Association Of Tricuspid Regurgitation And Severity Of Mitral Stenosis In Patients With Rheumatic Heart Disease.

PubMed

Ahmed, Rehan; Kazmi, Nasir; Naz, Farhat; Malik, Saqib; Gillani, Saima

2016-01-01

Rheumatic heart disease is a common ailment in Pakistan and Mitral stenosis is its flag bearer Severity of mitral stenosis is the key factor in deciding for mitral valve surgery. This case series study was conducted at Ayub Teaching Hospital .Cases of Rheumatic heart disease with mitral stenosis were diagnosed clinically. 2D echocardiography was used to find severity of mitral stenosis. Data was entered into SPSS-17.0 and results were recorded and analysed. Pearson's two tailed correlation was used to find the correlation between presence of tricuspid regurgitation in patients with severe mitral stenosis, p was <0.05. A total 35 patients with pure mitral stenosis were included in study, out of which 8 were male and 27 were females. Mean age in males was 34.5±15.85 years while in females it was 31±8 years. Twenty-two out of 35 (62.86%) patients had tricuspid regurgitation while 13 out 35 (37.14%) had no tricuspid regurgitation. Mean (MVA) mitral valve area in patients with tricuspid regurgitation was 0.84±0.3 cm2 while mean (MVA) mitral valve area in patients without tricuspid regurgitation was 1.83±0.7 cm2. Mean left atrial (L.A) size was 45.23±1.5 mm2 in patients with tricuspid regurgitation, while it was 44.13±6.14 mm2 in patients without tricuspid regurgitation. Mean RSVP was 57.5mmHg in patients with tricuspid regurgitation while RSVP could not be calculated in patients without tricuspid regurgitation. It was concluded that tricuspid regurgitation was strongly associated with severe mitral stenosis as almost all patients with severe mitral stenosis had tricuspid regurgitation and none of the patients with mild mitral stenosis had tricuspid regurgitation.

[Quantitative determination of blood regurgitation via the mitral valve].

PubMed

Sandrikov, V A

1981-11-01

A method of quantitative determination of blood regurgitation through the mitral valve is considered. Verification experiment on 5 animals with the determination of correlation coefficient of true and predicted regurgitation has shown it to be 0.855 on the average. Besides, observations were undertaken on 621 patient with varying pathology of the heart. A quantitative characteristics of blood regurgitation in patients with mitral defects is given. The method can be used not only under operation conditions, but also in catheterization of the cardiac cavities without administering of an opaque substance.

Natural history of coexistent tricuspid regurgitation in patients with degenerative mitral valve disease: implications for future guidelines.

PubMed

Goldstone, Andrew B; Howard, Jessica L; Cohen, Jeffrey E; MacArthur, John W; Atluri, Pavan; Kirkpatrick, James N; Woo, Y Joseph

2014-12-01

The management of coexistent tricuspid regurgitation in patients with mitral regurgitation remains controversial. We sought to define the incidence and natural history of coexistent tricuspid regurgitation in patients undergoing isolated mitral surgery for degenerative mitral regurgitation, as well as the effect of late secondary tricuspid regurgitation on cardiovascular symptom burden and survival. To minimize confounding, analysis was limited to 495 consecutive patients who underwent isolated mitral surgery for degenerative mitral valve disease between 2002 and 2011. Patients with coexistent severe tricuspid regurgitation were excluded because such patients typically undergo concomitant tricuspid intervention. Grade 1 to 3 coexistent tricuspid regurgitation was present in 215 patients (43%) preoperatively. Actuarial freedom from grade 3 to 4 tricuspid regurgitation 1, 5, and 9 years after surgery was 100% ± 0%, 90% ± 2%, and 64% ± 7%, respectively. Older age (P < .001) and grade of preoperative tricuspid regurgitation (P = .006) independently predicted postoperative progression of tricuspid regurgitation on multivariable analysis. However, when limited to patients with mild or absent tricuspid regurgitation, indexed tricuspid annular diameter was the only significant risk factor for late tricuspid regurgitation (P = .04). New York Heart Association functional class and long-term survival did not worsen with development of late secondary tricuspid regurgitation (P = .4 and P = .6, respectively). However, right ventricular dysfunction was significantly more common in patients with more severe late tricuspid regurgitation (P = .007). Despite durable correction of degenerative mitral regurgitation, less than severe tricuspid regurgitation is likely to progress after surgery if uncorrected. Given the low incremental risk of tricuspid annuloplasty, a more aggressive strategy of concomitant tricuspid repair may be warranted. Copyright © 2014 The American Association

Prevalence of Late Functional Tricuspid Regurgitation in Degenerative Mitral Regurgitation Surgery.

PubMed

Vaturi, Mordehay; Kotler, Tali; Shapira, Yaron; Weisenberg, Daniel; Monakier, Daniel; Sagie, Alexander

2016-03-01

Although significant late tricuspid regurgitation (TR) may develop after surgery for degenerative mitral regurgitation (MR), the use of routine tricuspid annuloplasty is debatable. The study aim was to determine the prevalence and predictors of significant late TR after surgery for degenerative MR. A total of 112 patients who had undergone surgery for degenerative MR without concomitant tricuspid valve repair (average follow up 7.7 ± 4.0 years) was studied retrospectively. The prevalence of post-surgical TR and predictors of progression were determined. The majority of patients (97%) had non-significant TR (less than moderate) prior to surgery, although an overall trend of progression towards significant TR (grades 2 or 3) was noted in 17 patients (p = 0.0006). Of the 18 patients (16%) with late postoperative significant TR, only nine (8%) had severe TR with only a single referral to surgery. New-onset post-surgical atrial fibrillation was more common in patients who developed late significant TR (p = 0.002). Multivariate analysis of the pre-surgery variables, age >65 years and left ventricular dysfunction were shown to be independent predictors of late functional TR. Significant progression in TR after surgery for degenerative MR was rare in this patient cohort. The impact of older age and left ventricular dysfunction at the time of surgery showed a strong association with post-surgical atrial fibrillation.

Effects of heart rate on experimentally produced mitral regurgitation in dogs.

PubMed

Yoran, C; Yellin, E L; Hori, M; Tsujioka, K; Laniado, S; Sonnenblick, E H; Frater, R W

1983-12-01

The effects of increasing heart rate (HR) on the hemodynamics of acute mitral regurgitation (MR) were studied in 8 open-chest dogs. Filling volume, regurgitant volume and stroke volume were calculated from electromagnetic probe measurements of mitral and aortic flows. The left atrial-left ventricular systolic pressure gradient was measured with micromanometers. The calculated effective mitral regurgitant orifice area varied from 10 to 128 mm2, with a consequent regurgitant fraction (regurgitant volume/filling volume) of 24 to 62%. After crushing the sinus node, HR was increased stepwise from 90 to 180 beats/min by atrial pacing while maintaining aortic pressure constant. With increasing HR, filling volume, stroke volume, regurgitant volume and regurgitant time decreased; total cardiac output, forward cardiac output, regurgitant output, systolic pressure gradient, regurgitant fraction and the regurgitant orifice did not change; left ventricular end-diastolic pressure decreased; and left atrial v-wave amplitude increased. These results indicate that in acute experimental MR with a wide spectrum of incompetence, the relative distribution of forward and regurgitant flows did not change with large increases in HR. At rates greater than 150 beats/min the atrial contraction occurs early and increases the amplitude of the left atrial v wave. This may contribute to the severity of pulmonary congestion in patients with MR.

Efficacy of chordal cutting in alleviating ischemic mitral regurgitation: insights from 3-dimensional echocardiography

PubMed Central

Sai-Sudhakar, Chittoor B; Vandse, Rashmi; Armen, Todd A; Bickle, Katherine M; Nathan, Nadia S

2007-01-01

Background Ischemic mitral regurgitation often complicates severe ischemic heart disease and adversely affects the prognosis in these patients. There is wide variation in the clinical spectrum of ischemic mitral regurgitation due to varying location and chronicity of ischemia and anomalies in annular and ventricular remodeling. As a result, there is lack of consensus in treating these patients. Treatment has to be individualized for each patient. Most of the available surgical options do not consistently correct this condition in all the patients. Chordal cutting is one of the newer surgical approaches in which cutting a limited number of critically positioned basal chordae have found success by relieving the leaflet tethering and thereby improving the coaptation of leaflets. Three-dimensional echocardiography is a potentially valuable tool in identifying the specific pattern of tethering and thus the suitability of this procedure in a given clinical scenario. Case Presentation A 66-year-old man with cardiomyopathy and ischemic mitral regurgitation presented to us with the features of congestive heart failure. The three-dimensional echocardiography revealed severe mitral regurgitation associated with the tethering of the lateral (P1) and medial (P3) scallops of the posterior leaflet of the mitral valve due to secondary chordal attachments. The ejection fraction was only 15% with severe global systolic and diastolic dysfunction. Mitral regurgitation was successfully corrected with mitral annuloplasty and resection of the secondary chordae tethering the medial and lateral scallops of the posterior leaflet of the mitral valve. Conclusion Cutting the second order chordae along with mitral annuloplasty could be a novel method to remedy Ischemic mitral regurgitation by relieving the tethering of the valve leaflets. The preoperative three-dimensional echocardiography should be considered in all patients with Ischemic mitral regurgitation to assess the complex three

Efficacy of chordal cutting in alleviating ischemic mitral regurgitation: insights from 3-dimensional echocardiography.

PubMed

Sai-Sudhakar, Chittoor B; Vandse, Rashmi; Armen, Todd A; Bickle, Katherine M; Nathan, Nadia S

2007-09-25

Ischemic mitral regurgitation often complicates severe ischemic heart disease and adversely affects the prognosis in these patients. There is wide variation in the clinical spectrum of ischemic mitral regurgitation due to varying location and chronicity of ischemia and anomalies in annular and ventricular remodeling. As a result, there is lack of consensus in treating these patients. Treatment has to be individualized for each patient. Most of the available surgical options do not consistently correct this condition in all the patients. Chordal cutting is one of the newer surgical approaches in which cutting a limited number of critically positioned basal chordae have found success by relieving the leaflet tethering and thereby improving the coaptation of leaflets. Three-dimensional echocardiography is a potentially valuable tool in identifying the specific pattern of tethering and thus the suitability of this procedure in a given clinical scenario. A 66-year-old man with cardiomyopathy and ischemic mitral regurgitation presented to us with the features of congestive heart failure. The three-dimensional echocardiography revealed severe mitral regurgitation associated with the tethering of the lateral (P1) and medial (P3) scallops of the posterior leaflet of the mitral valve due to secondary chordal attachments. The ejection fraction was only 15% with severe global systolic and diastolic dysfunction. Mitral regurgitation was successfully corrected with mitral annuloplasty and resection of the secondary chordae tethering the medial and lateral scallops of the posterior leaflet of the mitral valve. Cutting the second order chordae along with mitral annuloplasty could be a novel method to remedy Ischemic mitral regurgitation by relieving the tethering of the valve leaflets. The preoperative three-dimensional echocardiography should be considered in all patients with Ischemic mitral regurgitation to assess the complex three-dimensional interactions between the mitral

Predictors and Clinical Impact of Functional Mitral Stenosis Induced by Restrictive Annuloplasty for Ischemic and Functional Mitral Regurgitation.

PubMed

Kainuma, Satoshi; Taniguchi, Kazuhiro; Toda, Koichi; Funatsu, Toshihiro; Kondoh, Haruhiko; Miyagawa, Shigeru; Yoshikawa, Yasushi; Hata, Hiroki; Saito, Shunsuke; Ueno, Takayoshi; Kuratani, Toru; Daimon, Takashi; Masai, Takafumi; Sawa, Yoshiki

2017-11-24

There are few reports of the determinants of "functional" mitral stenosis in terms of a residual mitral valve (MV) pressure gradient >5 mmHg following restrictive mitral annuloplasty (RMA) or the effect on long-term outcome in patients with functional mitral regurgitation (MR).Methods and Results:Serial cardiac catheterization and echocardiographic studies were performed in 55 patients with functional MR who underwent RMA using a 24/26-mm semi-rigid complete ring. The mean postoperative (1 month) catheter-measured MV gradient was 3.4±1.6 mmHg, which was independently associated with corresponding cardiac output [standardized partial regression coefficient (SPRC)=0.59] and indexed effective orifice area (SPRC=-0.25). Body surface area (BSA) had the greatest contribution to MV gradient (SPRC=0.38), followed by use of a 24-mm ring (SPRC=0.33) and hemodialysis (SPRC=0.26). Receiver-operating characteristic curve analysis demonstrated an optimal BSA cutoff value of 1.86 m 2 to predict post-MV stenosis (21% for <1.86 m 2 vs. 86% for ≥1.86 m 2 , P=0.002). During follow-up (75±32 months), freedom from adverse events did not differ between patients with (n=16) and without (n=39) an MV gradient ≥5 mmHg (log-rank P=0.24). Post-RMA MV gradient was determined not only by the degree of annular reduction but also by patients' hemodynamic factors (e.g., cardiac output). Implantation of a 24/26-mm annuloplasty ring for patients with BSA ≥1.86 m 2 indicated a high likelihood of post-MV stenosis. However, mild MV stenosis did not adversely affect late outcome after RMA.

Exercise-induced changes in mitral regurgitation in patients with prior myocardial infarction and left ventricular dysfunction: relation to mitral deformation and left ventricular function and shape.

PubMed

Giga, Vojislav; Ostojic, Miodrag; Vujisic-Tesic, Bosiljka; Djordjevic-Dikic, Ana; Stepanovic, Jelena; Beleslin, Branko; Petrovic, Milan; Nedeljkovic, Milan; Nedeljkovic, Ivana; Milic, Natasa

2005-09-01

The aim of this study was to assess the relationship between exercise-induced changes in mitral regurgitation (MR) and echocardiographic characteristics of mitral deformation, global left ventricular (LV) function and shape at rest and after exercise. Forty consecutive patients with ischaemic MR due to prior myocardial infarction (MI), ejection fraction <45% in sinus rhythm underwent exercise-echocardiographic testing. Exercise-induced changes in effective regurgitant orifice (ERO) were compared with baseline and exercise-induced changes in mitral deformation and global LV function and shape. There was significant correlation between exercise-induced changes in ERO and changes in coaptation distance (r=0.80, P<0.0001), tenting area (r=0.79, P<0.0001) and mitral annular diameter (r=0.65, P<0.0001), as well as in end-systolic sphericity index (r=-0.50, P=0.001, respectively), and wall motion score index (r=0.44, P=0.004). In contrast, exercise-induced changes in ERO were not related to the echocardiographic features at rest. By stepwise multiple regression model, the exercise-induced changes in mitral deformation were found to independently correlate with exercise-induced changes in ERO (generalized r(2)=0.80, P<0.0001). Exercise-induced changes in severity of ischaemic MR in patients with LV dysfunction due to prior MI were independently related to changes in mitral deformation.

Impact of mitral valve geometry on hemodynamic efficacy of surgical repair in secondary mitral regurgitation.

PubMed

Padala, Muralidhar; Gyoneva, Lazarina I; Thourani, Vinod H; Yoganathan, Ajit P

2014-01-01

Mitral valve geometry is significantly altered secondary to left ventricular remodeling in non-ischemic and ischemic dilated cardiomyopathies. Since the extent of remodeling and asymmetry of dilatation of the ventricle differ significantly between individual patients, the valve geometry and tethering also differ. The study aim was to determine if mitral valve geometry has an impact on the efficacy of surgical repairs to eliminate regurgitation and restore valve closure in a validated experimental model. Porcine mitral valves (n = 8) were studied in a pulsatile heart simulator, in which the mitral valve geometry can be precisely altered and controlled throughout the experiment. Baseline hemodynamics for each valve were measured (Control), and the valves were tethered in two distinct ways: annular dilatation with 7 mm apical papillary muscle (PM) displacement (Tether 1, symmetric), and annular dilatation with 7 mm apical, 7 mm posterior and 7 mm lateral PM displacement (Tether 2, asymmetric). Mitral annuloplasty was performed on each valve (Annular Repair), succeeded by anterior leaflet secondary chordal cutting (Sub-annular Repair). The efficacy of each repair in the setting of a given valve geometry was quantified by measuring the changes in mitral regurgitation (MR), leaflet coaptation length, tethering height and area. At baseline, none of the valves was regurgitant. Significant leaflet tethering was measured in Tether 2 over Tether 1, but both groups were significantly higher compared to baseline (60.9 +/- 31 mm2 for Control versus 129.7 +/- 28.4 mm2 for Tether 1 versus 186.4 +/- 36.3 mm2 for Tether 2). Consequently, the MR fraction was higher in Tether 2 group (23.0 +/- 5.7%) than in Tether 1 (10.5 +/- 5.5%). Mitral annuloplasty reduced MR in both groups, but remnant regurgitation after the repair was higher in Tether 2. After chordal cutting a similar trend was observed with trace regurgitation in Tether 1 group at 3.6 +/- 2.8%, in comparison to 18.6 +/- 4

MitraClip in CRT non-responders with severe mitral regurgitation.

PubMed

Seifert, Martin; Schau, Thomas; Schoepp, Maren; Arya, Anita; Neuss, Michael; Butter, Christian

2014-11-15

Severe mitral regurgitation (MR) ≥ 3+ and left ventricular dyssynchrony in heart failure patients are markers of CRT non response. The MitraClip (MC) implantation is a therapy for MR ≥ 3+ in patients with high surgical risk of mitral valve reconstruction. We investigated 42 patients with CRT and MR ≥ 3+ who received an MC device at our center. One and two year mortality rates were compared with the predicted mortality by Seattle Heart Failure Model (SHFM) and meta-analysis global group in chronic heart failure (MAGGIC), using the baseline characteristics of patients at the time of MC implantation. The median time interval between CRT and MC implantation was 20.1 (4.5-43.3) months. In 19 patients we observed a functional regurgitation with normal leaflets and in 23 patients a degenerative mechanism for mitral regurgitation. There was no change in mean QRS duration by biventricular pacing or MC implantation. The use of MC led to significant reductions in: median N-terminal pro-brain natriuretic peptide (NT-proBNP) level (pg/ml) from 3923 to 2636 (p = 0.02), tricuspid regurgitation pressure gradient (TRPG) from 43 to 35 mmHg (p = 0.019) and in left ventricular end-diastolic volume (LVEDV) by MC (p = 0.008). At the 2 year follow-up interval the all-cause mortality was 25%. MC implantation leads to an improvement of NT-proBNP level, TRPG and LVEDV in both functional and degenerative MR but does not influence QRS duration. Two year all-cause mortality was 25% and did not differ significantly from that predicted by SHFM and MAGGIC. Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.

Mild mitral and tricuspid regurgitation secondary to pericardial constriction.

PubMed

Mittal, S R

2014-06-01

A 26 years female presented with pericardial effusion. On follow up she developed pericardial constriction with new appearance of mild mitral and tricuspid regurgitation without any other pathology. Fibrosis along posterior atrioventricular groove could be responsible for regurgitation.

Concomitant Transapical Transcatheter Valve Implantations: Edwards Sapien Valve for Severe Mitral Regurgitation in a Patient with Failing Mitral Bioprostheses and JenaValve for the Treatment of Pure Aortic Regurgitation.

PubMed

Aydin, Unal; Gul, Mehmet; Aslan, Serkan; Akkaya, Emre; Yildirim, Aydin

2015-04-28

Transcatheter valve implantation is a novel interventional technique, which was developed as an  alternative therapy for surgical aortic valve replacement in inoperable patients with severe aortic stenosis. Despite limited experience in using transcatheter valve implantation for mitral and aortic regurgitation, transapical transcatheter aortic valve implantation and valve-in-valve implantation for degenerated mitral valve bioprosthesis can be performed in high-risk patients who are not candidates for conventional replacement surgery. In this case, we present the simultaneous transcatheter valve implantation via transapical approach for both degenerated bioprosthetic mitral valve with severe regurgitation and pure severe aortic regurgitation.

Examination of mitral regurgitation with a goat heart model for the development of intelligent artificial papillary muscle.

PubMed

Shiraishi, Y; Yambe, T; Yoshizawa, M; Hashimoto, H; Yamada, A; Miura, H; Hashem, M; Kitano, T; Shiga, T; Homma, D

2012-01-01

Annuloplasty for functional mitral or tricuspid regurgitation has been made for surgical restoration of valvular diseases. However, these major techniques may sometimes be ineffective because of chamber dilation and valve tethering. We have been developing a sophisticated intelligent artificial papillary muscle (PM) by using an anisotropic shape memory alloy fiber for an alternative surgical reconstruction of the continuity of the mitral structural apparatus and the left ventricular myocardium. This study exhibited the mitral regurgitation with regard to the reduction in the PM tension quantitatively with an originally developed ventricular simulator using isolated goat hearts for the sophisticated artificial PM. Aortic and mitral valves with left ventricular free wall portions of isolated goat hearts (n=9) were secured on the elastic plastic membrane and statically pressurized, which led to valvular leaflet-papillary muscle positional change and central mitral regurgitation. PMs were connected to the load cell, and the relationship between the tension of regurgitation and PM tension were measured. Then we connected the left ventricular specimen model to our hydraulic ventricular simulator and achieved hemodynamic simulation with the controlled tension of PMs.

Treatment of Heart Failure With Associated Functional Mitral Regurgitation Using the ARTO System: Initial Results of the First-in-Human MAVERIC Trial (Mitral Valve Repair Clinical Trial).

PubMed

Rogers, Jason H; Thomas, Martyn; Morice, Marie-Claude; Narbute, Inga; Zabunova, Milana; Hovasse, Thomas; Poupineau, Mathieu; Rudzitis, Ainars; Kamzola, Ginta; Zvaigzne, Ligita; Greene, Samantha; Erglis, Andrejs

2015-07-01

MAVERIC (Mitral Valve Repair Clinical Trial) reports the safety and efficacy of the ARTO system in patients with symptomatic heart failure and functional mitral regurgitation (FMR). The ARTO system percutaneously modifies the mitral annulus to improve leaflet coaptation in FMR. The MAVERIC trial is a prospective, nonrandomized first-in-human study. Key inclusion criteria were systolic heart failure New York Heart Association functional classes II to IV, FMR grade ≥2+, left ventricular (LV) ejection fraction ≤40%, LV end-diastolic diameter >50 mm and ≤75 mm. Exclusion criteria were clinical variables that precluded feasibility of the ARTO procedure. Primary outcomes were safety (30-day major adverse events) and efficacy (MR reduction, LV volumes, and functional status). Eleven patients received the ARTO system, and there were no procedural adverse events. From baseline to 30 days, there were meaningful improvements. Effective regurgitant orifice area decreased from 30.3 ± 11.1 mm(2) to 13.5 ± 7.1 mm(2) and regurgitant volumes from 45.4 ± 15.0 ml to 19.5 ± 10.2 ml. LV end-systolic volume index improved from 77.5 ± 24.3 ml/m(2) to 68.5 ± 21.4 ml/m(2), and LV end-diastolic volume index 118.7 ± 28.6 ml/m(2) to 103.9 ± 21.2 ml/m(2). Mitral annular anteroposterior diameter decreased from 45.0 ± 3.3 mm to 38.7 ± 3.0 mm. Functional status was 81.8% New York Heart Association functional class III/IV improving to 54.6% functional class I/II. At 30 days, there were 2 adverse events: 1 pericardial effusion requiring surgical drainage; and 1 asymptomatic device dislodgement. The ARTO system is a novel transcatheter device that can be used safely with meaningful efficacy in the treatment of FMR. (Mitral Valve Repair Clinical Trial [MAVERIC]; NCT02302872). Copyright © 2015 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

An unusual presentation of ischaemic mitral regurgitation as P2 prolapse.

PubMed

Thompson, David S; Punjabi, Prakash P

2017-11-01

A 54-year-old gentleman presented with pulmonary oedema secondary to anterolateral papillary muscle (PPM) rupture and acute mitral regurgitation subsequent to myocardial ischaemia (MI). Angiography revealed complete occlusion of the first obtuse marginal (OM1) branch of the circumflex coronary artery and a 70% occlusion of the left anterior descending (LAD) coronary artery. Operatively, unusual anatomy was noted; an accessory head was attached superiorly to the anterior lateral PPM. This gave rise to chordae that were subsequently attached to the posterior second (P2) scallop. Additionally, the P2 scallop was deficient in chordae from the posteromedial PPM, thus, loss of this accessory head led to severe mitral regurgitation. We review the PPM anatomy and pathological context of PPM rupture and ischaemic mitral regurgitation.

Modulation of the tissue reninangiotensin-aldosterone system in dogs with chronic mild regurgitation through the mitral valve.

PubMed

Fujii, Yoko; Orito, Kensuke; Muto, Makoto; Wakao, Yoshito

2007-10-01

To investigate whether the tissue and plasma renin-angiotensin-aldosterone system (RAAS) is activated in dogs with mild regurgitation through the mitral valve and determine the contribution of chymase and angiotensin-converting enzyme (ACE) to the activation of the RAAS and potential production of angiotensin II during the chronic stage of mild mitral valve regurgitation. 5 Beagles with experimentally induced mild mitral valve regurgitation and 6 clinically normal (control) Beagles. Tissue ACE and chymase-like activities and plasma RAAS were measured and the RAAS evaluated approximately 1,000 days after experimental induction of mitral valve regurgitation in the 5 dogs. Dogs with experimentally induced mitral valve regurgitation did not have clinical signs of the condition, although echocardiography revealed substantial eccentric hyper- trophy. On the basis of these findings, dogs with mitral valve regurgitation were classified as International Small Animal Cardiac Health Council class Ib. Plasma activity of renin and plasma concentrations of angiotensin I, angiotensin II, and aldosterone were not significantly different between dogs with mitral valve regurgitation and clinically normal dogs. Tissue ACE activity was significantly increased and chymase-like activity significantly decreased in dogs with mitral valve regurgitation, compared with values in clinically normal dogs. The tissue RAAS was modulated without changes in the plasma RAAS in dogs with mild mitral valve regurgitation during the chronic stage of the condition. An ACE-dependent pathway may be a major route for production of angiotensin II during this stage of the condition.

Tricuspid regurgitation in mitral valve disease incidence, prognostic implications, mechanism, and management.

PubMed

Shiran, Avinoam; Sagie, Alex

2009-02-03

Tricuspid regurgitation (TR) in patients with mitral valve (MV) disease is associated with poor outcome and predicts poor survival, heart failure, and reduced functional capacity. It is common if left untreated after MV replacement mainly in rheumatic patients, but it is also common in patients with ischemic mitral regurgitation. It is less common, however, in those with degenerative mitral regurgitation. It might appear many years after surgery and might not resolve after correcting the MV lesion. Late TR might be caused by prosthetic valve dysfunction, left heart disease, right ventricular (RV) dysfunction and dilation, persistent pulmonary hypertension, chronic atrial fibrillation, or by organic (mainly rheumatic) tricuspid valve disease. Most commonly, late TR is functional and isolated, secondary to tricuspid annular dilation. Outcome of isolated tricuspid valve surgery is poor, because RV dysfunction has already occurred at that point in many patients. MV surgery or balloon valvotomy should be performed before RV dysfunction, severe TR, or advanced heart failure has occurred. Tricuspid annuloplasty with a ring should be performed at the initial MV surgery, and the tricuspid annulus diameter (>or=3.5 cm) is the best criterion for performing the annuloplasty. In this article we will review the current data available for understanding the prognostic implications, mechanism, and management of TR in patients with MV disease.

Mitral regurgitation after previous aortic valve surgery for bicuspid aortic valve insufficiency.

PubMed

Girdauskas, Evaldas; Disha, Kushtrim; Espinoza, Andres; Misfeld, Martin; Reichenspurner, Hermann; Borger, Michael A; Kuntze, Thomas

2017-06-01

Regurgitant bicuspid aortic valves (BAV) are reported to be associated with myxomatous degeneration of the anterior mitral leaflet. We examined the risk of late new-onset mitral regurgitation (MR) in patients who underwent aortic valve/aortic root surgery for BAV regurgitation and concomitant root dilatation. A total of 97 consecutive patients (47±11 years, 94% men) were identified from our institutional BAV database (N.=640) based on the following criteria: 1) BAV regurgitation; 2) aortic root diameter >40 mm; 3) no relevant mitral valve disease (i.e., MR<2+) and no simultaneous mitral intervention at the time of BAV surgery. All patients underwent isolated aortic valve replacement (AVR subgroup, N.=59) or aortic root replacement with a composite graft (i.e., for root aneurysm >50 mm) (ARR subgroup, N.=38) from 1995 through 2008. Echocardiographic follow-up (1009 patient-years) was obtained for all 96 (100%) hospital survivors. The primary endpoint was freedom from new-onset MR>2+ and redo mitral valve surgery. Nine patients (9.4%) showed new-onset MR>2+ after mean echocardiographic follow-up of 10.4±4.0 years postoperatively. Myxomatous degeneration and prolapse of the anterior mitral leaflet was found in all 9 patients, and the posterior leaflet was involved in 3 of them. Two patients (2%) in AVR subgroup underwent re-do mitral surgery. No MR>2+ occurred in ARR subgroup. Freedom from MR>2+ or mitral surgery at 15 years was significantly lower in AVR subgroup vs. ARR subgroup (i.e., 38% vs. 100%, P=0.01). The risk of new-onset MR is significantly increased in patients with BAV regurgitation and aortic root dilatation who undergo isolated AVR rather than root replacement. The mechanism by which aortic root replacement may prevent the occurrence of late MR in BAV root phenotype patients is to be determined.

Is mitral valve repair superior to replacement for chronic ischemic mitral regurgitation with left ventricular dysfunction?

PubMed Central

2010-01-01

Background This study was undertaken to compare mitral valve repair and replacement as treatments for ischemic mitral regurgitation (IMR) with left ventricular dysfunction (LVD). Specifically, we sought to determine whether the choice of mitral valve procedure affected survival, and discover which patients were predicted to benefit from mitral valve repair and which from replacement. Methods A total of 218 consecutive patients underwent either mitral valve repair (MVP, n = 112) or mitral valve replacement (MVR, n = 106). We retrospectively reviewed the clinical material, operation methods, echocardiography check during operation and follow-up. Patients details and follow-up outcomes were compared using multivariate and Kaplan-Meier analyses. Results No statistical difference was found between the two groups in term of intraoperative data. Early mortality was 3.2% (MVP 2.7% and MVR 3.8%). At discharge, Left ventricular end-systolic and end-diastolic diameter and left ventricular ejection fraction (LVEF) were improved more in the MVP group than MVR group (P < 0.05), however, in follow-up no statistically significant difference was observed between the MVR and MVP group (P > 0.05). Follow-up mitral regurgitation grade was significantly improved in the MVR group compared with the MVP group (P < 0.05). The Kaplan-Meier survival estimates at 1, 3, and 5 years were simlar between MVP and MVR group. Logistic regression revealed poor survival was associated with old age(#75), preoperative renal insufficiency and low left ventricular ejection fraction (< 30%). Conclusion Mitral valve repair is the procedure of choice in the majority of patients having surgery for severe ischemic mitral regurgitation with left ventricular dysfunction. Early results of MVP treatment seem to be satisfactory, but several lines of data indicate that mitral valve repair provided less long-term benefit than mitral valve replacement in the LVD patients. PMID:21059216

Pulmonary arterial pressure detects functional mitral stenosis after annuloplasty for primary mitral regurgitation: An exercise stress echocardiographic study.

PubMed

Samiei, Niloufar; Tajmirriahi, Marzieh; Rafati, Ali; Pasebani, Yeganeh; Rezaei, Yousef; Hosseini, Saeid

2018-02-01

The restrictive mitral valve annuloplasty (RMA) is the treatment of choice for degenerative mitral regurgitation (MR), but postoperative functional mitral stenosis remains a matter of debate. In this study, we sought to determine the impact of mitral stenosis on the functional capacity of patients. In a cross-sectional study, 32 patients with degenerative MR who underwent RMA using a complete ring were evaluated. All participants performed treadmill exercise test and underwent echocardiographic examinations before and after exercise. The patients' mean age was 50.1 ± 12.5 years. After a mean follow-up of 14.1 ± 5.9 months (6-32 months), the number of patients with a mitral valve peak gradient >7.5 mm Hg, a mitral valve mean gradient >3 mm Hg, and a pulmonary arterial pressure (PAP) ≥25 mm Hg at rest were 50%, 40.6%, and 62.5%, respectively. 13 patients (40.6%) had incomplete treadmill exercise test. All hemodynamic parameters were higher at peak exercise compared with at rest levels (all P < .05). The PAP at rest and at peak exercise as well as peak transmitral gradient at peak exercise were higher in patients with incomplete exercise compared with complete exercise test (all P < .05). The PAP at rest (a sensitivity and a specificity of 84.6% and 52.6%, respectively; area under the curve [AUC] = .755) and at peak exercise (a sensitivity and a specificity of 100% and 47.4%, respectively; AUC = .755) discriminated incomplete exercise test. The RMA for degenerative MR was associated with a functional stenosis and the PAP at rest and at peak exercise discriminated low exercise capacity. © 2017, Wiley Periodicals, Inc.

Treatment of functional mitral regurgitation by percutaneous annuloplasty: results of the TITAN Trial

PubMed Central

Siminiak, Tomasz; Wu, Justina C.; Haude, Michael; Hoppe, Uta C.; Sadowski, Jerzy; Lipiecki, Janusz; Fajadet, Jean; Shah, Amil M.; Feldman, Ted; Kaye, David M.; Goldberg, Steven L.; Levy, Wayne C.; Solomon, Scott D.; Reuter, David G.

2012-01-01

Aims Functional mitral regurgitation (FMR) contributes to morbidity and mortality in heart failure (HF) patients. The aim of this study was to determine whether percutaneous mitral annuloplasty could safely and effectively reduce FMR and yield durable long-term clinical benefit. Methods and results The impact of mitral annuloplasty (Carillon Mitral Contour System) was evaluated in HF patients with at least moderate FMR. Patients in whom the device was placed then acutely recaptured for clinical reasons served as a comparator group. Quantitative measures of FMR, left ventricular (LV) dimensions, New York Heart Association (NYHA) class, 6 min walk distance (6MWD), and quality of life were assessed in both groups up to 12 months. Safety and key functional data were assessed in the implanted cohort up to 24 months. Thirty-six patients received a permanent implant; 17 had the device recaptured. The 30-day major adverse event rate was 1.9%. In contrast to the comparison group, the implanted cohort demonstrated significant reductions in FMR as represented by regurgitant volume [baseline 34.5 ±11.5 mL to 17.4 ±12.4 mL at 12 months (P < 0.001)]. There was a corresponding reduction in LV diastolic volume [baseline 208.5 ±62.0 mL to 178.9 ±48.0 mL at 12 months (P =0.015)] and systolic volume [baseline 151.8 ±57.1 mL to 120.7 ±43.2 mL at 12 months (P =0.015)], compared with progressive LV dilation in the comparator. The 6MWD markedly improved for the implanted patients by 102.5 ±164 m at 12 months (P =0.014) and 131.9 ±80 m at 24 months (P < 0.001). Conclusion Percutaneous reduction of FMR using a coronary sinus approach is associated with reverse LV remodelling. Significant clinical improvements persisted up to 24 months. PMID:22613584

Mitral Valve Structure in Addition to Myocardial Viability Determines the Outcome of Functional Mitral Regurgitation After Coronary Artery Bypass Grafting.

PubMed

Yoshida, Shohei; Fukushima, Satsuki; Miyagawa, Shigeru; Nakamura, Teruya; Yoshikawa, Yasushi; Hata, Hiroki; Saito, Shunsuke; Yoshioka, Daisuke; Domae, Keitaro; Kashiyama, Noriyuki; Yamamoto, Kouji; Shintani, Ayumi; Nakatani, Satoshi; Toda, Koichi; Sawa, Yoshiki

2017-10-25

Coronary artery bypass grafting (CABG) reduces functional mitral regurgitation (MR) associated with ischemic heart disease, although the predictive factors or mechanisms of reversibility of functional MR after CABG are not fully understood.We investigated whether mitral valve structure is associated with the outcome of functional MR after CABG.Methods and Results:From a consecutive series of 98 patients with mild-moderate functional MR preoperatively who underwent isolated CABG, we enrolled 66 patients who were followed up for >1 year postoperatively using echocardiography. The degree of MR was reduced in 34 patients (52%) postoperatively, in association with a lower rate of in-hospital treatment for cardiac failure in the long term, compared with the 32 patients (48%) with residual MR postoperatively. The patients with reduced MR postoperatively had longer estimated coaptation length and more anteriorly or centrally directed MR jets than those without reduced MR. On statistical analysis, the addition of estimated coaptation length and jet direction to the reported predictors (ejection fraction, left ventricular end-diastolic dimension, and tenting height) more accurately predicted changes in post-CABG MR than the reported 3 factors alone. Residual MR was associated with the emergence of congestive heart failure in the long term after CABG. A specific mitral valve structure, such as large mitral leaflet size or predominant tethering of the posterior leaflet, was a predictive factor for the reversibility of post-CABG functional MR.

Dissociation of end systole from end ejection in patients with long-term mitral regurgitation.

PubMed

Brickner, M E; Starling, M R

1990-04-01

To determine whether left ventricular (LV) end systole and end ejection uncouple in patients with long-term mitral regurgitation, 59 patients (22 control patients with atypical chest pain, 21 patients with aortic regurgitation, and 16 patients with mitral regurgitation) were studied with micromanometer LV catheters and radionuclide angiograms. End systole was defined as the time of occurrence (Tmax) of the maximum time-varying elastance (Emax), and end ejection was defined as the time of occurrence of minimum ventricular volume (minV) and zero systolic flow as approximated by the aortic dicrotic notch (Aodi). The temporal relation between end systole and end ejection in the control patients was Tmax (331 +/- 42 [SD] msec), minV (336 +/- 36 msec), and then, zero systolic flow (355 +/- 23 msec). This temporal relation was maintained in the patients with aortic regurgitation. In contrast, in the patients with mitral regurgitation, the temporal relation was Tmax (266 +/- 49 msec), zero systolic flow (310 +/- 37 msec, p less than 0.01 vs. Tmax), and then, minV (355 +/- 37 msec, p less than 0.001 vs. Tmax and p less than 0.01 vs. Aodi). Additionally, the average Tmax occurred earlier in the patients with mitral regurgitation than in the control patients and patients with aortic regurgitation (p less than 0.01, for both), whereas the average time to minimum ventricular volume was similar in all three patient groups. Moreover, the average time to zero systolic flow also occurred earlier in the patients with mitral regurgitation than in the control patients (p less than 0.01) and patients with aortic regurgitation (p less than 0.05). Because of the dissociation of end systole from minimum ventricular volume in the patients with mitral regurgitation, the end-ejection pressure-volume relations calculated at minimum ventricular volume did not correlate (r = -0.09), whereas those calculated at zero systolic flow did correlate (r = 0.88) with the Emax slope values. We conclude

Two-Year Outcomes of Surgical Treatment of Moderate Ischemic Mitral Regurgitation.

PubMed

Michler, Robert E; Smith, Peter K; Parides, Michael K; Ailawadi, Gorav; Thourani, Vinod; Moskowitz, Alan J; Acker, Michael A; Hung, Judy W; Chang, Helena L; Perrault, Louis P; Gillinov, A Marc; Argenziano, Michael; Bagiella, Emilia; Overbey, Jessica R; Moquete, Ellen G; Gupta, Lopa N; Miller, Marissa A; Taddei-Peters, Wendy C; Jeffries, Neal; Weisel, Richard D; Rose, Eric A; Gammie, James S; DeRose, Joseph J; Puskas, John D; Dagenais, François; Burks, Sandra G; El-Hamamsy, Ismail; Milano, Carmelo A; Atluri, Pavan; Voisine, Pierre; O'Gara, Patrick T; Gelijns, Annetine C

2016-05-19

In a trial comparing coronary-artery bypass grafting (CABG) alone with CABG plus mitral-valve repair in patients with moderate ischemic mitral regurgitation, we found no significant difference in the left ventricular end-systolic volume index (LVESVI) or survival after 1 year. Concomitant mitral-valve repair was associated with a reduced prevalence of moderate or severe mitral regurgitation, but patients had more adverse events. We now report 2-year outcomes. We randomly assigned 301 patients to undergo either CABG alone or the combined procedure. Patients were followed for 2 years for clinical and echocardiographic outcomes. At 2 years, the mean (±SD) LVESVI was 41.2±20.0 ml per square meter of body-surface area in the CABG-alone group and 43.2±20.6 ml per square meter in the combined-procedure group (mean improvement over baseline, -14.1 ml per square meter and -14.6 ml per square meter, respectively). The rate of death was 10.6% in the CABG-alone group and 10.0% in the combined-procedure group (hazard ratio in the combined-procedure group, 0.90; 95% confidence interval, 0.45 to 1.83; P=0.78). There was no significant between-group difference in the rank-based assessment of the LVESVI (including death) at 2 years (z score, 0.38; P=0.71). The 2-year rate of moderate or severe residual mitral regurgitation was higher in the CABG-alone group than in the combined-procedure group (32.3% vs. 11.2%, P<0.001). Overall rates of hospital readmission and serious adverse events were similar in the two groups, but neurologic events and supraventricular arrhythmias remained more frequent in the combined-procedure group. In patients with moderate ischemic mitral regurgitation undergoing CABG, the addition of mitral-valve repair did not lead to significant differences in left ventricular reverse remodeling at 2 years. Mitral-valve repair provided a more durable correction of mitral regurgitation but did not significantly improve survival or reduce overall adverse events or

Management of mitral regurgitation in Marfan syndrome: Outcomes of valve repair versus replacement and comparison with myxomatous mitral valve disease.

PubMed

Helder, Meghana R K; Schaff, Hartzell V; Dearani, Joseph A; Li, Zhuo; Stulak, John M; Suri, Rakesh M; Connolly, Heidi M

2014-09-01

The study objective was to evaluate patients with Marfan syndrome and mitral valve regurgitation undergoing valve repair or replacement and to compare them with patients undergoing repair for myxomatous mitral valve disease. We reviewed the medical records of consecutive patients with Marfan syndrome treated surgically between March 17, 1960, and September 12, 2011, for mitral regurgitation and performed a subanalysis of those with repairs compared with case-matched patients with myxomatous mitral valve disease who had repairs (March 14, 1995, to July 5, 2013). Of 61 consecutive patients, 40 underwent mitral repair and 21 underwent mitral replacement (mean [standard deviation] age, 40 [18] vs 31 [19] years; P = .09). Concomitant aortic surgery was performed to a similar extent (repair, 45% [18/40] vs replacement, 43% [9/21]; P = .87). Ten-year survival was significantly better in patients with Marfan syndrome with mitral repair than in those with replacement (80% vs 41%; P = .01). Mitral reintervention did not differ between mitral repair and replacement (cumulative risk of reoperation, 27% vs 15%; P = .64). In the matched cohort, 10-year survival after repair was similar for patients with Marfan syndrome and myxomatous mitral disease (84% vs 78%; P = .63), as was cumulative risk of reoperation (17% vs 12%; P = .61). Patients with Marfan syndrome and mitral regurgitation have better survival with repair than with replacement. Survival and risk of reoperation for patients with Marfan syndrome were similar to those for patients with myxomatous mitral disease. These results support the use of mitral valve repair in patients with Marfan syndrome and moderate or more mitral regurgitation, including those having composite replacement of the aortic root. Copyright © 2014 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

Left ventricular remodelling in chronic primary mitral regurgitation: implications for medical therapy.

PubMed

McCutcheon, Keir; Manga, Pravin

Surgical repair or replacement of the mitral valve is currently the only recommended therapy for severe primary mitral regurgitation. The chronic elevation of wall stress caused by the resulting volume overload leads to structural remodelling of the muscular, vascular and extracellular matrix components of the myocardium. These changes are initially compensatory but in the long term have detrimental effects, which ultimately result in heart failure. Understanding the changes that occur in the myocardium due to volume overload at the molecular and cellular level may lead to medical interventions, which potentially could delay or prevent the adverse left ventricular remodelling associated with primary mitral regurgitation. The pathophysiological changes involved in left ventricular remodelling in response to chronic primary mitral regurgitation and the evidence for potential medical therapy, in particular beta-adrenergic blockers, are the focus of this review.

Influence of mitral valve repair versus replacement on the development of late functional tricuspid regurgitation.

PubMed

Rajbanshi, Bijoy G; Suri, Rakesh M; Nkomo, Vuyisile T; Dearani, Joseph A; Daly, Richard C; Burkhart, Harold M; Stulak, John M; Joyce, Lyle D; Li, Zhuo; Schaff, Hartzell V

2014-11-01

To study the determinants of functional tricuspid regurgitation (TR) progression after surgical correction of mitral regurgitation, including the influence of mitral valve (MV) repair (MVr) versus replacement (MVR) for degenerative mitral regurgitation. From January 1995 to January 2006, 747 adults with MV prolapse underwent isolated MVr (n=683) or MVR (n=64; mechanical in 32). The mean age was 60.8 years, and 491 were men (66.0%). Moderate preoperative functional TR was present in 115 (15.4%). The MVR group had a greater likelihood of New York Heart Association class III or IV (75.0% vs 34.4%, P<.001), atrial fibrillation (20.3% vs 8.3%, P=.002), a lower left ventricular ejection fraction (61.0% vs 65.2%, P<.003), and a higher pulmonary artery pressure (50.1 vs 41.2 mm Hg, P=.001). The patients were monitored for a mean of 6.9 years (MVr) or 7.7 years (MVR; P=.075). During late follow-up, no difference was found between the groups in the development of moderately severe or severe TR: 1 to 5 years (3.0% vs 3.3%, P=.91) and >5 years (6.1% vs 6.5%; P=.93). The univariate predictors of severe TR after 5 years were older age (hazard ratio [HR], 1.1; P=.011), female gender (HR, 6.86; P=.005), higher pulmonary artery pressure (HR, 1.05; P=.022), and larger left atrial size (HR, 2.11; P=.035). Two patients (0.26%) who had undergone initial MVr required reoperation for late functional TR. Another 2 patients had had the tricuspid valve addressed concurrent with reoperation for MVr failure. No tricuspid reoperations were required in the MVR group. The risk of TR progression was low after MVr or MVR for MV prolapse. Timely MV surgery before the development of left atrial dilatation or pulmonary hypertension could further decrease the risk of TR progression during follow-up. Copyright © 2014 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.

Cost-utility analysis of percutaneous mitral valve repair in inoperable patients with functional mitral regurgitation in German settings.

PubMed

Borisenko, Oleg; Haude, Michael; Hoppe, Uta C; Siminiak, Tomasz; Lipiecki, Janusz; Goldberg, Steve L; Mehta, Nawzer; Bouknight, Omari V; Bjessmo, Staffan; Reuter, David G

2015-05-14

To determine the cost-effectiveness of the percutaneous mitral valve repair (PMVR) using Carillon® Mitral Contour System® (Cardiac Dimensions Inc., Kirkland, WA, USA) in patients with congestive heart failure accompanied by moderate to severe functional mitral regurgitation (FMR) compared to the prolongation of optimal medical treatment (OMT). Cost-utility analysis using a combination of a decision tree and Markov process was performed. The clinical effectiveness was determined based on the results of the Transcatheter Implantation of Carillon Mitral Annuloplasty Device (TITAN) trial. The mean age of the target population was 62 years, 77% of the patients were males, 64% of the patients had severe FMR and all patients had New York Heart Association functional class III. The epidemiological, cost and utility data were derived from the literature. The analysis was performed from the German statutory health insurance perspective over 10-year time horizon. Over 10 years, the total cost was €36,785 in the PMVR arm and €18,944 in the OMT arm. However, PMVR provided additional benefits to patients with an 1.15 incremental quality-adjusted life years (QALY) and an 1.41 incremental life years. The percutaneous procedure was cost-effective in comparison to OMT with an incremental cost-effectiveness ratio of €15,533/QALY. Results were robust in the deterministic sensitivity analysis. In the probabilistic sensitivity analysis with a willingness-to-pay threshold of €35,000/QALY, PMVR had a 84 % probability of being cost-effective. Percutaneous mitral valve repair may be cost-effective in inoperable patients with FMR due to heart failure.

Increased pulmonary transit times in asymptomatic dogs with mitral regurgitation.

PubMed

Lord, Peter; Eriksson, Anders; Häggström, Jens; Järvinen, Anna-Kaisa; Kvart, Clarence; Hansson, Kerstin; Maripuu, Enn; Mäkelä, Olli

2003-01-01

Pulmonary transit time (PTT) normalized to heart rate (nPTT) is a measure of the pulmonary blood volume (PBV) to stroke volume ratio (PBV/SV). It is an index of cardiac performance. To determine the effect of compensated mitral regurgitation (CMR) and decompensated mitral regurgitation (DMR) caused by valvular endocardiosis on the index nPTT, we measured nPTT by first-pass radionuclide angiocardiography and ECG in 13 normal dogs, 18 dogs with CMR, and 13 dogs with DMR. PTT was measured as time between onset of appearance of activity at the pulmonary trunk and the left atrium. In the normal dogs, the relationship between PTT and mean R-R interval (mRR) was PTT = 4.08 x mRR + 0.15 (R2 = 0.71). Normal nPTT was 4.4 +/- 0.6 (SD) (range. 3.6-5.3). in CMR, 6.3 +/- 1.6 (SD) (range, 4.0-9.7). and in DMR, 11.9 +/- 3.4 (SD) (range, 8.0-18.8). The differences among all groups were significant. Heart rates were 110 +/- 22 bpm in normal dogs, 111 +/- 20 in dogs with CMR, and 144 +/- 18 in dogs with DMR (P < .001 for difference between DMR group and normal and CMR groups). Increased nPTT in CMR indicates preclinical heart pump dysfunction. Heart rate-normalized pulmonary transit times may be a useful index of heart function in mitral regurgitation.

Development of mitral stenosis after single MitraClip insertion for severe mitral regurgitation.

PubMed

Cockburn, James; Fragkou, Paraskevi; Hildick-Smith, David

2014-02-01

We report the first case of mitral stenosis following Mitra-Clip insertion in a patient with symptomatic NYHA IV heart failure, secondary to severe mitral regurgitation (MR). A 79-year-old female with a history of prior aortic valve replacement underwent percutaneous mitral valve (MV) repair. A single clip was advanced coaxially down onto the MV under TOE guidance, with the anterior and posterior leaflets clipped together between A2 and P2. TOE confirmed a significant reduction in MR (grade 4 to grade 1). Despite initial symptomatic relief, she represented 3 months later with similar symptoms. Repeat TOE confirmed a well positioned Mitra-Clip with mild residual MR. However, the possibility of significant mitral stenosis was raised due to the presence of significant turbulence through the bi-orifice valve, with a peak gradient of 25 mm Hg. In addition there was evidence of severe functional tricuspid valve (TV) regurgitation with elevated pulmonary artery pressures (PAP 90 mm Hg), confirmed on subsequent right heart catheterization. After repeated heart team discussions and a failure of optimal medical therapy, and despite a logistic EuroScore of 35.5, minimally invasive surgical replacement of the MV and simultaneous TV repair was undertaken via a right thoracotomy. Despite procedural success and initial good postoperative response, the patient died subsequently from a combination of hospital-acquired pneumonia and significant gastrointestinal bleeding (post operative day 35). Mitra-Clip is a promising novel approach to MV repair. The establishment of further clinical and echocardiographic based selection criteria will help identify the correct patients for this treatment. Copyright © 2013 Wiley Periodicals, Inc.

Current surgical management of mitral regurgitation.

PubMed

Calvinho, Paulo; Antunes, Manuel

2008-04-01

From Walton Lillehei, who performed the first successful open mitral valve surgery in 1956, until the advent of robotic surgery in the 21st Century, only 50 years have passed. The introduction of the first heart valve prosthesis, in 1960, was the next major step forward. However, correction of mitral disease by valvuloplasty results in better survival and ventricular performance than mitral valve replacement. However, the European Heart Survey demonstrated that only 40% of the valves are repaired. The standard procedures (Carpentier's techniques and Alfieri's edge-to-edge suture) are the surgical basis for the new technical approaches. Minimally invasive surgery led to the development of video-assisted and robotic surgery and interventional cardiology is already making the first steps on endovascular procedures, using the classical concepts in highly differentiated approaches. Correction of mitral regurgitation is a complex field that is still growing, whereas classic surgery is still under debate as the new era arises.

Mitral regurgitation: anatomy is destiny.

PubMed

Athanasuleas, Constantine L; Stanley, Alfred W H; Buckberg, Gerald D

2018-04-26

Mitral regurgitation (MR) occurs when any of the valve and ventricular mitral apparatus components are disturbed. As MR progresses, left ventricular remodelling occurs, ultimately causing heart failure when the enlarging left ventricle (LV) loses its conical shape and becomes globular. Heart failure and lethal ventricular arrhythmias may develop if the left ventricular end-systolic volume index exceeds 55 ml/m2. These adverse changes persist despite satisfactory correction of the annular component of MR. Our goal was to describe this process and summarize evolving interventions that reduce the volume of the left ventricle and rebuild its elliptical shape. This 'valve/ventricle' approach addresses the spherical ventricular culprit and offsets the limits of treating MR by correcting only its annular component.

Prevalence of mitral valve regurgitation in 79 asymptomatic Norfolk terriers.

PubMed

Bodegård-Westling, A; Tidholm, A; Häggström, J

2017-04-01

To determine the prevalence of mitral valve regurgitation (MR) in asymptomatic Swedish Norfolk terriers. Seventy-nine privately owned Norfolk terriers. A prospective observational study was conducted where dogs were recruited via the Swedish Norfolk terrier club. All dogs were examined using the same protocol including physical examination and Doppler echocardiography. Fifteen dogs (19%) had a murmur at the time of the examination. A total of 35 dogs (44%) had MR, including 23 dogs (29%) with both MR and tricuspid valve regurgitation and 12 dogs (15%) with MR only, identified on Doppler echocardiography. In addition, 7 dogs (9%) had tricuspid valve regurgitation only. The prevalence of MR increased with increasing age (p < 0.0001). Mitral valve regurgitation is common in asymptomatic Norfolk terriers with and without murmurs and the prevalence increases with age. The impact of MR in this breed on survival remains to be elucidated by a longitudinal study. Copyright © 2017 Elsevier B.V. All rights reserved.

Mild-to-moderate functional tricuspid regurgitation in patients undergoing mitral valve surgery.

PubMed

Ro, Sun Kyun; Kim, Joon Bum; Jung, Sung Ho; Choo, Suk Jung; Chung, Cheol Hyun; Lee, Jae Won

2013-11-01

The decision to repair mild-to-moderate functional tricuspid regurgitation (TR) during mitral valve surgery remains controversial. We evaluated the effects of tricuspid valve (TV) repair for functional mild-to-moderate TR during mitral valve surgery. We enrolled 959 patients with mild-to-moderate functional TR who underwent mitral valve surgery with (repair group n = 431) or without (control group n = 528) concomitant TV repair from January 1994 to September 2010. There were no significant differences in early mortality or major morbidity rates. Median follow-up was 64.8 months (range, 0.03-203.6 months). After adjustment for baseline characteristics using a propensity score adjustment model, the repair group had similar risks for TV reoperation (hazard ratio [HR], 0.46; 95% confidence interval [CI], 0.10-2.07; P = .31); congestive heart failure (HR, 1.12; 95% CI, 0.37-3.36; P = .84); death (HR, 1.41; 95% CI, 0.82-2.42; P = .22); and the composite of death, TV reoperation, and congestive heart failure (HR, 1.24; 95% CI, 0.76-2.03; P = .39) compared with the control group. On multivariate Cox-regression analysis, old age, atrial fibrillation without a Maze procedure, diabetes mellitus, chronic renal failure, poor left ventricular ejection fraction, and redo surgery emerged as significant independent risk factors for the composite outcome of death, TV reoperation, and congestive heart failure. Early or late clinical benefits of concomitant TV repair for mild-to-moderate TR during mitral valve surgery were uncertain through a long-term follow-up of 959 patients. Several preoperative factors and the performance of Maze procedure for AF seem to be more important than TV repair in overall clinical outcomes. Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

Transcatheter aortic valve replacement in patients with severe mitral or tricuspid regurgitation at extreme risk for surgery.

PubMed

Little, Stephen H; Popma, Jeffrey J; Kleiman, Neal S; Deeb, G Michael; Gleason, Thomas G; Yakubov, Steven J; Checuti, Stan; O'Hair, Daniel; Bajwa, Tanvir; Mumtaz, Mubashir; Maini, Brijeshwar; Hartman, Alan; Katz, Stanley; Robinson, Newell; Petrossian, George; Heiser, John; Merhi, William; Moore, B Jane; Li, Shuzhen; Adams, David H; Reardon, Michael J

2018-05-01

Patients with symptomatic severe aortic stenosis and severe mitral regurgitation or severe tricuspid regurgitation were excluded from the major transcatheter aortic valve replacement trials. We studied these 2 subgroups in patients at extreme risk for surgery in the prospective, nonrandomized, single-arm CoreValve US Expanded Use Study. The primary end point was all-cause mortality or major stroke at 1 year. A favorable medical benefit was defined as a Kansas City Cardiomyopathy Questionnaire overall summary score greater than 45 at 6 months and greater than 60 at 1 year and with a less than 10-point decrease from baseline. There were 53 patients in each group. Baseline characteristics for the severe mitral regurgitation and severe tricuspid regurgitation cohorts were age 84.2 ± 6.4 years and 84.9 ± 6.5 years; male, 29 (54.7%) and 22 (41.5%), and mean Society of Thoracic Surgeons score 9.9% ± 5.0% and 9.2% ± 4.0%, respectively. Improvement in valve regurgitation from baseline to 1 year occurred in 72.7% of the patients with severe mitral regurgitation and in 61.8% of patients with severe tricuspid regurgitation. A favorable medical benefit occurred in 31 of 47 patients (66.0%) with severe mitral regurgitation and 33 of 47 patients (70.2%) with severe tricuspid regurgitation at 6 months, and in 25 of 44 patients (56.8%) with severe mitral regurgitation and 24 of 45 patients (53.3%) with severe tricuspid regurgitation at 1 year. All-cause mortality or major stroke for the severe mitral regurgitation and severe tricuspid regurgitation cohorts were 11.3% and 3.8% at 30 days and 21.0% and 19.2% at 1 year, respectively. There were no major strokes in either group at 1 year. Transcatheter aortic valve replacement in patients with severe mitral regurgitation or severe tricuspid regurgitation is reasonable and safe and leads to improvement in atrioventricular valve regurgitation. Copyright © 2018 The American Association for Thoracic Surgery

Percutaneous Repair of Postoperative Mitral Regurgitation After Left Ventricular Assist Device Implant.

PubMed

Cork, David P; Adamson, Robert; Gollapudi, Raghava; Dembitsky, Walter; Jaski, Brian

2018-02-01

Mitral regurgitation commonly improves after implantation of a left ventricular assist device without concomitant valvular repair owing to the mechanical unloading of the left ventricle. However, the development (or persistence) of significant mitral regurgitation after implantation of a left ventricular assist device is associated with adverse clinical events. We present a case of a left ventricular assist device patient who successfully underwent a percutaneous MitraClip procedure for repair of persistent late postoperative mitral insufficiency with demonstrable clinical and hemodynamic improvement. Copyright © 2018 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

[Backward flow signal in the left atrium studied by Doppler echocardiography. Differentiation from mitral regurgitation].

PubMed

Nagoshi, H; Miyairi, M; Asato, T; Naito, M; Honda, M

1983-03-01

A backward flow signal in the left atrium masquerading as mitral regurgitation was studied by a pulsed Doppler method. The subjects consisted of 20 normal volunteers, 12 cases with mitral valve prolapse syndrome, five cases with rheumatic mitral regurgitation, five cases with lone atrial fibrillation, four cases with asymmetric septal hypertrophy and three cases with the Björk-Shiley tilting disc valve in the mitral position. In two-dimensional echocardiography combined with pulsed Doppler method, a Doppler signal was recorded by locating a sample volume in the left atrium. In all of the cases with mitral valve prolapse syndrome and the cases with the prosthetic valve as well as in all of the normal subjects, the backward flow signal was observed in the left atrium. In three cases with mitral valve prolapse syndrome, it was differentiated from a transvalvular regurgitant flow signal. In all cases with rheumatic mitral regurgitation, the backward flow signal was masked by a turbulent flow signal representing regurgitation. In cases with mitral stenosis, the backward flow signal was scarcely recognized. The duration of the backward flow signal had no relationship with heart rate. The histogram of incidence on the scale of R-R interval revealed normal distribution with a mean value of 0.24 sec (+/- 0.09 sec). Therefore, in cases with tachycardia, the backward flow signal was seen throughout systole. The peak backward flow velocity of Doppler signals was correlated (r = 0.71, p less than 0.01) with the peak forward flow velocity in diastole. The faint backward flow signal seen in cases with mitral stenosis and post-extrasystolic potentiation of the backward flow signal were suggestive of the foregoing relationship. The mechanism producing the backward flow was postulated as a water hammer phenomenon caused by closure of the mitral valve.

Anatomical considerations of percutaneous transvenous mitral annuloplasty: a novel procedure for treatment of functional mitral regurgitation.

PubMed

Mehra, Lalit; Raheja, Shashi; Agarwal, Sneh; Rani, Yashoda; Kaur, Kulwinder; Tuli, Anita

2016-03-01

Percutaneous transvenous mitral annuloplasty (PTMA) has evolved as a latest procedure for the treatment of functional mitral regurgitation. It reduces mitral valve annulus (MVA) size and increases valve leaflet coaptation via compression of coronary sinus (CS). Anatomical considerations for this procedure were elucidated in the present study. In 40 formalin fixed adult cadaveric human hearts, relation of the venous channel formed by CS and great cardiac vein (GCV) to MVA and the adjacent arteries was described, at 6 points by making longitudinal sections perpendicular to the plane of MVA, numbered 1-6 starting from CS ostium. CS/GCV formed a semicircular venous channel on the atrial side of MVA. Based on the distance of CS/GCV from MVA, two patterns were identified. In 37 hearts, the venous channel at point 2 was widely separated from the MVA compared to the two ends and in three hearts a nonconsistent pattern was observed. GCV crossed circumflex artery superficially. GCV or CS crossed the left marginal artery and ventricular branches of circumflex artery superficially in 17 and 23 hearts, respectively. As the venous channel was related more to the left atrial wall, PTMA devices probably exert an indirect traction on MVA. The arteries crossing deep to the venous channel may be compressed by PTMA device leading to myocardial ischemia. Knowledge of the spatial relations of MVA and a preoperative and postoperative angiogram may help to reduce such complications during PTMA.

Effects of pimobendan for mitral valve regurgitation in dogs.

PubMed

Kanno, Nobuyuki; Kuse, Hiroshi; Kawasaki, Masaya; Hara, Akashi; Kano, Rui; Sasaki, Yoshihide

2007-04-01

Pimobendan has a dual mechanism of action: it increases myocardial contractility by increasing calcium sensitization to troponin C and it promotes vasodilation by inhibiting PDEIII. This study examined the effects of pimobendan on cardiac function, hemodynamics, and neurohormonal factors in dogs with mild mitral regurgitation (MR). The dogs were given 0.25 mg/kg of pimobendan orally every 12 hr for 4 weeks. With pimobendan, the heart rate and stroke volume did not change, but the systolic blood pressure gradually decreased and the degree of mitral valve regurgitation tended to decrease. Renal blood flow was significantly increased and the glomerular filtration rate was slightly increased at 2 and 4 weeks. Furthermore, over the 4-week period, the plasma norepinephrine concentration decreased significantly, the systolic index increased slightly, the left atrial diameter and the left ventricular diameters decreased significantly, and the heart size improved. Given these results, pimobendan appears to be useful for treating MR in dogs. However, further long-term studies of pimobendan involving a larger number of dogs with mild and moderate MR are needed to establish the safety of pimobendan and document improvements in quality of life.

Tricuspid and Mitral Valve Regurgitation with Bi-fascicular Block Following a Horse Kick.

PubMed

Kokubun, Tomoki; Oikawa, Masayoshi; Ichijo, Yasuhiro; Matsumoto, Yoshiyuki; Yokokawa, Tetsuro; Nakazato, Kazuhiko; Sato, Yoshiyuki; Takase, Shinya; Shinjo, Hiroharu; Yokoyama, Hitoshi; Suzuki, Hitoshi; Saitoh, Shu-Ichi; Takeishi, Yasuchika

2018-06-01

A 40-year-old man was transferred to our hospital following an isolated horse kick injury to the anterior chest wall. The case showed bi-fascicular block, severe tricuspid valve regurgitation due to ruptured chordae tendineae of the anterior leaflet, moderate mitral valve regurgitation due to prolapse of mitral anterior leaflet, and hypokinetic motion of the inferior septal wall. Both tricuspid and mitral insufficiency were completely repaired by a surgical operation. Fortunately, these injuries were not fatal in this case, but the comprehensive assessment of cardiac damage and careful observation are important for managing patients with cardiac injury.

Tricuspid but not Mitral Regurgitation Determines Mortality After TAVI in Patients With Nonsevere Mitral Regurgitation.

PubMed

Amat-Santos, Ignacio J; Castrodeza, Javier; Nombela-Franco, Luis; Muñoz-García, Antonio J; Gutiérrez-Ibanes, Enrique; de la Torre Hernández, José M; Córdoba-Soriano, Juan G; Jiménez-Quevedo, Pilar; Hernández-García, José M; González-Mansilla, Ana; Ruano, Javier; Tobar, Javier; Del Trigo, María; Vera, Silvio; Puri, Rishi; Hernández-Luis, Carolina; Carrasco-Moraleja, Manuel; Gómez, Itziar; Rodés-Cabau, Josep; San Román, José A

2018-05-01

Many patients undergoing transcatheter aortic valve implantation (TAVI) have concomitant mitral regurgitation (MR) of moderate grade or less. The impact of coexistent tricuspid regurgitation (TR) remains to be determined. We sought to analyze the impact of moderate vs none-to-mild MR and its trend after TAVI, as well as the impact of concomitant TR and its interaction with MR. Multicenter retrospective study of 813 TAVI patients treated through the transfemoral approach with MR ≤ 2 between 2007 and 2015. The mean age was 81 ± 7 years and the mean Society of Thoracic Surgeons score was 6.9% ± 5.1%. Moderate MR was present in 37.3% of the patients, with similar in-hospital outcomes and 6-month follow-up mortality to those with MR < 2 (11.9% vs 9.4%; P = .257). However, they experienced more rehospitalizations and worse New York Heart Association class (P = .008 and .001, respectively). Few patients (3.8%) showed an increase in the MR grade to > 2 post-TAVI. The presence of concomitant moderate/severe TR was associated with in-hospital and follow-up mortality rates of 13% and 34.1%, respectively, regardless of MR grade. Moderate-severe TR was independently associated with mortality (HR, 18.4; 95%CI, 10.2-33.3; P < .001). The presence of moderate MR seemed not to impact short- and mid-term mortality post-TAVI, but was associated with more rehospitalizations. The presence of moderate or severe TR was associated with higher mortality. This suggests that a thorough evaluation of the mechanisms underlying concomitant mitral and tricuspid valve regurgitation should be performed to determine the best strategy for avoiding TAVI-related futility. Copyright © 2018 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.

Reversal of severe mitral regurgitation by device closure of a large patent ductus arteriosus in a premature infant.

PubMed

Kheiwa, Ahmed; Ross, Robert D; Kobayashi, Daisuke

2017-01-01

We report a critically ill premature infant with severe mitral valve regurgitation associated with pulmonary hypertension and a severely dilated left atrium from a large patent ductus arteriosus. The mitral valve regurgitation improved significantly with normalisation of left atrial size 4 weeks after percutaneous closure of the patent ductus arteriosus. This case highlights the potential reversibility of severe mitral valve regurgitation with treatment of an underlying cardiac shunt.

Effects of the Mueller maneuver on functional mitral regurgitation and implications for obstructive sleep apnea.

PubMed

Pressman, Gregg S; Orban, Marek; Leinveber, Pavel; Parekh, Kunal; Singh, Manmeet; Kara, Tomas; Somers, Virend K

2015-06-01

Obstructive sleep apnea is prevalent and adversely affects cardiovascular health. However, little is known of the acute effects of an obstructive apnea on cardiovascular physiology. We hypothesized that pre-existing functional mitral regurgitation (MR) would worsen during performance of a Mueller maneuver (MM) used to simulate an obstructive apnea; 15 subjects with an ejection fraction ≤35% and pre-existing functional MR were studied with Doppler echocardiography. The radius of the proximal flow convergence was used as a measure of mitral regurgitant flow. Measurements were made at baseline, during the MM, and post-MM. Areas of all 4 chambers were also measured at these time points, both in systole and diastole. Mean flow convergence radius for the group decreased significantly during the transition from the late-MM to post-MM (0.65 → 0.57 mm, p = 0.001), implying increased MR during the MM. In addition, in 3 subjects, duration of MR increased during the MM. Right atrial (RA) areas, both systolic and diastolic, increased during the maneuver, whereas RA fractional area change decreased, indicating reduced RA emptying. Left ventricular emptying decreased early in the maneuver, probably because of the increased afterload burden, and then recovered. In conclusion, high negative intrathoracic pressure produces changes that, repeated hundreds of times per night in patients with obstructive sleep apnea, have the potential to worsen heart failure and predispose affected subjects to atrial fibrillation. Copyright © 2015 Elsevier Inc. All rights reserved.

Effects of the Mueller Maneuver on Functional Mitral Regurgitation and Implications for Obstructive Sleep Apnea

PubMed Central

Pressman, Gregg S.; Orban, Marek; Leinveber, Pavel; Parekh, Kunal; Singh, Manmeet; Kara, Tomas; Somers, Virend K.

2016-01-01

Obstructive sleep apnea (OSA) is prevalent and adversely impacts cardiovascular health. However, little is known of the acute effects of an obstructive apnea on cardiovascular physiology. We hypothesized that pre-existing functional mitral regurgitation (MR) would worsen during performance of a Mueller maneuver (MM) used to simulate an obstructive apnea. 15 subjects with an ejection fraction ≤35% and pre-existing functional MR were studied with Doppler echocardiography. The radius of the proximal flow convergence was used as a measure of mitral regurgitant flow. Measurements were made at baseline, during the MM, and post-MM. Areas of all 4 chambers were also measured at these time points, both in systole and diastole. Mean flow convergence radius for the group decreased significantly during the transition from the late-MM to post-MM (0.65 mm → 0.57 mm, p = 0.001), implying increased MR during the MM. In addition, in 3 subjects duration of MR increased during the MM. Right atrial (RA) areas, both systolic and diastolic, increased during the maneuver while RA fractional area change decreased, indicating reduced RA emptying. Left ventricular (LV) emptying decreased early in the maneuver, probably due to the increased afterload burden, and then recovered. In conclusion, high negative intrathoracic pressure produces changes which, repeated hundreds of times per night in OSA patients, have the potential to worsen heart failure and predispose affected individuals to atrial fibrillation. PMID:25846766

Impact of bileaflet mitral valve prolapse on quantification of mitral regurgitation with cardiac magnetic resonance: a single-center study.

PubMed

Vincenti, Gabriella; Masci, Pier Giorgio; Rutz, Tobias; De Blois, Jonathan; Prša, Milan; Jeanrenaud, Xavier; Schwitter, Juerg; Monney, Pierre

2017-07-27

To quantify mitral regurgitation (MR) with CMR, the regurgitant volume can be calculated as the difference between the left ventricular (LV) stroke volume (SV) measured with the Simpson's method and the reference SV, i.e. the right ventricular SV (RVSV) in patients without tricuspid regurgitation. However, for patients with prominent mitral valve prolapse (MVP), the Simpson's method may underestimate the LV end-systolic volume (LVESV) as it only considers the volume located between the apex and the mitral annulus, and neglects the ventricular volume that is displaced into the left atrium but contained within the prolapsed mitral leaflets at end systole. This may lead to an underestimation of LVESV, and resulting an over-estimation of LVSV, and an over-estimation of mitral regurgitation. The aim of the present study was to assess the impact of prominent MVP on MR quantification by CMR. In patients with MVP (and no more than trace tricuspid regurgitation) MR was quantified by calculating the regurgitant volume as the difference between LVSV and RVSV. LVSV uncorr was calculated conventionally as LV end-diastolic (LVEDV) minus LVESV. A corrected LVESV corr was calculated as the LVESV plus the prolapsed volume, i.e. the volume between the mitral annulus and the prolapsing mitral leaflets. The 2 methods were compared with respect to the MR grading. MR grades were defined as absent or trace, mild (5-29% regurgitant fraction (RF)), moderate (30-49% RF), or severe (≥50% RF). In 35 patients (44.0 ± 23.0y, 14 males, 20 patients with MR) the prolapsed volume was 16.5 ± 8.7 ml. The 2 methods were concordant in only 12 (34%) patients, as the uncorrected method indicated a 1-grade higher MR severity in 23 (66%) patients. For the uncorrected/corrected method, the distribution of the MR grades as absent-trace (0 vs 11, respectively), mild (20 vs 18, respectively), moderate (11 vs 5, respectively), and severe (4 vs 1, respectively) was significantly different (p�

Synergistic Utility of Brain Natriuretic Peptide and Left Ventricular Global Longitudinal Strain in Asymptomatic Patients With Significant Primary Mitral Regurgitation and Preserved Systolic Function Undergoing Mitral Valve Surgery.

PubMed

Alashi, Alaa; Mentias, Amgad; Patel, Krishna; Gillinov, A Marc; Sabik, Joseph F; Popović, Zoran B; Mihaljevic, Tomislav; Suri, Rakesh M; Rodriguez, L Leonardo; Svensson, Lars G; Griffin, Brian P; Desai, Milind Y

2016-07-01

In asymptomatic patients with ≥3+ mitral regurgitation and preserved left ventricular (LV) ejection fraction who underwent mitral valve surgery, we sought to discover whether baseline LV global longitudinal strain (LV-GLS) and brain natriuretic peptide provided incremental prognostic utility. Four hundred and forty-eight asymptomatic patients (61±12 years and 69% men) with ≥3+ primary mitral regurgitation and preserved left ventricular ejection fraction, who underwent mitral valve surgery (92% repair) at our center between 2005 and 2008, were studied. Baseline clinical and echocardiographic data (including LV-GLS using Velocity Vector Imaging, Siemens, PA) were recorded. The Society of Thoracic Surgeons score was calculated. The primary outcome was death. Mean Society of Thoracic Surgeons score, left ventricular ejection fraction, mitral effective regurgitant orifice, indexed LV end-diastolic volume, and right ventricular systolic pressure were 4±1%, 62±3%, 0.55±0.2 cm(2), 58±13 cc/m(2), and 37±15 mm Hg, respectively. Forty-five percent of patients had flail. Median log-transformed BNP and LV-GLS were 4.04 (absolute brain natriuretic peptide: 60 pg/dL) and -20.7%. At 7.7±2 years, death occurred in 41 patients (9%; 0% at 30 days). On Cox analysis, a higher Society of Thoracic Surgeons score (hazard ratio 1.55), higher baseline right ventricular systolic pressure (hazard ratio 1.11), more abnormal LV-GLS (hazard ratio 1.17), and higher median log-transformed BNP (hazard ratio 2.26) were associated with worse longer-term survival (all P<0.01). Addition of LV-GLS and median log-transformed BNP to a clinical model (Society of Thoracic Surgeons score and baseline right ventricular systolic pressure) provided incremental prognostic utility (χ(2) for longer-term mortality increased from 31-47 to 61; P<0.001). In asymptomatic patients with significant primary mitral regurgitation and preserved left ventricular ejection fraction who underwent mitral valve

Novel pathogenetic mechanisms and structural adaptations in ischemic mitral regurgitation.

PubMed

Silbiger, Jeffrey J

2013-10-01

Ischemic mitral regurgitation (MR) is a common complication of myocardial infarction thought to result from leaflet tethering caused by displacement of the papillary muscles that occurs as the left ventricle remodels. The author explores the possibility that left atrial remodeling may also play a role in the pathogenesis of ischemic MR, through a novel mechanism: atriogenic leaflet tethering. When ischemic MR is hemodynamically significant, the left ventricle compensates by dilating to preserve forward output using the Starling mechanism. Left ventricular dilatation, however, worsens MR by increasing the mitral valve regurgitant orifice, leading to a vicious cycle in which MR begets more MR. The author proposes that several structural adaptations play a role in reducing ischemic MR. In contrast to the compensatory effects of left ventricular enlargement, these may reduce, rather than increase, its severity. The suggested adaptations involve the mitral valve leaflets, the papillary muscles, the mitral annulus, and the left ventricular false tendons. This review describes the potential role each may play in reducing ischemic MR. Therapies that exploit these adaptations are also discussed. Copyright © 2013 American Society of Echocardiography. Published by Mosby, Inc. All rights reserved.

Do we have to operate on moderate functional mitral regurgitation during aortic valve replacement for aortic stenosis?

PubMed

Kowalówka, Adam R; Onyszczuk, Magdalena; Wańha, Wojciech; Deja, Marek A

2016-11-01

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was 'Do we have to operate on moderate functional mitral regurgitation (FMR) during aortic valve replacement (AVR) for aortic stenosis (AS)?' Altogether 325 papers were found using the reported search, of which 9 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The current evidence obtained from these papers revealed that the significant predictors of improvement outcome include lower preoperative mitral regurgitation and lower preoperative left ventricle fractional area change. We also know that persistent atrial fibrillation, enlarged left atrium, increased indexed left ventricular mass, pulmonary hypertension and preoperative peak aortic valve gradient <60 mmHg are predictors of deterioration. Generally, we observed a trend towards improvement or non-progression of FMR following AVR for AS. In the six papers that suggest conservative treatment of FMR, the degree of mitral regurgitation (MR) improved in 45-95%, remained unchanged in 19-38% and deteriorated in 1-14%. In the three papers favoring surgical treatment of MR, the degree of MR improved in 46-69%, stay unchanged in 34-53% and deteriorated in 10%. The current evidence suggests that moderate or less grade of FMR without predictors of deterioration should be treated conservatively and moderate-severe and severe FMR warrants additional surgical procedure. A clearly randomized study, especially in patients with moderate and moderate-severe FMR for AS, seems appropriate to further elucidate surgical strategy. © The Author 2016. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

The Electrophysiologic Effects of Acute Mitral Regurgitation in a Canine Model.

PubMed

Lawrance, Christopher P; Henn, Matthew C; Miller, Jacob R; Kopek, Michael A; Zhang, Andrew J; Schuessler, Richard B; Damiano, Ralph J

2017-04-01

Atrial fibrillation (AF) occurs in 30% of patients with mitral regurgitation referred for surgical intervention. However, the underlying mechanisms in this population are poorly understood. This study examined the effects of acute left atrial volume overload on atrial electrophysiology and the inducibility of AF. Ten canines underwent insertion of an atrioventricular shunt between the left ventricle and left atrium. Shunt and aortic flows were calculated, and the shunt was titrated to a shunt fraction to 40% to 50% of cardiac output. An epicardial plaque with 250 bipolar electrodes was used to determine activation and refractory periods. Biatrial pressures and volumes, conduction times, and atrial fibrillation inducibility were recorded. Data were collected at baseline and 20 minutes after shunt opening and closure. Mean shunt flow was 1.3 ± 0.5 L/min with a shunt fraction of 43% ± 6% simulating moderate to severe mitral regurgitation. Compared with baseline, left atrial volumes and maximum pressures increased by 27% and 29%, respectively, after shunt opening. Biatrial effective refractory periods did not change significantly after shunt opening or closure. Conduction times increased by 9% with shunt opening and returned to baseline after closure. AF duration or inducibility did not change with shunt opening. This canine model of mitral regurgitation demonstrated that acute left atrial volume overload did not increase the inducibility of atrial arrhythmias in contrast with experimental and clinical findings of chronic left atrial volume overload. This suggests that the substrates for AF in patients with mitral regurgitation are a result of chronic remodeling. Copyright © 2017 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Noninvasive estimation of left atrial pressure in patients with congestive heart failure and mitral regurgitation by Doppler echocardiography.

PubMed

Gorcsan, J; Snow, F R; Paulsen, W; Nixon, J V

1991-03-01

A completely noninvasive method for estimating left atrial pressure in patients with congestive heart failure and mitral regurgitation has been devised with the use of continuous-wave Doppler echocardiography and brachial sphygmomanometry. Of 46 patients studied with mitral regurgitation, 35 (76%) had jets with distinct Doppler spectral envelopes recorded. The peak ventriculoatrial gradient was obtained by measuring peak mitral regurgitant velocity in systole and using the modified Bernoulli equation. This gradient was then subtracted from peak brachial systolic blood pressure, an estimate of left ventricular systolic pressure, to yield left atrial pressure (left atrial pressure = systolic blood pressure - mitral regurgitant pressure gradient). Noninvasive estimates of left atrial pressure from 35 patients were plotted against simultaneous recordings of mean pulmonary capillary wedge pressure resulting in the correlation y = 0.88x + 3.3, r = 0.88, standard error of estimate = +/- 4 mm Hg (p less than 0.001). Therefore, continuous-wave Doppler echocardiography and sphygmomanometry may be used in selected patients with congestive heart failure and mitral regurgitation for noninvasive estimation of left atrial pressure.

Mitochondrial apoptotic pathway activation in the atria of heart failure patients due to mitral and tricuspid regurgitation.

PubMed

Chang, Jen-Ping; Chen, Mien-Cheng; Liu, Wen-Hao; Lin, Yu-Sheng; Huang, Yao-Kuang; Pan, Kuo-Li; Ho, Wan-Chun; Fang, Chih-Yuan; Chen, Chien-Jen; Chen, Huang-Chung

2015-08-01

Apoptosis occurs in atrial cardiomyocytes in mitral and tricuspid valve disease. The purpose of this study was to examine the respective roles of the mitochondrial and tumor necrosis factor-α receptor associated death domain (TRADD)-mediated death receptor pathways for apoptosis in the atrial cardiomyocytes of heart failure patients due to severe mitral and moderate-to-severe tricuspid regurgitation. This study comprised eighteen patients (7 patients with persistent atrial fibrillation and 11 in sinus rhythm). Atrial appendage tissues were obtained during surgery. Three purchased normal human left atrial tissues served as normal controls. Moderately-to-severely myolytic cardiomyocytes comprised 59.7±22.1% of the cardiomyocytes in the right atria and 52.4±12.9% of the cardiomyocytes in the left atria of mitral and tricuspid regurgitation patients with atrial fibrillation group and comprised 58.4±24.8% of the cardiomyocytes in the right atria of mitral and tricuspid regurgitation patients with sinus rhythm. In contrast, no myolysis was observed in the normal human adult left atrial tissue samples. Immunohistochemical analysis showed expression of cleaved caspase-9, an effector of the mitochondrial pathways, in the majority of right atrial cardiomyocytes (87.3±10.0%) of mitral and tricuspid regurgitation patients with sinus rhythm, and right atrial cardiomyocytes (90.6±31.4%) and left atrial cardiomyocytes (70.7±22.0%) of mitral and tricuspid regurgitation patients with atrial fibrillation. In contrast, only 5.7% of cardiomyocytes of the normal left atrial tissues showed strongly positive expression of cleaved caspase-9. Of note, none of the atrial cardiomyocytes in right atrial tissue in sinus rhythm and in the fibrillating right and left atria of mitral and tricuspid regurgitation patients, and in the normal human adult left atrial tissue samples showed cleaved caspase-8 expression, which is a downstream effector of TRADD of the death receptor pathway

Optimal Surgical Management of Severe Ischemic Mitral Regurgitation: To Repair or to Replace?

PubMed Central

Perrault, Louis P.; Moskowitz, Alan J.; Kron, Irving L.; Acker, Michael A.; Miller, Marissa A.; Horvath, Keith A.; Thourani, Vinod H.; Argenziano, Michael; D'Alessandro, David A.; Blackstone, Eugene H.; Moy, Claudia S.; Mathew, Joseph P.; Hung, Judy; Gardner, Timothy J.; Parides, Michael K.

2013-01-01

Background Ischemic mitral regurgitation (MR), a complication of myocardial infarction and coronary artery disease more generally, is associated with a high mortality rate and estimated to affect 2.8 million Americans. With 1-year mortality rates as high as 40%, recent practice guidelines of professional societies recommend repair or replacement, but there remains a lack of conclusive evidence supporting either intervention. The choice between therapeutic options is characterized by the trade-off between reduced operative morbidity and mortality with repair versus a better long-term correction of mitral insufficiency with replacement. The long-term benefits of repair versus replacement remain unknown, which has led to significant variation in surgical practice. Methods and Results This paper describes the design of a prospective randomized clinical trial to evaluate the safety and effectiveness of mitral valve repair and replacement in patients with severe ischemic mitral regurgitation. This trial is being conducted as part of the Cardiothoracic (CT) Surgical Trials Network. This paper addresses challenges in selecting a feasible primary endpoint, characterizing the target population (including the degree of MR), and analytical challenges in this high mortality disease. Conclusions The paper concludes by discussing the importance of information on functional status, survival, neurocognition, quality of life and cardiac physiology in therapeutic decision-making. PMID:22054660

Quantification of annular dilatation and papillary muscle separation in functional mitral regurgitation: role of anterior mitral leaflet length as reference.

PubMed

Jorapur, Vinod; Voudouris, Apostolos; Lucariello, Richard J

2005-07-01

We hypothesized that anterior mitral leaflet length (ALL) does not differ significantly between normal subjects and patients with functional mitral regurgitation (FMR) and hence may be used as a reference measurement to quantify annular dilatation and papillary muscle separation. We prospectively studied 50 controls, 15 patients with systolic left ventricular dysfunction (LVD) with significant FMR, and 15 patients with LVD without significant FMR. Significant MR was defined as an effective regurgitant orifice area > or = 0.2 cm2 as measured by the flow convergence method. Annular diameter, interpapillary distance, and ALL were measured, and the following ratios were derived: annular diameter indexed to ALL (ADI) and interpapillary distance indexed to ALL (IPDI). There was no significant difference in ALL among the three groups. The mean ADI was 1.26 times controls in patients with LVD without significant FMR compared to 1.33 times controls in patients with LVD with significant FMR (P = 0.06, no significant difference between groups). The mean IPDI was 1.42 times controls in patients with LVD without significant FMR compared to 2.1 times controls in patients with LVD with significant FMR (P < 0.0001, significant difference between groups). There was no significant difference in ALL between controls and patients with LVD. ALL can be used as a reference measurement to quantify annular dilatation and papillary muscle separation in patients with FMR. Interpapillary distance but not annular diameter indexed to ALL correlates with severity of FMR.

Restrictive annuloplasty to treat functional mitral regurgitation: optimize the restriction to improve the results?

PubMed

Totaro, Pasquale; Adragna, Nicola; Argano, Vincenzo

2008-03-01

Today, the 'gold standard' treatment of functional mitral regurgitation (MR) is the subject of much discussion. Although restrictive annuloplasty is currently considered the most reproducible technique, the means by which the degree of annular restriction is optimized remains problematic. The study was designed in order to identify whether the degree of restriction of the mitral annulus could influence early and midterm results following the treatment of functional MR using restrictive annuloplasty. A total of 32 consecutive patients with functional MR grade > or = 3+ was enrolled, among whom the mean anterior-posterior (AP) mitral annulus diameter was 39 +/- 3 mm. Restrictive mitral annuloplasty (combined with coronary artery bypass grafting) was performed in all patients using a Carpentier-Edwards Classic or Physio ring (size 26 or 28). The degree of AP annular restriction was calculated for each patient, and correlated with early and mid-term residual MR and left ventricular (LV) reverse remodeling (in terms of LV end-diastolic diameter (LVEDD) and LV end-diastolic volume (LVEDV) reduction). All surviving patients were examined at a one-year follow up. The mean AP mitral annulus restriction achieved was 48 +/- 4%. Intraoperatively, transesophageal echocardiography showed no residual MR in any patient. Before discharge from hospital, transthoracic echocardiography confirmed an absence of residual MR and showed significant LV reverse remodeling (LVEDV from 121 +/- 25 ml to 97 +/- 26 ml; LVEDD from 55 +/- 6 mm to 47 +/- 8 mm). A significant correlation (r = 0.57, p < 0.001) was identified between the degree of AP annulus restriction and LVEDV reduction. A cut-off of annular restriction of 40% (based on AP annulus measurement) correlated with a more significant reverse remodeling. The early postoperative data, with no recurrence of significant MR, was confirmed at a one-year follow up examination. A marked restriction of the AP mitral annulus diameter (> 40% of

Anatomic regurgitant orifice area obtained using 3D-echocardiography as an indicator of severity of mitral regurgitation in dogs with myxomatous mitral valve disease.

PubMed

Müller, S; Menciotti, G; Borgarelli, M

2017-10-01

To determine feasibility and repeatability of measuring the anatomic regurgitant orifice area (AROA) using real-time three-dimensional transthoracic echocardiography (RT3DE) in dogs with myxomatous mitral valve disease (MMVD), and to investigate differences in the AROA of dogs with different disease severity and in different American College of Veterinary Internal Medicine (ACVIM) stages. Sixty privately-owned dogs diagnosed with MMVD. The echocardiographic database of our institution was retrospectively searched for dogs diagnosed with MMVD and RT3DE data set acquisition. Dogs were classified into mild, moderate, or severe MMVD according to a Mitral Regurgitation Severity Score (MRSS), and into stage B1, B2 or C according to ACVIM staging. The RT3DE data sets were imported into dedicated software and a short axis plane crossing the regurgitant orifice was used to measure the AROA. Feasibility, inter- and intra-observer variability of measuring the AROA was calculated. Differences in the AROA between dogs in different MRSS and ACVIM stages were investigated. The AROA was measurable in 60 data sets of 81 selected to be included in the study (74%). The inter- and intra-observer coefficients of variation were 26% and 21%, respectively. The AROA was significantly greater in dogs with a severe MRSS compared with dogs with mild MRSS (p=0.045). There was no difference between the AROA of dogs in different ACVIM clinical stages. Obtaining the AROA using RT3DE is feasible and might provide additional information to stratify mitral regurgitation severity in dogs with MMVD. Diagnostic and prognostic utility of the AROA deserves further investigation. Copyright © 2017 Elsevier B.V. All rights reserved.

Modified loop technique in three dogs with mitral regurgitation.

PubMed

Aoki, Takuma; Fujii, Yoko; Sunahara, Hiroshi; Takano, Hiroshi; Wakao, Yoshito

2013-01-31

Mitral valvuloplasty (MVP) is used in dogs with refractory mitral regurgitation (MR); however, it is difficult to tie the artificial chord, i.e., the expanded polytetrafluoroethylene suture, at the planned height of the mitral valve, because of the slippery nature of the knot. The loop technique has resolved these difficulties in humans. Premanufactured loops (length, 8.0-15.0 mm with 1.0-mm increments) were used in the new modified loop technique. In the current study, cardiac murmurs disappeared, and the MR markedly improved or completely disappeared approximately 3 months after surgery in 3 dogs. Therefore, this new technique might be effective in dogs.

Assessment of mitral apparatus in patients with acute inferoposterior myocardial infarction and ischaemic mitral regurgitation with two-dimensional echocardiography from anatomically correct imaging planes.

PubMed

Mėlinytė, Karolina; Valuckiene, Živile; Jurkevičius, Renaldas

2017-01-01

Ischaemic mitral regurgitation (IMR) is associated with adverse prognosis after myocardial infarction (MI) as a result of left ventricular remodelling and geometric deformation of the mitral apparatus (MA). The aim of this study was to assess MA from anatomically correct imaging planes in acute inferoposterior MI and IMR. Ninety-three patients with no structural cardiac valve abnormalities and the first acute inferoposterior MI were prospectively enrolled into the study. Two-dimensional transthoracic echocardiography for MA assessment was performed within 48 h of presentation after reperfusion therapy. Based on the degree of mitral regurgitation (MR), patients were divided into either a no significant MR (NMR) group (n = 52 with no or mild, grade 0-I MR) or an IMR group (n = 41 with grade ≥ 2 MR). The control group consisted of 45 healthy individuals. Ischaemic MR was related with dilatation of the left ventricle chambers, decrease in ejection fraction, increase in mitral annulus diameter and area, and changes in subvalvular apparatus when compared with the NMR group or healthy individuals. Ischaemic MR in acute inferoposterior MI is related with worse lesions in MA geometry that cause insufficiency of mitral valve function.

Influence of percutaneous mitral valve repair using the MitraClip® system on renal function in patients with severe mitral regurgitation.

PubMed

Rassaf, Tienush; Balzer, Jan; Rammos, Christos; Zeus, Tobias; Hellhammer, Katharina; v Hall, Silke; Wagstaff, Rabea; Kelm, Malte

2015-04-01

In patients with mitral regurgitation (MR), changes in cardiac stroke volume, and thus renal preload and afterload may affect kidney function. Percutaneous mitral valve repair (PMVR) with the MitraClip® system can be a therapeutic alternative to surgical valve repair. The influence of MitraClip® therapy on renal function and clinical outcome parameters is unknown. Sixty patients with severe MR underwent PMVR using the MitraClip® system in an open-label observational study. Patients were stratified according to their renal function. All clips have been implanted successfully. Effective reduction of MR by 2-3 grades acutely improved KDOQI class. Lesser MR reduction (MR reduction of 0-1 grades) led to worsening of renal function in patients with pre-existing normal or mild (KDOQI 1-2) compared to severe (KDOQI 3-4) renal dysfunction. Reduction of MR was associated with improvement in Minnesota Living with Heart Failure Questionnaire (MLHFQ), NYHA-stadium, and 6-minute walk test. Successful PMVR was associated with an improvement in renal function. The improvement in renal function was associated with the extent of MR reduction and pre-existing kidney dysfunction. Our data emphasize the relevance of PVMR to stabilize the cardiorenal axis in patients with severe MR. © 2014 Wiley Periodicals, Inc.

Quantification of mitral valve regurgitation in dogs with degenerative mitral valve disease by use of the proximal isovelocity surface area method.

PubMed

Gouni, Vassiliki; Serres, François J; Pouchelon, Jean-Louis; Tissier, Renaud; Lefebvre, Hervé P; Nicolle, Audrey P; Sampedrano, Carolina Carlos; Chetboul, Valérie

2007-08-01

To determine the within-day and between-day variability of regurgitant fraction (RF) assessed by use of the proximal isovelocity surface area (PISA) method in awake dogs with degenerative mitral valve disease (MVD), measure RF in dogs with MVD, and assess the correlation between RF and several clinical and Doppler echocardiographic variables. Prospective study. 6 MVD-affected dogs with no clinical signs and 67 dogs with MVD of differing severity (International Small Animal Cardiac Health Council [ISACHC] classification). The 6 dogs were used to determine the repeatability and reproducibility of the PISA method, and RF was then assessed in 67 dogs of various ISACHC classes. Mitral valve regurgitation was also assessed from the maximum area of regurgitant jet signal-to-left atrium area (ARJ/LAA) ratio determined via color Doppler echocardiographic mapping. Within- and between-day coefficients of variation of RF were 8% and 11%, respectively. Regurgitation fraction was significantly correlated with ISACHC classification and heart murmur grade and was higher in ISACHC class III dogs (mean +/- SD, 72.8 +/- 9.5%) than class II (57.9 +/- 20.1%) or I (40.7 +/- 19.2%) dogs. Regurgitation fraction and left atriumto-aorta ratio, fractional shortening, systolic pulmonary arterial pressure, and ARJ/LAA ratio were significantly correlated. Results suggested that RF is a repeatable and reproducible variable for noninvasive quantitative evaluation of mitral valve regurgitation in awake dogs. Regurgitation fraction also correlated well with disease severity. It appears that this Doppler echocardiographic index may be useful in longitudinal studies of MVD in dogs.

Vena contracta analysis by color Doppler three-dimensional transesophageal echocardiography shows geometrical differences between prolapse and pseudoprolapse in eccentric mitral regurgitation.

PubMed

Berdejo, Javier; Shiota, Maiko; Mihara, Hirotsugu; Itabashi, Yuji; Utsunomiya, Hiroto; Shiota, Takahiro

2017-05-01

Evaluation of eccentric mitral regurgitation (MR) remains extremely difficult and the role played by its etiology, functional or degenerative, is not well understood. This study aimed to demonstrate the value of three-dimensional transesophageal echocardiography (3DTEE) in the evaluation of eccentric MR identifying geometric differences in the vena contracta area between functional and degenerative etiologies. We studied 61 patients with eccentric MR (30 functional and 31 degenerative). Regurgitant orifice area was determined by the two-dimensional proximal isovelocity surface area (2DPISA) and the 3DTEE methods. The ratio between maximum and minimum lengths of the vena contracta was calculated in each patient. Effective regurgitant orifice area by the 2DPISA method was smaller than that estimated by 3DTEE (0.56±0.21 vs 0.72±0.25 cm 2 ). A better correlation between both methods was seen in degenerative mitral regurgitation (DMR; r=.83), with a mean underestimation of 8.2% by the 2DPISA method. A much worse correlation was found in functional mitral regurgitation (FMR; r=.39), where a mean underestimation by the 2DPISA method of 29.1% was observed. There was a more elongated and curved vena contracta in FMR compared to that in DMR (length ratio: 3.4±1.0 vs 2.2±0.7, P<.0001). Three-dimensional transesophageal echocardiography identifies a more elongated regurgitant orifice in eccentric FMR compared to that in eccentric DMR. This difference may explain the greater underestimation of effective regurgitant orifice area by the 2DPISA method in FMR. High-quality 3DTEE analysis of vena contracta area would be a highly recommended alternative. © 2017, Wiley Periodicals, Inc.

Safety and efficacy of percutaneous balloon mitral valvotomy in severe mitral stenosis with moderate mitral regurgitation - A prospective study.

PubMed

Desabandhu, Vinayakumar; Peringadan, Nithin Gopalan; Krishnan, Mangalath Narayanan

Percutaneous balloon mitral valvotomy (PBMV) is generally considered as a contraindication in patients with mitral stenosis (MS) associated with moderate to severe mitral regurgitation (MR). We sought to compare the safety and efficacy of PBMV in patients with severe MS and with moderate MR with those with less than moderate or no MR. Symptomatic patients of MS with mitral valve area ≤1.5cm 2 were screened into two groups: Group I with moderate MR and Group II with less than moderate or no MR. Clinical and echocardiographic assessments were done at 24h, 1 month, and 6 months post-procedure. A treadmill testing was done prior to PBMV and at 6 months. Primary safety outcome was a composite of cardiovascular death and development of severe MR with or without requirement for mitral valve replacement at 30 days of procedure. Efficacy of the procedure was measured as improvement in functional class, treadmill time, and mitral valve area (MVA) at 6 months. Seventeen patients with moderate MR and 208 patients with less than moderate MR underwent PBMV. Primary outcome showed no significant difference [2 (11.7%) in Group I vs. 8 (3.85%) in Group II, p=0.36]; occurrence of severe MR was higher in Group I [RR=4.87, 95% C.I.=1.42-16.69]. In Group I patients, improvement in treadmill time was seen in 12 (70.59%), functional class in 13 (76.47%), and MVA in all patients. In patients having severe MS associated with moderate MR, PBMV may be a safe option and provides sustained symptomatic benefit. Copyright © 2016 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.

Atrial function as a guide to timing of intervention in mitral valve prolapse with mitral regurgitation.

PubMed

Ring, Liam; Rana, Bushra S; Wells, Francis C; Kydd, Anna C; Dutka, David P

2014-03-01

The purpose of this study was to determine the clinical utility of left atrial (LA) functional indexes in patients with mitral valve prolapse (MVP) and mitral regurgitation (MR). Timing of surgery for MVP remains challenging. We hypothesized that assessment of LA function may provide diagnostic utility in these patients. We studied 192 consecutive patients in sinus rhythm with MVP, classified into 3 groups: moderate or less MR (MOD group, n = 54); severe MR without surgical indication (SEV group, n = 52); and severe MR with ≥1 surgical indication (SURG group, n = 86). Comparison was made with 50 control patients. Using 2D speckle imaging, average peak contractile, conduit, and reservoir atrial strain was recorded. Using Simpson's method we recorded maximal left atrial volume (LAVmax) and minimal left atrial volume (LAVmin), from which the total left atrial emptying fraction (TLAEF) was derived: (LAVmax-LAVmin)/LAVmax × 100%. TLAEF was similar in the MOD and control groups (61% vs. 57%; p = NS), was reduced in the SEV group (55%; p < 0.001 vs. control group), and markedly lower in the SURG group (40%; p < 0.001 vs. other groups). Reservoir strain demonstrated a similar pattern. Contractile strain was similarly reduced in the MOD and SEV groups (MOD 15%; SEV 14%; p = NS; both p < 0.05 vs. control group 20%) and further reduced in the SURG group (8%; p < 0.001 vs. other groups). By multivariate analysis, TLAEF (odds ratio [OR]: 0.78; p < 0.001), reservoir strain (OR: 0.91; p = 0.028), and contractile strain (OR: 0.86; p = 0.021) were independent predictors of severe MR requiring surgery. Using receiver-operating characteristic analysis, TLAEF <50% demonstrated 91% sensitivity and 92% specificity for predicting MVP with surgical indication (area under the curve: 0.96; p < 0.001). We report the changes in left atrial function in humans with MVP and the relationship of LA dysfunction to clinical indications for mitral valve surgery. We propose that the

Tricuspid regurgitation after successful mitral valve surgery

PubMed Central

Katsi, Vasiliki; Raftopoulos, Leonidas; Aggeli, Constantina; Vlasseros, Ioannis; Felekos, Ioannis; Tousoulis, Dimitrios; Stefanadis, Christodoulos; Kallikazaros, Ioannis

2012-01-01

The tricuspid valve (TV) is inseparably connected with the mitral valve (MV) in terms of function. Any pathophysiological condition concerning the MV is potentially a threat for the normal function of the TV as well. One of the most challenging cases is functional tricuspid regurgitation (TR) after surgical MV correction. In the past, TR was considered to progressively revert with time after left-sided valve restoration. Nevertheless, more recent studies showed that TR could develop and evolve postoperatively over time, as well as being closely associated with a poorer prognosis in terms of morbidity and mortality. Pressure and volume overload are usually the underlying pathophysiological mechanisms; structural alterations, like tricuspid annulus dilatation, increased leaflet tethering and right ventricular remodelling are almost always present when regurgitation develops. The most important risk factors associated with a higher probability of late TR development involve the elderly, female gender, larger left atrial size, atrial fibrillation, right chamber dilatation, higher pulmonary artery systolic pressures, longer times from the onset of MV disease to surgery, history of rheumatic heart disease, ischaemic heart disease and prosthetic valve malfunction. The time of TR manifestation can be up to 10 years or more after an MV surgery. Echocardiography, including the novel 3D Echo techniques, is crucial in the early diagnosis and prognosis of future TV disease development. Appropriate surgical technique and timing still need to be clarified. PMID:22457188

Identical tricuspid ring sizing in simultaneous functional tricuspid and mitral valve repair: A simple and effective strategy.

PubMed

Huffman, Lynn C; Nelson, Jennifer S; Lehman, April N; Krajacic, Marguerite C; Bolling, Steven F

2014-02-01

Mitral valve repair for functional mitral regurgitation is common. Concomitant tricuspid valve repair for associated functional tricuspid regurgitation has gained favor. Controversy exists regarding annuloplasty sizing for tricuspid valve repair. Patients with heart failure having functional mitral regurgitation at the University of Michigan and undergoing mitral valve repair and tricuspid valve repair using identical sized annuloplasty rings between April 2007 and January 2012 were identified. Demographic and clinical records were retrospectively reviewed. Institutional review board approval was obtained for this study. Fifty-three patients met inclusion criteria. Mean age was 65 ± 1.7 years. Preoperative New York Heart Association class was III or IV in 81% (43) and mean left ventricular ejection fraction was 33% ± 2.2%. All patients had moderate or greater mitral regurgitation preoperatively and moderate or severe tricuspid regurgitation or a preoperative tricuspid annulus diameter greater than 40 mm. There was no 30-day mortality. Mean immediate postoperative tricuspid valve gradient was 1.75 ± 0.12 mm Hg and was 2.3 ± 0.19 mm Hg at 4 weeks. Four weeks postoperatively 88% (42/48) of patients had tricuspid regurgitation considered to be mild or less. There was no significant decline in right ventricular function by echocardiography over this time period. Functional tricuspid regurgitation can be repaired using an undersized rigid annuloplasty ring. Our data suggest that an identical sizing strategy can be used for tricuspid valve repair, as was used for mitral valve repair, without development of tricuspid stenosis or negative effect on right ventricular function. This method seems to prevent recurrence of significant tricuspid regurgitation. The technique we describe provides effective and reproducible results. Copyright © 2014 The American Association for Thoracic Surgery. All rights reserved.

Modified edge-to-edge technique for correction of congenital mitral regurgitation in infants and children.

PubMed

Zhang, Gang; Zhang, Fusheng; Zhu, Mei; Zhang, Wenlong; Fan, Quanxin; Zou, Chengwei; Wang, Anbiao

2011-10-01

Since 2008, 28 patients with congenital mitral regurgitation have undergone mitral valve repair with a modified edge-to-edge technique at our institution. The regurgitant mitral leaflet was sutured with a pledget-reinforced, horizontal mattress suture with No. 4-0 polypropylene on the ventricle side and a pledget-reinforced mattress suture with Gore-Tex sutures (W.L. Gore & Associates, Flagstaff, AZ) and Dacron pledgets (Chest, Shanghai) placed on the anterior and posterior annulus corresponding to the edge-to-edge suturing site. Early results are encouraging, but a longer follow-up is needed. Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Safety and Efficacy of Transcatheter Closure of Patent Ductus Arteriosus With Severe Mitral Regurgitation in Adults.

PubMed

Wang, Zhongkai; Chen, Tao; Chen, Liang; Qin, Yongwen; Zhao, Xianxian

2016-01-01

Transcatheter closure is the usual treatment for patent ductus arteriosus (PDA), but its safety and efficacy have not been reported in adult PDA patients with severe mitral regurgitation. A retrospective study on 27 consecutive patients diagnosed with PDA and severe mitral regurgitation and treated using transcatheter closure between September 2010 and September 2012 at the Department of Cardiology of Changhai Hospital in Changhai, China. Left ventricular (LV) diastolic volume and function, pulmonary artery pressure, and instantaneous reverse-flow volume were examined by echocardiography before PDA closure, immediately after closure, and 1 year after closure. After the procedure, the LV diastolic volume (P<.05) and instantaneous reverse-flow volume (P<.001) were significantly decreased. There was no effect on the ejection fraction (P>.05). Pulmonary arterial systolic pressure was unchanged 1 year after closure (from 46.41 ± 19.92 mm Hg to 45.43 ± 13.64 mm Hg; P=.58). All procedures were uneventful and only mild complications occurred (hemolysis in 2 cases, subcutaneous hematoma in 4 cases, and fever in 2 cases). Transcatheter closure can decrease the LV volume and instantaneous reverse-flow volume in adult PDA patients with severe mitral regurgitation. This procedure is effective and has a good safety profile.

Surgical treatment of functional ischemic mitral regurgitation.

PubMed

Jensen, Henrik

2015-03-01

literature, including three randomized studies and a meta analysis, indicate that combined CABG and mitral valve ring annuloplasty has no late survival difference compared with CABG alone, and early mortality might even be higher. Meanwhile, adding a mitral valve ring annuloplasty results in a lower NYHA functional class, most likely as a consequence of a lower incidence of persistent or recurrent FIMR. More randomized studies are being conducted to further address this topic. Mitral valve ring annuloplasty vs. mitral valve replacement. The early survival may be higher after repair compared with replacement, meanwhile, the literature is more ambiguous in terms of late survival advantages, and recent reports find no late survival advantage from repair over replacement. The recurrence rates after ring annuloplasty addressed above were also present in this subset of patients, whereas the incidence of recurrent FIMR after valve replacement is scarcely reported. There was an overall tendency of slightly higher incidence of reoperations after ring annuloplasty. The mitral valve annulus: Innovations in mitral valve ring annuloplasty: The latest innovation in mitral valve ring annuloplasty design includes adjustable rings, allowing adjustment of septo-lateral dimensions intra- or postoperatively. Minimally invasive ring annuloplasty using indirect coronary sinus devices, has been introduced, but so far have produced suboptimal results in terms of safety and efficacy. Also, first in man testing of direct percutaneous catheter based mitral annuloplasty techniques have been conducted. Leaflets and chordae: Direct repair techniques: Surgical methods have been developed to directly address the mitral valve leaflets and chordae tendineae to correct leaflet tethering in FIMR. Both the Alfieri stich and the minimally invasive MitraClip attaches the anterior and posterior leaflets, typically the A2-P2 region, to correct incomplete leaflet coaptation. Patch augmentation of the posterior

Reverse remodeling and the mechanism of mitral regurgitation improvement in patients with dilated cardiomyopathy.

PubMed

Kuperstein, Rafael; Blechman, Ido; Ben Zekry, Sagit; Klempfner, Robert; Freimark, Dov; Arad, Michael

2015-01-01

Functional mitral regurgitation (MR) is a common finding in dilated cardiomyopathy. Left ventricular (LV) reverse remodeling with LV size reduction and improvement in LV function is a well recognized phenomenon. We aimed to evaluate the impact of LV remodeling on the mechanism leading to functional MR. Among 188 patients with non-ischemic dilated cardiomyopathy, 10 patients significantly improved their LV function, reduced LV size and MR severity during follow-up (RRMR). A comparison was made between their baseline and follow-up echocardiographic examinations and to a matched-control group of patients who did not improve (no RRMR). LV and left atrium (LA) dimensions and volumes, LV mass (LVM), LV ejection fraction (LVEF) (Simpsons), sphericity index (SI), mitral valve tenting area (TA) coaptation distance (CD), effective regurgitant orifice (ERO), and regurgitant volume were calculated. Multivariable analysis was performed in order to evaluate which echocardiographic parameters related to MR improvement in reverse remodeling. LV and LA dimensions and volumes, LVM, SI, TA, CD, ERO and right ventricle, in the RRMR group significantly decreased at follow-up (p < 0.04 for all). When compared to no RRMR, despite a similar ERO (0.2 ± 0.05 vs. 0.2 ± 0.08, p = 0.13) and a larger regurgitant volume (38 ± 9 vs. 29 ± 8 mL, p = 0.05) and despite similar clinical characteristics and medical treatment we found significantly higher LVEF, smaller LV dimensions and volumes, smaller LVM and SI in the RRMR group (p < 0.05 for all). On multivariable analysis the SI was the sole predictor of RRMR (p = 0.04, OR = 0.76, CI 0.58-0.99). Reverse remodeling characterized by improvement in LV function, reduction in LV size and an associated reduction in MR severity is related to LV SI at baseline.

Quantification of functional mitral regurgitation by real-time 3D echocardiography: comparison with 3D velocity-encoded cardiac magnetic resonance.

PubMed

Marsan, Nina Ajmone; Westenberg, Jos J M; Ypenburg, Claudia; Delgado, Victoria; van Bommel, Rutger J; Roes, Stijntje D; Nucifora, Gaetano; van der Geest, Rob J; de Roos, Albert; Reiber, Johan C; Schalij, Martin J; Bax, Jeroen J

2009-11-01

The aim of this study was to evaluate feasibility and accuracy of real-time 3-dimensional (3D) echocardiography for quantification of mitral regurgitation (MR), in a head-to-head comparison with velocity-encoded cardiac magnetic resonance (VE-CMR). Accurate grading of MR severity is crucial for appropriate patient management but remains challenging. VE-CMR with 3D three-directional acquisition has been recently proposed as the reference method. A total of 64 patients with functional MR were included. A VE-CMR acquisition was applied to quantify mitral regurgitant volume (Rvol). Color Doppler 3D echocardiography was applied for direct measurement, in "en face" view, of mitral effective regurgitant orifice area (EROA); Rvol was subsequently calculated as EROA multiplied by the velocity-time integral of the regurgitant jet on the continuous-wave Doppler. To assess the relative potential error of the conventional approach, color Doppler 2-dimensional (2D) echocardiography was performed: vena contracta width was measured in the 4-chamber view and EROA calculated as circular (EROA-4CH); EROA was also calculated as elliptical (EROA-elliptical), measuring vena contracta also in the 2-chamber view. From these 2D measurements of EROA, the Rvols were also calculated. The EROA measured by 3D echocardiography was significantly higher than EROA-4CH (p < 0.001) and EROA-elliptical (p < 0.001), with a significant bias between these measurements (0.10 cm(2) and 0.06 cm(2), respectively). Rvol measured by 3D echocardiography showed excellent correlation with Rvol measured by CMR (r = 0.94), without a significant difference between these techniques (mean difference = -0.08 ml/beat). Conversely, 2D echocardiographic approach from the 4-chamber view significantly underestimated Rvol (p = 0.006) as compared with CMR (mean difference = 2.9 ml/beat). The 2D elliptical approach demonstrated a better agreement with CMR (mean difference = -1.6 ml/beat, p = 0.04). Quantification of EROA and

Mitral valve plasty for mitral regurgitation after blunt chest trauma.

PubMed

Kumagai, H; Hamanaka, Y; Hirai, S; Mitsui, N; Kobayashi, T

2001-06-01

A 21 year-old woman was admitted to our hospital because of chest and back pain after blunt chest trauma. On admission, consciousness was clear and a physical examination showed labored breathing. Her vital signs were stable, but her breathing gradually worsened, and artificial respiration was started. The chest roentgenogram and a subsequent chest computed tomographic scans revealed contusions, hemothorax of the left lung and multiple rib fractures. A transthoracic echocardiography (TTE) revealed normal left ventricular wall motion and mild mitral regurgitation (MR). TTE was carried out repeatedly, and revealed gradually progressive MR and prolapse of the posterior medial leaflet, although there was no congestive heart failure. After her general condition had recovered, surgery was performed. Intraoperative transesophageal echocardiography (TEE) revealed torn chordae at the posterior medial leaflet. The leaflet where the chorda was torn was cut and plicated, and posterior mitral annuloplasty was performed using a prosthetic ring. One month later following discharge, the MR had disappeared on TTE.

Treatment of severe mitral regurgitation caused by lesions in both leaflets using multiple mitral valve plasty techniques in a small dog

PubMed Central

Yokoyama, Satoko; Kanemoto, Isamu; Mihara, Kippei; Ando, Takanori; Kawase, Koudai; Sahashi, Yasuaki; Iguchi, Kazuhito

2017-01-01

Mitral valve plasty (MVP) is preferred over mitral valve replacement (MVR) for mitral regurgitation in humans because of its favorable effect on quality of life. In small dogs, it is difficult to repair multiple lesions in both leaflets using MVP. Herein, we report a case of severe mitral regurgitation caused by multiple severe lesions in the posterior leaflet (PL) in a mixed Chihuahua. Initially, we had planned MVR with an artificial valve. However, MVP combined with artificial chordal reconstruction of both leaflets, semicircular suture annuloplasty, and valvuloplasty using a newly devised direct scallop suture for the PL was attempted in this dog. The dog recovered well and showed no adverse cardiac signs, surviving two major operations. The dog died 4 years and 10 months after the MVP due to non-cardiovascular disease. Our additional technique of using a direct scallop suture seemed useful for PL repair involving multiple scallops in a small dog. PMID:29201662

Injectable Microsphere Gel Progressively Improves Global Ventricular Function, Regional Contractile Strain, and Mitral Regurgitation after Myocardial Infarction

PubMed Central

McGarvey, Jeremy R; Kondo, Norihiro; Witschey, Walter RT; Takebe, Manabu; Aoki, Chikashi; Burdick, Jason A.; Spinale, Francis G; Gorman, Joseph H; Pilla, James J; Gorman, Robert C

2014-01-01

Background There is continued need for therapies which reverse or abate the remodeling process following myocardial infarction (MI). In this study, we evaluate the longitudinal effects of calcium hydroxyapatite microsphere gel on regional strain, global ventricular function, and mitral regurgitation (MR) in a porcine MI model. Methods Twenty five Yorkshire swine were enrolled. Five were dedicated weight-matched controls. Twenty underwent posterolateral infarction by direct ligation of the circumflex artery and its branches. Infarcted animals were randomly divided into four groups: one week treatment, one week control, four week treatment, and four week control. Following infarction, animals received either twenty 150μl calcium hydroxyapatite gel or saline injections within the infarct. At their respective timepoints, echocardiograms, cardiac MRI, and tissue were collected for evaluation of MR, regional and global left ventricular function, wall thickness, and collagen content. Results Global and regional LV function were depressed in all infarcted subjects at one week compared to healthy controls. By four weeks post-infarction, global function had significantly improved in the calcium hydroxyapatite group compared to infarcted controls (EF 48.5±1.9% vs. 38.0±1.7%, p<0.01). Similarly, regional borderzone radial contractile strain (16.3±1.5% vs. 11.2±1.5%, p=0.04), MR grade (0.4±0.2 vs. 1.2±0.2, p=0.04), and infarct thickness (7.8±0.5mm vs. 4.5±0.2mm, p<0.01) were improved at this timepoint in the treatment group compared to infarct controls. Conclusions Calcium hydroxyapatite injection following MI progressively improves global LV function, borderzone function, and mitral regurgitation. Using novel biomaterials to augment infarct material properties is viable alternative in the current management of heart failure. PMID:25524397

Mitral Valve Stenosis after Open Repair Surgery for Non-rheumatic Mitral Valve Regurgitation: A Review.

PubMed

Shabsigh, Muhammad; Lawrence, Cassidy; Rosero-Britton, Byron R; Kumar, Nicolas; Kimura, Satoshi; Durda, Michael Andrew; Essandoh, Michael

2016-01-01

Mitral stenosis (MS) after mitral valve (MV) repair is a slowly progressive condition, usually detected many years after the index MV surgery. It is defined as a mean transmitral pressure gradient (TMPG) >5 mmHg or a mitral valve area (MVA) <1.5 cm(2). Pannus formation around the mitral annulus or extending to the mitral leaflets is suggested as the main mechanism for developing delayed MS after MV repair. On the other hand, early stenosis is thought to be a direct result of an undersized annuloplasty ring. Furthermore, in MS following ischemic mitral regurgitation (MR) repair, subvalvular tethering is the hypothesized pathophysiology. MS after MV repair has an incidence of 9-54%. Several factors have been associated with a higher risk for developing MS after MV repair, including the use of flexible Duran annuloplasty rings versus rigid Carpentier-Edwards rings, complete annuloplasty rings versus partial bands, small versus large anterior leaflet opening angle, and anterior leaflet tip opening length. Intraoperative echocardiography can measure the anterior leaflet opening angle, the anterior leaflet tip opening dimension, the MVA and the mean TMPG, and may help identify patients at risk for developing MS after MV repair.

Mitral Valve Stenosis after Open Repair Surgery for Non-rheumatic Mitral Valve Regurgitation: A Review

PubMed Central

Shabsigh, Muhammad; Lawrence, Cassidy; Rosero-Britton, Byron R.; Kumar, Nicolas; Kimura, Satoshi; Durda, Michael Andrew; Essandoh, Michael

2016-01-01

Mitral stenosis (MS) after mitral valve (MV) repair is a slowly progressive condition, usually detected many years after the index MV surgery. It is defined as a mean transmitral pressure gradient (TMPG) >5 mmHg or a mitral valve area (MVA) <1.5 cm2. Pannus formation around the mitral annulus or extending to the mitral leaflets is suggested as the main mechanism for developing delayed MS after MV repair. On the other hand, early stenosis is thought to be a direct result of an undersized annuloplasty ring. Furthermore, in MS following ischemic mitral regurgitation (MR) repair, subvalvular tethering is the hypothesized pathophysiology. MS after MV repair has an incidence of 9–54%. Several factors have been associated with a higher risk for developing MS after MV repair, including the use of flexible Duran annuloplasty rings versus rigid Carpentier–Edwards rings, complete annuloplasty rings versus partial bands, small versus large anterior leaflet opening angle, and anterior leaflet tip opening length. Intraoperative echocardiography can measure the anterior leaflet opening angle, the anterior leaflet tip opening dimension, the MVA and the mean TMPG, and may help identify patients at risk for developing MS after MV repair. PMID:27148540

A three-dimensional insight into the complexity of flow convergence in mitral regurgitation: adjunctive benefit of anatomic regurgitant orifice area.

PubMed

Chandra, Sonal; Salgo, Ivan S; Sugeng, Lissa; Weinert, Lynn; Settlemier, Scott H; Mor-Avi, Victor; Lang, Roberto M

2011-09-01

Mitral effective regurgitant orifice area (EROA) using the flow convergence (FC) method is used to quantify the severity of mitral regurgitation (MR). However, it is challenging and prone to interobserver variability in complex valvular pathology. We hypothesized that real-time three-dimensional (3D) transesophageal echocardiography (RT3D TEE) derived anatomic regurgitant orifice area (AROA) can be a reasonable adjunct, irrespective of valvular geometry. Our goals were to 1) to determine the regurgitant orifice morphology and distance suitable for FC measurement using 3D computational flow dynamics and finite element analysis (FEA), and (2) to measure AROA from RT3D TEE and compare it with 2D FC derived EROA measurements. We studied 61 patients. EROA was calculated from 2D TEE images using the 2D-FC technique, and AROA was obtained from zoomed RT3DE TEE acquisitions using prototype software. 3D computational fluid dynamics by FEA were applied to 3D TEE images to determine the effects of mitral valve (MV) orifice geometry on FC pattern. 3D FEA analysis revealed that a central regurgitant orifice is suitable for FC measurements at an optimal distance from the orifice but complex MV orifice resulting in eccentric jets yielded nonaxisymmetric isovelocity contours close to the orifice where the assumptions underlying FC are problematic. EROA and AROA measurements correlated well (r = 0.81) with a nonsignificant bias. However, in patients with eccentric MR, the bias was larger than in central MR. Intermeasurement variability was higher for the 2D FC technique than for RT3DE-based measurements. With its superior reproducibility, 3D analysis of the AROA is a useful alternative to quantify MR when 2D FC measurements are challenging.

Did we misunderstand how to calculate total stroke work in mitral regurgitation by echocardiography?

PubMed

Shingu, Yasushige; Matsui, Yoshiro

2012-01-01

Total stroke work (TSW) is used for the estimation of cardiac efficiency in mitral regurgitation (MR). We should be cautious about the interpretation of this parameter, especially when it is assessed by non-invasive methods such as echocardiography. For the calculation of regurgitant stroke work, regurgitant volume is usually multiplied by left atrial (LA) pressure. However, by considering the left ventricular (LV) pressure-volume loop, it would be more appropriate to multiply regurgitant volume and the LV pressure, not the atrial one. We might underestimate TSW when we use LA pressure for the estimation of regurgitant stroke work.

Geometric differences of the mitral apparatus between ischemic and dilated cardiomyopathy with significant mitral regurgitation: real-time three-dimensional echocardiography study

NASA Technical Reports Server (NTRS)

Kwan, Jun; Shiota, Takahiro; Agler, Deborah A.; Popovic, Zoran B.; Qin, Jian Xin; Gillinov, Marc A.; Stewart, William J.; Cosgrove, Delos M.; McCarthy, Patrick M.; Thomas, James D.

2003-01-01

BACKGROUND: This study was conducted to elucidate the geometric differences of the mitral apparatus in patients with significant mitral regurgitation caused by ischemic cardiomyopathy (ICM-MR) and by idiopathic dilated cardiomyopathy (DCM-MR) by use of real-time 3D echocardiography (RT3DE). METHODS AND RESULTS: Twenty-six patients with ICM-MR caused by posterior infarction, 18 patients with DCM-MR, and 8 control subjects were studied. With the 3D software, commissure-commissure plane and 3 perpendicular anteroposterior (AP) planes were generated for imaging the medial, central, and lateral sides of the mitral valve (MV) during mid systole. In 3 AP planes, the angles between the annular plane and each leaflet (anterior, Aalpha; posterior, Palpha) were measured. In ICM-MR, Aalpha measured in the medial and central planes was significantly larger than that in the lateral plane (39+/-5 degrees, 34+/-6 degrees, and 27+/-5 degrees, respectively; P<0.01), whereas Palpha showed no significant difference in any of the 3 AP planes (61+/-7 degrees, 57+/-7 degrees, and 56+/-7 degrees, P>0.05). In DCM-MR, both Aalpha (38+/-8 degrees, 37+/-9 degrees, and 36+/-7 degrees, P>0.05) and Palpha (59+/-6 degrees, 58+/-5 degrees, and 57+/-6 degrees, P>0.05) revealed no significant differences in the 3 planes. CONCLUSIONS: The pattern of MV deformation from the medial to the lateral side was asymmetrical in ICM-MR, whereas it was symmetrical in DCM-MR. RT3DE is a helpful tool for differentiating the geometry of the mitral apparatus between these 2 different types of functional mitral regurgitation.

Mechanisms and Predictors of Mitral Regurgitation after High-Risk Myocardial Infarction

PubMed Central

Meris, Alessandra; Amigoni, Maria; Verma, Anil; Thune, Jens Jakob; Køber, Lars; Velazquez, Eric; McMurray, John J. V.; Pfeffer, Marc A.; Califf, Robert; Levine, Robert A.; Solomon, Scott D.

2012-01-01

Background Mitral regurgitation (MR) has been associated with adverse outcomes after myocardial infarction (MI). Without structural valve disease, functional MR has been related to left ventricular (LV) remodeling and geometric deformation of the mitral apparatus. The aims of this study were to elucidate the mechanistic components of MR after high-risk MI and to identify predictors of MR progression during follow-up. Methods The Valsartan in Acute Myocardial Infarction Echo substudy prospectively enrolled 610 patients with LV dysfunction, heart failure, or both after MI. MR at baseline, 1 month, and 20 months was quantified by mapping jet expansion in the left atrium in 341 patients with good-quality echocardiograms. Indices of LV remodeling, left atrial size, and diastolic function and parameters of mitral valve deformation, including tenting area, coaptation depth, anterior leaflet concavity, annular diameters, and contractility, were assessed and related to baseline MR. The progression of MR was further analyzed, and predictors of worsening among the baseline characteristics were identified. Results Tenting area, coaptation depth, annular dilatation, and left atrial size were all associated with the degree of baseline MR. Tenting area was the only significant and independent predictor of worsening MR; a tenting area of 4 cm2 was a useful cutoff to identify worsening of MR after MI and moderate to severe MR after 20 months. Conclusions Increased mitral tenting and larger mitral annular area are determinants of MR degree at baseline, and tenting area is an independent predictor of progression of MR after MI. Although LV remodeling itself contributes to ischemic MR, this influence is directly dependent on alterations in mitral geometry. PMID:22305962

Measurements of the pulmonary vasculature on thoracic radiographs in healthy dogs compared to dogs with mitral regurgitation.

PubMed

Oui, Heejin; Oh, Juyeon; Keh, Seoyeon; Lee, Gahyun; Jeon, Sunghoon; Kim, Hyunwook; Yoon, Junghee; Choi, Jihye

2015-01-01

This study reassessed the previously reported radiographic method of comparing pulmonary vessels versus rib diameter for differentiating healthy dogs and dogs with mitral regurgitation. The width of the right cranial pulmonary artery and vein at the fourth rib level, right caudal pulmonary artery and vein at the ninth rib level, and the diameters of the fourth rib and ninth rib were measured in prospectively recruited healthy dogs (n = 40) and retrospectively recruited dogs with mitral regurgitation (n = 58). In healthy dogs, the pulmonary arteries and accompanying veins were similar in size. The cranial lobar vessels were smaller than the fourth rib. However, 67.5% of right caudal pulmonary artery diameters and 65% of vein diameters were larger than the ninth rib in healthy dogs. The right caudal pulmonary vein diameter in dogs with mitral regurgitation, particularly those within moderate and severe grades, was significantly larger than that in healthy dogs (P < 0.001). The comparative method used to detect enlargement of the right caudal pulmonary vein relative to the accompanying pulmonary artery had the highest sensitivity (80.2%) and specificity (82.5%) for predicting mitral regurgitation. A cut-off of 1.22 when applying the ninth rib criterion had better specificity (73%) than the most used value ≤ 1 (89.7% sensitivity and 63.8% specificity), although it has less sensitivity (73%). We recommend using the accompanying pulmonary artery and 1.22 × the diameter of the ninth rib as a radiographic criterion for assessing the size of the right caudal pulmonary vein and differentiating healthy dogs from those with mitral regurgitation. © 2014 American College of Veterinary Radiology.

Diastolic mitral and tricuspid regurgitation by Doppler echocardiography in patients with atrioventricular block: new insight into the mechanism of atrioventricular valve closure.

PubMed

Schnittger, I; Appleton, C P; Hatle, L K; Popp, R L

1988-01-01

The purpose of this study was to prospectively determine the incidence of diastolic mitral and tricuspid regurgitation in atrioventricular (AV) block using Doppler echocardiography. The temporal relation between mitral and tricuspid diastolic insufficiency and the diastolic murmur recorded in patients with complete heart block was also investigated. Twenty-two consecutive patients with AV block (referred to the Echo-Doppler laboratory for routine clinical studies), aged 18 to 87 years, were enrolled in the study. Eleven patients had third degree AV block and a ventricular-inhibited (VVI) pacemaker, two patients had second degree AV block, seven patients had first degree AV block, one patient had blocked premature atrial complexes and one patient had atrial flutter with 4:1 AV block. Diastolic mitral regurgitation was detected in 20 patients, and diastolic tricuspid regurgitation in 21. A mid-diastolic murmur was detected in all patients except in the three youngest. The murmur occurred before diastolic regurgitation and coincided with peak forward flow through the AV valve after atrial contraction. M-mode mitral valve echocardiograms obtained in nine patients demonstrated near closure of some portions of the mitral valve after atrial contraction. Effective closure of the valve, however, did not occur unless ventricular systole supervened. In conclusion, diastolic mitral and tricuspid regurgitation are almost universally present in patients with AV block and are associated with a diastolic murmur. The murmur coincides with forward AV valve flow. Diastolic regurgitation is silent. Effective AV valve closure is not established until ventricular systole occurs, as demonstrated by M-mode echocardiographic recording of the mitral valve.

Different mechanisms for diastolic mitral regurgitation illustrated by three comparative cases.

PubMed

Sisu, Roxana C; Vinereanu, Dragos

2011-04-01

Diastolic mitral regurgitation (DMR) has been reported in patients with AV block, aortic regurgitation, cardiomyopathies, and in patients with long filling periods in atrial tachyarrhythmias. The mechanism for DMR is a reversal in the atrioventricular gradient during diastole. However, because of its relatively low velocity, it may be difficult to diagnose noninvasively. We present three different cases of diastolic MR in 2:1 second-degree AV block, atrial flutter, and dilated cardiomyopathy, with different locations in diastole. Diastolic tricuspid regurgitation commonly accompanies DMR. Careful analysis of echocardiographical images related with online ECG is very important in order to delineate systolic and DMR, and their timing in systole and diastole. © 2011, Wiley Periodicals, Inc.

Systemic Artery to Pulmonary Artery Fistula Associated with Mitral Regurgitation: Successful Treatment with Endovascular Embolization

DOE Office of Scientific and Technical Information (OSTI.GOV)

Iwazawa, Jin, E-mail: iwazawa.jin@nissay-hp.or.j; Nakamura, Kenji; Hamuro, Masao

We present the case of a 60-year-old woman with symptomatic mitral regurgitation caused by a left-to-right shunt via anastomoses consisting of microfistulae, most likely of inflammatory origin, between the right subclavian artery and the right pulmonary artery. The three arteries responsible for fistulous formation, including the internal mammary, thyrocervical, and lateral thoracic arteries, were successfully occluded by transcatheter embolization using superabsorbent polymer microsphere (SAP-MS) particles combined with metallic coils. No complications have been identified following treatment with SAP-MS particles. This approach significantly reduced the patient's mitral regurgitation and she has remained asymptomatic for more than 4 years.

Mitral Regurgitation after Percutaneous Balloon Mitral Valvotomy in Patients with Rheumatic Mitral Stenosis: A Single-Center Study

PubMed Central

Aslanabadi, Naser; Toufan, Mehrnoush; Salehi, Rezvaneyeh; Alizadehasl, Azin; Ghaffari, Samad; Sohrabi, Bahram; Separham, Ahmad; Manafi, Ataolaah; Mehdizadeh, Mohammad Bagher; Habibzadeh, Afshin

2014-01-01

Abstract Background: Percutaneous balloon mitral valvotomy (BMV) is the gold standard treatment for rheumatic mitral stenosis (MS) in that it causes significant changes in mitral valve area (MVA) and improves leaflet mobility. Development of or increase in mitral regurgitation (MR) is common after BMV. This study evaluated MR severity and its changes after BMV in Iranian patients. Methods: We prospectively evaluated consecutive patients with severe rheumatic MS undergoing BMV using the Inoue balloon technique between February 2010 and January 2013 in Madani Heart Center, Tabriz, Iran. New York Heart Association (NYHA) functional class and echocardiographic and catheterization data, including MVA, mitral valve mean and peak gradient (MVPG and MVMG), left atrial (LA) pressure, pulmonary artery systolic pressure (PAPs), and MR severity before and after BMV, were evaluated. Results: Totally, 105 patients (80% female) at a mean age of 45.81 ± 13.37 years were enrolled. NYHA class was significantly improved after BMV: 55.2% of the patients were in NYHA functional class III before BMV compared to 36.2% after the procedure (p value < 0.001). MVA significantly increased (mean area = 0.64 ± 0.29 cm2 before BMV vs. 1.90 ± 0.22 cm2 after BMV; p value < 0.001) and PAPs, LA pressure, MVPG, and MVMG significantly decreased. MR severity did not change in 82 (78.1%) patients, but it increased in 18 (17.1%) and decreased in 5 (4.8%) patients. Patients with increased MR had a significantly higher calcification score (2.03 ± 0.53 vs.1.50 ± 0.51; p value < 0.001) and lower MVA before BMV (0.81 ± 0.23 vs.0.94 ± 0.18; p value = 0.010). There were no major complications. Conclusion: In our study, BMV had excellent immediate hemodynamic and clinical results inasmuch as MR severity increased only in some patients and, interestingly, decreased in a few. Our results, underscore BMV efficacy in severe MS. The echocardiographic calcification score was useful for identifying patients

Increased mitral valve regurgitation and myocardial hypertrophy in two dogs with long-term pimobendan therapy.

PubMed

Tissier, R; Chetboul, V; Moraillon, R; Nicolle, A; Carlos, C; Enriquez, B; Pouchelon, J-L

2005-01-01

The aim of this article is to describe original adverse effects in two dogs chronically treated with the inodilator pimobendan. We report a German shepherd (i.e., dog 1) and a poodle (i.e., dog 2) that were referred to our cardiology unit after receiving pimobendan for 10 and 5 mo, respectively. In both dogs, conventional echo-Doppler examination demonstrated mitral valve regurgitation and myocardial hypertrophy. Tissue Doppler imaging (TDI) was performed in the first case and revealed an abnormal relaxation phase. After the first examination, pimobendan administration was stopped in both cases and dogs were re-examined 3 and 1 mo later, respectively. Mitral valve regurgitation assessed by echocardiography decreased in both dogs, and the systolic heart murmur disappeared in dog 1. Importantly, most echocardiographic and TDI parameters tended to normalize in dog 1, suggesting, at least partial reversal of both myocardial hypertrophy and relaxation abnormality produced during inodilator therapy. This is the first report to describe an increase in mitral regurgitation under clinical conditions in dogs treated with pimobendan. We also suggest that pimobendan may induce ventricular hypertrophy. However, prospective studies are needed to confirm this observation.

Diagnostic value of color flow mapping and Doppler echocardiography in the quantification of mitral regurgitation in patients with mitral valve prolapse or rheumatic heart disease.

PubMed

Pinheiro, Aurélio Carvalho; Mancuso, Frederico José Neves; Hemerly, Daniela Fernanda Alli; Kiyose, Alberto Takeshi; Campos, Orlando; de Andrade, José Lázaro; de Paola, Angelo Amato Vicenzo; de Camargo Carvalho, Antonio Carlos; Moises, Valdir Ambrosio

2007-10-01

The objective was to analyze the diagnostic value of the echocardiographic methods used for quantification of mitral regurgitation (MR) in patients with mitral valve prolapse (MVP) or rheumatic heart disease (RHD). The study included 50 patients with MR (mean age of 46.1 years; 35 women), 27 (54%) with RHD and 23 (46%) with MVP. Quantification of the mitral valve regurgitation was obtained by regurgitant orifice area (ROA) and regurgitant volume (RV) by the flow convergence region (FCR) and two-dimensional Doppler echocardiographic methods, regurgitant fraction, jet area (JA), jet area/left atrial area ratio (JA/LAA), and vena contracta (VC). Patients were clinically followed to identify cardiovascular events. Data were analyzed by Pearson, kappa, and receiver operator characteristic curve tests; significance was defined as a P value less than .05. The correlation between the two methods for ROA and RV were r = 0.79 and r = 0.80, respectively, and between these parameters and regurgitant fraction, VC, JA, and JA/LAA varied from r = 0.54 to r = 0.94 (P lt; .05); the agreement varied from kappa = 0.19 to kappa = 0.83. The highest accuracy to identify patients with clinically significant MR (events at follow-up) was 96% for ROA by FCR, 94% for VC, 86% for RV by FCR, and 86% for JA. No method showed a significant difference between MVP and RHD. The methods analyzed had significant correlation and good agreement. ROA by FCR and VC had the best performance to identify severe MR; no significant difference between MVP and RHD was observed.

Surgical treatment of tricuspid regurgitation after mitral valve surgery: a retrospective study in China

PubMed Central

2012-01-01

Background Functional tricuspid regurgitation (TR) occurs in patients with rheumatic mitral valve disease even after mitral valve surgery. The aim of this study was to analyze surgical results of TR after previous successful mitral valve surgery. Methods From September 1996 to September 2008, 45 patients with TR after previous mitral valve replacement underwent second operation for TR. In those, 43 patients (95.6%) had right heart failure symptoms (edema of lower extremities, ascites, hepatic congestion, etc.) and 40 patients (88.9%) had atrial fibrillation. Twenty-six patients (57.8%) were in New York Heart Association (NYHA) functional class III, and 19 (42.2%) in class IV. Previous operations included: 41 for mechanical mitral valve replacement (91.1%), 4 for bioprosthetic mitral valve replacement (8.9%), and 7 for tricuspid annuloplasty (15.6%). Results The tricuspid valves were repaired with Kay's (7 cases, 15.6%) or De Vega technique (4 cases, 8.9%). Tricuspid valve replacement was performed in 34 cases (75.6%). One patient (2.2%) died. Postoperative low cardiac output (LCO) occurred in 5 patients and treated successfully. Postoperative echocardiography showed obvious reduction of right atrium and ventricle. The anterioposterior diameter of the right ventricle decreased to 25.5 ± 7.1 mm from 33.7 ± 6.2 mm preoperatively (P < 0. 05). Conclusion TR after mitral valve replacement in rheumatic heart disease is a serious clinical problem. If it occurs or progresses late after mitral valve surgery, tricuspid valve annuloplasty or replacement may be performed with satisfactory results. Due to the serious consequence of untreated TR, aggressive treatment of existing TR during mitral valve surgery is recommended. PMID:22490269

Triple-orifice valve repair in severe Barlow disease with multiple-jet mitral regurgitation: report of mid-term experience.

PubMed

Fucci, Carlo; Faggiano, Pompilio; Nardi, Matilde; D'Aloia, Antonio; Coletti, Giuseppe; De Cicco, Giuseppe; Latini, Leonardo; Vizzardi, Enrico; Lorusso, Roberto

2013-09-10

Barlow disease represents a surgical challenge for mitral valve repair (MR) in the presence of mitral insufficiency (MI) with multiple regurgitant jets. We hereby present our mid-term experience using a modified edge-to-edge technique to address this peculiar MI. From March 2003 till December 2010, 25 consecutive patients (mean age 54 ± 7 years, 14 males) affected by severe Barlow disease with multiple regurgitant jets were submitted to MR. Preoperative transesophageal echo (TEE) in all the cases showed at least 2 regurgitant jets, involving one or both leaflets in more than one segment. In all the patients, a triple orifice valve (TOV) repair with annuloplasty was performed. Intra-operative TEE and postoperative transthoracic echocardiography (TTE) were carried out to evaluate results of the TOV repair. There was no in-hospital death and one late death (non-cardiac related). At intra-operative TEE, the three orifices showed a mean total valve area of 2.9 ± 0.1cm(2) (range 2.5-3.3 cm(2)) with no residual regurgitation (2 cases of trivial MI) and no sign of valve stenosis (mean transvalvular gradient 4.6 ± 1.5 mmHg). At follow up (mean 38 ± 22 months), TTE showed favourable MR and no recurrence of significant MI (6 cases of trivial and 1 of mild MI). Stress TTE was performed in 5 cases showing persistent effective valve function (2 cases of trivial MI at peak exercise). All the patients showed significant NYHA functional class improvement. This report indicates that the TOV technique is effective in correcting complex Barlow mitral valves with multiple jets. Further studies are required to confirm long-term applicability and durability in more numerous clinical cases. Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.

Coronary artery bypass surgery with or without mitral valve annuloplasty in moderate functional ischemic mitral regurgitation: final results of the Randomized Ischemic Mitral Evaluation (RIME) trial.

PubMed

Chan, K M John; Punjabi, Prakash P; Flather, Marcus; Wage, Riccardo; Symmonds, Karen; Roussin, Isabelle; Rahman-Haley, Shelley; Pennell, Dudley J; Kilner, Philip J; Dreyfus, Gilles D; Pepper, John R

2012-11-20

The role of mitral valve repair (MVR) during coronary artery bypass grafting (CABG) in patients with moderate ischemic mitral regurgitation (MR) is uncertain. We conducted a randomized, controlled trial to determine whether repairing the mitral valve during CABG may improve functional capacity and left ventricular reverse remodeling compared with CABG alone. Seventy-three patients referred for CABG with moderate ischemic MR and an ejection fraction >30% were randomized to receive CABG plus MVR (34 patients) or CABG only (39 patients). The study was stopped early after review of interim data. At 1 year, there was a greater improvement in the primary end point of peak oxygen consumption in the CABG plus MVR group compared with the CABG group (3.3 mL/kg/min versus 0.8 mL/kg/min; P<0.001). There was also a greater improvement in the secondary end points in the CABG plus MVR group compared with the CABG group: left ventricular end-systolic volume index, MR volume, and plasma B-type natriuretic peptide reduction of 22.2 mL/m(2), 28.2 mL/beat, and 557.4 pg/mL, respectively versus 4.4 mL/m(2) (P=0.002), 9.2 mL/beat (P=0.001), and 394.7 pg/mL (P=0.003), respectively. Operation duration, blood transfusion, intubation duration, and hospital stay duration were greater in the CABG plus MVR group. Deaths at 30 days and 1 year were similar in both groups: 3% and 9%, respectively in the CABG plus MVR group, versus 3% (P=1.00) and 5% (P=0.66), respectively in the CABG group. Adding mitral annuloplasty to CABG in patients with moderate ischemic MR may improve functional capacity, left ventricular reverse remodeling, MR severity, and B-type natriuretic peptide levels, compared with CABG alone. The impact of these benefits on longer term clinical outcomes remains to be defined.

Disruption of Desmin-Mitochondrial Architecture in Patients with Regurgitant Mitral Valves and Preserved Ventricular Function

PubMed Central

Soorappan, Rajasekaran Namakkal; Ahmad, Shama; Mariappan, Nithya; Litovsky, Silvio; Gupta, Himanshu; Lloyd, Steven G; Denney, Thomas S; Powell, Pamela Cox; Aban, Inmaculada; Collawn, James; Davies, James E; McGiffin, David C; Dell’Italia, Louis J

2016-01-01

Objective Recent studies have demonstrated improved outcomes in patients receiving early surgery for degenerative mitral valvular regurgitation (MR) rather than adhering to conventional guidelines for surgical intervention. However, studies providing a mechanistic basis for these findings are limited. Methods Left ventricular (LV) myocardium from 22 patients undergoing mitral valve repair for Class I indications was evaluated for desmin, the voltage-dependent anion channel, αβ-crystallin, and α, β unsaturated aldehyde 4-hydroxynonelal by fluorescence microscopy and in 6 normal control LV autopsy specimens. Cardiomyocyte ultrastructure was examined by transmission electron microscopy. Magnetic resonance imaging with tissue tagging was performed in 55 normal subjects and 22 MR patients pre- and 6 months post-mitral valve repair. Results LV end-diastolic volume was 1.5-fold (p<0.0001) higher and LV mass to volume ratio was lower in MR (p=0.004) vs. normal and improvement six months after mitral valve surgery. However, LV ejection fraction decreased from 65 ± 7 to 52 ± 9% (p<0.0001) and LV circumferential (p<0.0001) and longitudinal strain decreased significantly below normal values (p=0.002) post-surgery. MR hearts had a 53% decrease in desmin (p<0.0001) and a 2.6-fold increase in desmin aggregates (p<0.0001) vs. normal along with significant, intense perinuclear staining of α, β unsaturated aldehyde 4-hydroxynonelal in areas of mitochondrial breakdown and clustering. Transmission electron microscopy demonstrated numerous electron dense deposits, myofibrillar loss, Z-line abnormalities and extensive granulofilamentous debris identified as desmin positive by immunogold transmission electron microscopy. Conclusion Despite well-preserved preoperative LV ejection fraction, severe oxidative stress and disruption of cardiomyocyte desmin-mitochondrial sarcomeric architecture may explain post-operative LV functional decline and further supports the move toward earlier

Management of Organic Mitral Regurgitation: Guideline Recommendations and Controversies

PubMed Central

Gurzun, Maria-Magdalena; Popescu, Andreea C.; Ginghina, Carmen

2015-01-01

Mitral regurgitation (MR) represents the second most frequent valvular heart disease. The appropriate management of organic MR remains unclear in many aspects, especially in several specific clinical scenarios. This review aims to discuss the current guideline recommendations regarding the management of organic MR, while highlighting the controversial aspects encountered in daily clinical practice. The role of imaging is essential in establishing the most appropriate type of surgical treatment (repair or replace), which is based on morphological mitral valve (MV) characteristics (reparability of the valve) and local surgical expertise in valve repair. The potential advantages of 3-dimensional echocardiography in assessing the MV are discussed. Other modern imaging techniques (tissue Doppler and speckle tracking) may provide additional useful information in borderline cases. Exercise echocardiography (evaluating MR severity, pulmonary pressure, or right ventricular function) may have an important role in the management of difficult cases. Finally, the moment when surgery is no longer an option and alternative solutions should be sought is also discussed. Although in everyday clinical practice the timing of surgery is not always straightforward, some newer clinical and echocardiographic indicators can guide this decision and help improve the outcome of these patients. PMID:25810729

[Tricuspid valve regurgitation : Indications and operative techniques].

PubMed

Lange, R; Piazza, N; Günther, T

2017-11-01

Functional tricuspid valve (TV) regurgitation secondary to left heart disease (e.g. mitral insufficiency and stenosis) is observed in 75% of the patients with TV regurgitation and is thus the most common etiology; therefore, the majority of patients who require TV surgery, undergo concomitant mitral and/or aortic valve surgery. Uncorrected moderate and severe TV regurgitation may persist or even worsen after mitral valve surgery, leading to progressive heart failure and death. Patients with moderate to severe TV regurgitation show a 3-year survival rate of 40%. Surgery is indicated in patients with severe TV regurgitation undergoing left-sided valve surgery and in patients with severe isolated primary regurgitation without severe right ventricular (RV) dysfunction. For patients requiring mitral valve surgery, tricuspid valve annuloplasty should be considered even in the absence of significant regurgitation, when severe annular dilatation (≥40 mm or >21 mm/m 2 ) is present. Functional TV regurgitation is primarily treated with valve reconstruction which carries a lower perioperative risk than valve replacement. Valve replacement is rarely required. Tricuspid valve repair with ring annuloplasty is associated with better survival and a lower reoperation rate than suture annuloplasty. Long-term results are not available. The severity of the heart insufficiency and comorbidities (e.g. renal failure and liver dysfunction) are the essential determinants of operative mortality and long-term survival. Tricuspid valve reoperations are rarely necessary and associated with a considerable mortality.

Measured posterior annuloplasty for repair of non-ischemic mitral regurgitation. A single unit follow-up.

PubMed

Jyrala, Aarne; Gatto, Nicole M; Kay, Gregory L

2010-01-01

The aim of this report is to evaluate short- and long-term outcomes of annuloplasty method of our choice: measured posterior annuloplasty (MPA). MPA is a piece of a Duran ring cut to the length of free-edge of anterior mitral leaflet (AML) and anchored with multiple pledgeted U-sutures from trigone to trigone into the posterior annulus. From 1988 to 2000, 103 consecutive patients with non-ischemic mitral regurgitation were scheduled preoperatively to be repaired by MPA. Preoperative mitral valve regurgitation (MR) grade was 3.8+/-0.5 and decreased to 0.1+/-0.3 (P<0.0001) after repair. One patient was converted to insertion of mechanical prosthesis after grade 3 MR persisted after septal myectomy and MPA. Three patients needed instant revision of the repair one due to SAM and two due to stenosis. No patient had a stenosis or unacceptable (>1) MR after the procedure. There was one operative death (1.0%) and 3 hospital/30-day deaths (2.9%). Sixteen patients (16.3%) expired during the follow-up to 91 months (mean 57.4+/-19.5, median 60 months) none due to failure of MPA. There were no reoperations due to failure of MPA. Three patients had a reoperation, one for dehiscence of reconstruction after P2 resection and two patients due to progression of anterior leaflet degeneration and calcification with 4+ MR. New York Heart Association (NYHA) functional classification decreased from 2.3+/-0.8 to 1.4+/-0.6 (P<0.0001) and only one patient had an increase from II to III. Eighty-eight patients (96.7%) were in NYHA class I-II. Ten patients had an increase of MR from 0 to trace or 1 and one from 0 to 2. Two patients were diagnosed with mild stenosis without need of reoperation. MPA is a durable and stable alternative for repair of non-ischemic mitral regurgitation of different etiologies. The technique gives an objective measure of the length of the band and no patient is left with a significant MR or mitral valve stenosis (MS). First-time success rate is very high and instant

Correlation of the flow patterns among the four pulmonary veins as assessed by transesophageal echocardiography: influence of significant mitral regurgitation.

PubMed

Hwang, J J; Lin, J M; Hsu, K L; Lai, L P; Tseng, Y Z; Lee, Y T; Lien, W P

1999-01-01

To evaluate the correlation of the flow patterns of the four pulmonary veins as assessed by transesophageal echocardiography and the influence of significant mitral regurgitation on this correlation. Eighty-eight patients with normal sinus rhythm and variable underlying cardiovascular diseases underwent transthoracic and transesophageal echocardiographic studies. Doppler flow of the four pulmonary veins could not be adequately interpreted in 19 patients (22%). The left atrial dimension of these patients was significantly larger than that of the patients with complete study of the flow in the four pulmonary veins (49 +/- 6 vs. 43 +/- 7 mm; p < 0.05). Of the 69 patients with complete evaluation of the four pulmonary veins, 48 patients without significant mitral regurgitation were analyzed as group A, and the remaining 21 patients as group B. The peak systolic and diastolic forward flow velocities of the four pulmonary veins were measured and the ratio of peak systolic (S) to diastolic (D) flow velocity was calculated. Group A had a significantly larger S/D ratio in all four pulmonary veins than group B (p < 0.05 in each pulmonary vein measurement). There was good correlation of the flow pattern represented as S/D ratio between left upper and lower pulmonary veins (r = 0.90) and between right upper and lower pulmonary veins (r = 0.89) in group A. The correlation of the flow pattern among the four pulmonary veins deteriorated in group B. Pulmonary veins on the same side share rather similar flow patterns in comparison with pulmonary veins on the opposite sides. The correlation of flow patterns among the four pulmonary veins is good in subjects without significant mitral regurgitation, but it worsens in patients with significant mitral regurgitation. Therefore, cautious interpretation of flow patterns of the four pulmonary veins in patients with significant regurgitation is indicated for grading the severity of mitral regurgitation.

Early Activation of Growth Pathways in Mitral Leaflets Exposed to Aortic Regurgitation: New Insights from an Animal Model.

PubMed

Marsit, Ons; Royer, Olivier; Drolet, Marie-Claude; Arsenault, Marie; Couet, Jacques; Morin, Stéphane; Levine, Robert A; Pibarot, Philippe; Beaudoin, Jonathan

2017-05-01

Mitral leaflet enlargement in patients with chronic aortic regurgitation (AR) has been identified as an adaptive mechanism potentially able to prevent functional mitral regurgitation (FMR) in response to left ventricular (LV) dilatation. The timing of valve enlargement is not known, and the related mechanisms are largely unexplored. AR was induced in 58 rats, and another 54 were used as sham controls. Animals were euthanized at different time points after AR creation (48 h, one week, and three months), and AR severity, FMR and LV dilatation were assessed using echocardiography. Mitral valves were harvested to document the reactivation of embryonic growth pathways. AR animals had increased LV dimensions and mitral annulus size. No animal developed FMR. No change in leaflet length or thickness was seen at 48 h; however, anterior mitral leaflets were longer and thicker in AR animals at one week and three months. Molecular changes were present early (at 48 h and at one week), with positive staining for transforming growth factor-b1 (TGF-b1), Alpha-smooth muscle actin (α-SMA) and matrix metalloproteinase-2 (MMP-2), which suggested active matrix remodeling. Increased gene expression for collagen 1, TGF-β1, α-SMA and MMP-2 was found in the mitral valve at 48 h and at one week, but after three months their expression had returned to normal. This model of AR induces active expansion and thickening of the mitral leaflets. Growth signals are expressed acutely, but not at three months, which suggests that most of this enlargement occurs at an early stage. The stimulation of valvular growth could represent a new strategy for the prevention of FMR.

Severe mitral regurgitation due to mitral leaflet aneurysm diagnosed by three-dimensional transesophageal echocardiography: a case report.

PubMed

Konishi, Takao; Funayama, Naohiro; Yamamoto, Tadashi; Hotta, Daisuke; Kikuchi, Kenjiro; Ohori, Katsumi; Nishihara, Hiroshi; Tanaka, Shinya

2016-11-22

A small mitral valve aneurysm (MVA) presenting as severe mitral regurgitation (MR) is uncommon. A 47-year-old man with a history of hypertension complained of exertional chest discomfort. A transthoracic echocardiogram (TTE) revealed the presence of MR and prolapse of the posterior leaflet. A 6-mm in diameter MVA, not clearly visualized by TTE, was detected on the posterior leaflet on a three-dimensional (3D) transesophageal echocardiography (TEE). The patient underwent uncomplicated triangular resection of P2 and mitral valve annuloplasty, and was discharged from postoperative rehabilitation, 2 weeks after the operation. Histopathology of the excised leaflet showed myxomatous changes without infective vegetation or signs of rheumatic heart disease. A small, isolated MVA is a cause of severe MR, which might be overlooked and, therefore, managed belatedly. 3D TEE was helpful in imaging its morphologic details.

Polymer Injection Therapy to Reverse Remodel the Papillary Muscles: Efficacy in Reducing Mitral Regurgitation in a Chronic Ischemic Model

PubMed Central

Solis, Jorge; Levine, Robert A.; Johnson, Benjamin; Guerrero, J. Luis; Handschumacher, Mark D.; Suzanne, Suzanne; Lam, Kaitlyn; Berlin, Jason; Braithwaite, Gavin J.C.; Muratoglu, Orhun K.; Vlahakes, Gus J.; Hung, Judy

2010-01-01

Ischemic mitral regurgitation (IMR) results from displacement of the papillary muscles due to ischemic ventricular distortion. Recurrent IMR is frequent after annuloplasty, particularly when left ventricular remodeling continues to progress. Our hypothesis is that repositioning of the papillary muscles can be achieved by injection of polyvinyl-alcohol (PVA) hydrogel polymer into the myocardium in chronic MR despite advanced left ventricular remodeling. Methods Nine sheep underwent ligation of circumflex branches to produce chronic ischemic MR over eight weeks. Once MR developed, PVA was injected into the myocardium underlying the infarcted PM. 2D and 3D echocardiograms and hemodynamic data were obtained pre infarct (baseline), pre PVA (Chronic MR) and post PVA. Results One animal died early, one did not develop MR, and the remaining 7 developed moderate MR. PVA injection significantly decreased the MR from moderate to trace. This was associated with a decrease in infarcted papillary muscle-to-mitral annulus tethering distance (32.6 ± 4.4 to 27.6 ± 4.2 mm, P<0.05), tenting volume (2.1±0.3 to 1.6 ± 0.3 mm2 P<0.05) and leaflet closure area (9.3 ± 0.8 to 8.2 ± 0.7 mm2, P<0.04). PVA was not associated with significant decreases in LVEF (42 ± 3 % vs 40 ± 2 %, p=ns) or end-systolic elastance. Measures of left ventricular diastolic function, tau (99 ± 55 ms to 87 ± 36;) and left ventricular stiffness coefficient (0.04 ± 0.03 to 0.05 ± 0.03) did not increase post PVA. Conclusions PVA hydrogel injections improve coaptation and reduce remodeling in chronic MR without impairing LV systolic and diastolic function. This new approach offers a potential alternative for relieving ischemic mitral regurgitation by correcting papillary muscle position, thus relieving tethering that causes ischemic mitral regurgitation. PMID:20736444

Dynamic change in mitral regurgitant orifice area: comparison of color Doppler echocardiographic and electromagnetic flowmeter-based methods in a chronic animal model.

PubMed

Shiota, T; Jones, M; Teien, D E; Yamada, I; Passafini, A; Ge, S; Sahn, D J

1995-08-01

The aim of the present study was to investigate dynamic changes in the mitral regurgitant orifice using electromagnetic flow probes and flowmeters and the color Doppler flow convergence method. Methods for determining mitral regurgitant orifice areas have been described using flow convergence imaging with a hemispheric isovelocity surface assumption. However, the shape of flow convergence isovelocity surfaces depends on many factors that change during regurgitation. In seven sheep with surgically created mitral regurgitation, 18 hemodynamic states were studied. The aliasing distances of flow convergence were measured at 10 sequential points using two ranges of aliasing velocities (0.20 to 0.32 and 0.56 to 0.72 m/s), and instantaneous flow rates were calculated using the hemispheric assumption. Instantaneous regurgitant areas were determined from the regurgitant flow rates obtained from both electromagnetic flowmeters and flow convergence divided by the corresponding continuous wave velocities. The regurgitant orifice sizes obtained using the electromagnetic flow method usually increased to maximal size in early to midsystole and then decreased in late systole. Patterns of dynamic changes in orifice area obtained by flow convergence were not the same as those delineated by the electromagnetic flow method. Time-averaged regurgitant orifice areas obtained by flow convergence using lower aliasing velocities overestimated the areas obtained by the electromagnetic flow method ([mean +/- SD] 0.27 +/- 0.14 vs. 0.12 +/- 0.06 cm2, p < 0.001), whereas flow convergence, using higher aliasing velocities, estimated the reference areas more reliably (0.15 +/- 0.06 cm2). The electromagnetic flow method studies uniformly demonstrated dynamic change in mitral regurgitant orifice area and suggested limitations of the flow convergence method.

Calculation of Left Ventricular Diastolic Time Constant (TAU) in Dogs with Mitral Regurgitation Using Continuous-Wave Doppler.

PubMed

Wen, Chaoyang; Sun, Jing; Fan, Chunzhi; Dou, Jianping

2018-05-04

The left ventricular diastolic time constant (Tau) cannot be practically measured non-invasively. Thus, the aim of this study was to investigate a new method for the evaluation of Tau using continuous-wave (CW) Doppler in dogs with mitral regurgitation. Guided by ultrasound, we created 12 beagle models of mitral regurgitation and acute ischemic left ventricular diastolic dysfunction. Raw audio signals of the CW Doppler spectra were collected, and new mitral regurgitation Doppler spectra were observed after computer re-processing. The new Doppler spectra contour line was constructed using MATLAB (Version R2009), and two time intervals, t1-t2 and t1-t3, were measured on the descending branch of the mitral regurgitation Doppler spectrum and were substituted into Bai's equation group. The Doppler-derived Tau (Tau-d) was resolved and compared with the simultaneous catheter-derived Tau (Tau-c). No significant difference (p > 0.05) between Tau-d (49.33 ± 18.79 ms) and Tau-c (48.76 ± 17.60 ms) was found. A correlation analysis between Tau-d and Tau-c suggested a strong positive relationship (r = 0.85, p = 0.000). Bland-Altman plots of Tau-d and Tau-c revealed fair agreement. Compared with previous non-invasive approaches, this method is simpler and more accurate. There is a strong positive relationship and fair agreement between Tau-d and Tau-c. Copyright © 2018 World Federation for Ultrasound in Medicine and Biology. Published by Elsevier Inc. All rights reserved.

Dobutamine stress echocardiography for assessment of systolic function in dogs with experimentally induced mitral regurgitation.

PubMed

Suzuki, R; Matsumoto, H; Teshima, T; Mochizuki, Y; Koyama, H

2014-01-01

Systolic dysfunction is associated with poor outcomes in dogs with myxomatous mitral valve disease. However, assessment of systolic variables by conventional echocardiographic methods is difficult in these dogs because of mitral regurgitation (MR). We hypothesized that assessment of systolic function by dobutamine stress may identify systolic dysfunction in dogs with MR, and that 2-dimensional speckle-tracking echocardiography (2D-STE) could quantitatively evaluate myocardial function. Anesthetized dogs with experimentally induced MR. Dogs were examined for systolic myocardial deformations using 2D-STE during dobutamine infusion before and 3 and 6 months after MR induction. We evaluated peak systolic rotation and rotation rate in each basal and apical view; peak systolic torsion and torsion rate were also calculated. Invasive peak positive first derivatives of left ventricular pressure (dp/dt) were significantly decreased in dogs 6 months after induction of MR compared with pre-MR results. After 3 and 6 months of MR, dogs had diminished peak systolic torsion values and torsion rates in response to dobutamine infusion compared with pre-MR results (3 months, P < .001 and P = .006; 6 months, P = .003 and P = .021). These results were significantly correlated with overall invasive dp/dt (r = 0.644, P < .001; r = 0.696, P < .001). Decreased torsion during dobutamine infusion in dogs with MR may reflect latent systolic dysfunction. Dobutamine infusion, therefore, may be useful for the assessment of systolic function in dogs with MR. Copyright © 2014 by the American College of Veterinary Internal Medicine.

Multi-Modality Imaging in the Evaluation and Treatment of Mitral Regurgitation.

PubMed

Bouchard, Marc-André; Côté-Laroche, Claudia; Beaudoin, Jonathan

2017-10-13

Mitral regurgitation (MR) is frequent and associated with increased mortality and morbidity when severe. It may be caused by intrinsic valvular disease (primary MR) or ventricular deformation (secondary MR). Imaging has a critical role to document the severity, mechanism, and impact of MR on heart function as selected patients with MR may benefit from surgery whereas other will not. In patients planned for a surgical intervention, imaging is also important to select candidates for mitral valve (MV) repair over replacement and to predict surgical success. Although standard transthoracic echocardiography is the first-line modality to evaluate MR, newer imaging modalities like three-dimensional (3D) transesophageal echocardiography, stress echocardiography, cardiac magnetic resonance (CMR), and computed tomography (CT) are emerging and complementary tools for MR assessment. While some of these modalities can provide insight into MR severity, others will help to determine its mechanism. Understanding the advantages and limitations of each imaging modality is important to appreciate their respective role for MR assessment and help to resolve eventual discrepancies between different diagnostic methods. With the increasing use of transcatheter mitral procedures (repair or replacement) for high-surgical-risk patients, multimodality imaging has now become even more important to determine eligibility, preinterventional planning, and periprocedural guidance.

Frequency, Mechanism and Severity of Mitral Regurgitation: Are There any Differences Between Primary and Secondary Mitral Regurgitation?

PubMed

Zamorano, José L; Manuel Monteagudo, Juan; Mesa, Dolores; Gonzalez-Alujas, Teresa; Sitges, Marta; Carrasco-Chinchilla, Fernando; Li, Chi-Hion; Grande-Trillo, Antonio; Martinez, Amparo; Matabuena, Javier; Alonso-Rodriguez, David; Fernandez-Golfin, Covadonga

2016-11-01

Although mitral regurgitation (MR) is a well-recognized prognosis factor, its true prevalence is probably underestimated and its etiology and mechanisms have not been sufficiently explored. The study aim was to evaluate the burden of MR, focusing attention on its frequency, severity, etiology, mechanism, and other associated conditions. Between February and June 2015, a total of 39,855 consecutive echocardiographic studies was performed at nine tertiary hospitals, and were prospectively included in the study. MR severity was graded into four groups, ranging from none or trace to severe MR, in accordance with the recommendations of the European Association of Cardiovascular Imaging. Patients with moderate to severe MR were selected for the analysis. MR was detected in 22.6% of cases. MR severity was mild in 82.5% of patients (n = 7,376), moderate in 11.7% (n = 1,048), and severe in 5.8% (n = 521). Concomitant valvular heart disease was present in 3,544 patients (39.7%), with tricuspid regurgitation the most frequently encountered (21.6%). Among moderate and severe MR, primary MR was more frequent than secondary MR (58.8% versus 23.5%), with degenerative valve disease being the most common cause of primary MR (49.2%). A third group composed of mixed forms of MR was described in 17.8% of cases. MR is a common finding on echocardiography, and is frequently associated with other valvular heart disease. Most MRs are of degenerative origin. The primary and secondary forms of MR differ significantly in their clinical presentation with regard to gender, age, and ventricular function. There appears to be a gap for a 'mixed' group, though further studies are needed to confirm this suggestion.

Role of tricuspid valve repair for moderate tricuspid regurgitation during minimally invasive mitral valve surgery.

PubMed

Pfannmueller, Bettina; Verevkin, Alexander; Borger, Michael Andrew; Mende, Meinhard; Davierwala, Piroze; Garbade, Jens; Mohr, Friedrich Wilhelm; Misfeld, Martin

2013-08-01

The aim of this study was to investigate the impact of short- and mid-term survival of tricuspid valve (TV) repair versus conservative therapy in patients with preoperative moderate functional tricuspid regurgitation (TR) undergoing minimally invasive mitral valve (MV) surgery. Between January 2002 and December 2009, a total of 430 patients with pure mitral regurgitation and concomitant moderate TR underwent minimally invasive MV surgery for mitral regurgitation at the Leipzig Heart Center without (n = 336; group A) and with (n = 94; group B) TV surgery. Mean age was 66.7 ± 10.3 years, mean LVEF was 58.0 ± 13.8%, and 206 patients (47.9%) were male. Average logEuroSCORE was 12.4 ± 11.4%. Follow-up was on average 4.6 ± 2.4 years and 97% completed. Predischarge echocardiography showed no or mild TR in 51.1% of patients in group A versus 84.2% of patients in group B (p < 0.01). Overall 30-day mortality was 2.8% with no differences between both groups. Five-year survival was 82.9 ± 4.1% for patients with TV repair versus 85.0 ± 2.2% for patients without TV repair (p = 0.1) and it was 85.7 ± 3.3% in patients with moderate and more postoperative TR versus 90.1 ± 2.5% in patients with less than moderate postoperative TR (p = 0.08). Five-year freedom from TV-related reoperation was 98.8 ± 0.7% for patients in group A versus 98.9 ± 0.1% for patients in group B (p = 0.8). Patients undergoing MV surgery with moderate functional TR do not experience increased perioperative complication rates when a concomitant TV repair is performed. Our observations, combined with those of other groups, support current recommendations to perform concomitant TV repair in such patients, particularly if tricuspid annular dilation is present. Georg Thieme Verlag KG Stuttgart · New York.

Transcatheter Mitral Annuloplasty in Chronic Functional Mitral Regurgitation: 6-Month Results With the Cardioband Percutaneous Mitral Repair System.

PubMed

Nickenig, Georg; Hammerstingl, Christoph; Schueler, Robert; Topilsky, Yan; Grayburn, Paul A; Vahanian, Alec; Messika-Zeitoun, David; Urena Alcazar, Marina; Baldus, Stephan; Volker, Rudolph; Huntgeburth, Michael; Alfieri, Ottavio; Latib, Azeem; La Canna, Giovanni; Agricola, Eustachio; Colombo, Antonio; Kuck, Karl-Heinz; Kreidel, Felix; Frerker, Christian; Tanner, Felix C; Ben-Yehuda, Ori; Maisano, Francesco

2016-10-10

This study sought to show safety and efficacy of the Cardioband system during 6 months after treatment. Current surgical and medical treatment options for functional mitral regurgitation (FMR) are limited. The Cardioband system (Valtech Cardio, OrYehuda, Israel) is a novel transvenous, transseptal direct annuloplasty device. Thirty-one patients (71.8 ± 6.9 years of age; 83.9% male; EuroSCORE II: 8.6 ± 5.9) with moderate to severe FMR, symptomatic heart failure, and depressed left ventricular function (left ventricular ejection fraction 34 ± 11%) were prospectively enrolled. Procedural success rate, defined as delivery of the entire device, was 100%. There were no periprocedural deaths (0%), and mortality rate at 1 month or prior to hospital discharge and at 7 months was 5% and 9.7% respectively. Cinching of the implanted Cardioband reduced the annular septolateral dimension by >30% from 3.7 ± 0.5 cm at baseline to 2.5 ± 0.4 cm after 1 month and to 2.4 ± 0.4 cm after 6 months, respectively (p < 0.001). Percentage of patients with FMR ≥3 was reduced from 77.4% to 10.7% 1 month after the procedure (p < 0.001) and 13.6% (p < 0.001) at 7 months. Percentage of patients with New York Heart Association functional class III/IV decreased from 95.5% to 18.2% after 7 months (p < 0.001); exercise capacity as assessed by 6-min walking test increased from 250 ± 107 m to 332 ± 118 m (p < 0.001) and quality of life (Minnesota Living With Heart Failure Questionnaire) was also significantly improved (p < 0.001). In this feasibility trial in symptomatic patients with FMR, transcatheter mitral annuloplasty with the Cardioband was effective in reducing MR and was associated with improvement in heart failure symptoms and demonstrated a favorable safety profile. (Cardioband With Transfemoral Delivery System; NCT01841554). Copyright © 2016 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Outcome after percutaneous edge-to-edge mitral repair for functional and degenerative mitral regurgitation: a systematic review and meta-analysis.

PubMed

Chiarito, Mauro; Pagnesi, Matteo; Martino, Enrico Antonio; Pighi, Michele; Scotti, Andrea; Biondi-Zoccai, Giuseppe; Latib, Azeem; Landoni, Giovanni; Mario, Carlo Di; Margonato, Alberto; Maisano, Francesco; Feldman, Ted; Alfieri, Ottavio; Colombo, Antonio; Godino, Cosmo

2018-02-01

Differences in terms of safety and efficacy of percutaneous edge-to-edge mitral repair between patients with functional and degenerative mitral regurgitation (MR) are not well established. We performed a systematic review and meta-analysis to clarify these differences. PubMed, EMBASE, Google scholar database and international meeting abstracts were searched for all studies about MitraClip. Studies with <25 patients or where 1-year results were not delineated between MR aetiology were excluded. This study is registered with PROSPERO. A total of nine studies investigating the mid-term outcome of percutaneous edge-to-edge repair in patients with functional versus degenerative MR were included in the meta-analysis (n=2615). At 1 year, there were not significant differences among groups in terms of patients with MR grade≤2 (719/1304 vs 295/504; 58% vs 54%; risk ratio (RR) 1.12; 95% CI: 0.86 to 1.47; p=0.40), while there was a significantly lower rate of mitral valve re-intervention in patients with functional MR compared with those with degenerative MR (77/1770 vs 80/818; 4% vs 10%; RR 0.60; 95% CI: 0.38 to 0.97; p=0.04). One-year mortality rate was 16% (408/2498) and similar among groups (RR 1.26; 95% CI: 0.90 to 1.77; p=0.18). Functional MR group showed significantly higher percentage of patients in New York Heart Association class III/IV (234/1480 vs 49/583; 16% vs 8%; p<0.01) and re-hospitalisation for heart failure (137/605 vs 31/220; 23% vs 14%; p=0.03). No differences were found in terms of single leaflet device attachment (25/969 vs 20/464; 3% vs 4%; p=0.81) and device embolisation (no events reported in both groups) at 1 year. This meta-analysis suggests that percutaneous edge-to-edge repair is likely to be an efficacious and safe option in patients with both functional and degenerative MR. Large, randomised studies are ongoing and awaited to fully assess the clinical impact of the procedure in these two different MR aetiologies. © Article author

Criteria for mitral regurgitation classification were inadequate for dilated cardiomyopathy.

PubMed

Mancuso, Frederico José Neves; Moisés, Valdir Ambrosio; Almeida, Dirceu Rodrigues; Oliveira, Wercules Antonio; Poyares, Dalva; Brito, Flavio Souza; Paola, Angelo Amato Vincenzo de; Carvalho, Antonio Carlos Camargo; Campos, Orlando

2013-11-01

Mitral regurgitation (MR) is common in patients with dilated cardiomyopathy (DCM). It is unknown whether the criteria for MR classification are inadequate for patients with DCM. We aimed to evaluate the agreement among the four most common echocardiographic methods for MR classification. Ninety patients with DCM were included. Functional MR was classified using four echocardiographic methods: color flow jet area (JA), vena contracta (VC), effective regurgitant orifice area (ERO) and regurgitant volume (RV). MR was classified as mild, moderate or important according to the American Society of Echocardiography criteria and by dividing the values into terciles. The Kappa test was used to evaluate whether the methods agreed, and the Pearson correlation coefficient was used to evaluate the correlation between the absolute values of each method. MR classification according to each method was as follows: JA: 26 mild, 44 moderate, 20 important; VC: 12 mild, 72 moderate, 6 important; ERO: 70 mild, 15 moderate, 5 important; RV: 70 mild, 16 moderate, 4 important. The agreement was poor among methods (kappa=0.11; p<0.001). It was observed a strong correlation between the absolute values of each method, ranging from 0.70 to 0.95 (p<0.01) and the agreement was higher when values were divided into terciles (kappa = 0.44; p < 0.01) CONCLUSION: The use of conventional echocardiographic criteria for MR classification seems inadequate in patients with DCM. It is necessary to establish new cutoff values for MR classification in these patients.

Autophagy as a mechanism for myolysis of cardiomyocytes in mitral regurgitation.

PubMed

Chen, Mien-Cheng; Chang, Jen-Ping; Wang, Ya-Hui; Liu, Wen-Hao; Ho, Wan-Chun; Chang, Hsueh-Wen

2011-03-01

Myolysis of atrial cardiomyocytes occurs in patients with severe mitral and tricuspid regurgitation. This morphological remodelling may involve autophagy. This study comprised 20 patients (10 with long-standing persistent atrial fibrillation and 10 with sinus rhythm) with severe mitral and tricuspid regurgitation. Atrial appendageal tissues were obtained during surgery. The appearance of autophagosomes (LC3B) in myocytes can reflect autophagy induction. Complement 9 is used as a reliable marker of oncosis. In the fibrillating right atria, 68·4 ± 18·9% of total myocytes showed moderate-to-severe myolysis, while 64·2 ± 15·8% of total myocytes comprised these cells in right atrial myocardium with sinus rhythm. Immunohistochemical study revealed LC3B-positive myocytes in 8·0% of myocytes without myolysis, 11·9% of myocytes with mild myolysis and 49·4% of myocytes with moderate-to-severe myolysis in right atrial myocardium with sinus rhythm (P < 0·0001). Similarly, in the fibrillating right atria, LC3B-positive myocytes were observed in 5·9% of myocytes without myolysis, 12·2% of myocytes with mild myolysis and 50·7% of myocytes with moderate-to-severe myolysis (P < 0·0001). Moreover, in the fibrillating left atria, LC3B-positive myocytes were observed in 4·9% of myocytes without myolysis, 12·6% of myocytes with mild myolysis and 52·0% of myocytes with moderate-to-severe myolysis (P < 0·0001). None of the atrial myocytes displayed intracellular deposition of complement 9. Induction of autophagy, but not oncosis, occurs in most cases of atrial cardiomyocytes with severe mitral and tricuspid regurgitation, even those without atrial fibrillation, and is closely associated with the development of myolysis in this disease. © 2010 The Authors. European Journal of Clinical Investigation © 2010 Stichting European Society for Clinical Investigation Journal Foundation.

Therapeutic strategy for functional tricuspid regurgitation in patients undergoing mitral valve repair for severe mitral regurgitation.

PubMed

Kitai, Takeshi; Furukawa, Yutaka; Murotani, Kenta; Krittanawong, Chayakrit; Kaji, Shuichiro; Koyama, Tadaaki; Okada, Yukikatsu

2017-01-15

The aim of this study was to determine optimal patient selection and selection of a prosthetic ring size for tricuspid valve (TV) repair at the time of mitral valve (MV) repair. We prospectively enrolled 167 consecutive patients undergoing MV repair. TV repair was indicated if patients had at least one of the following conditions representing tricuspid annular dilatation: (1) tricuspid regurgitation (TR)≥moderate, (2) history of right heart failure, (3) atrial fibrillation, and (4) pulmonary hypertension. The size of the ring was targeted to a normal-sized systolic tricuspid annuls in relation to the patient's body surface area (BSA). Serial echocardiographic studies were performed preoperatively, at discharge, and at 1, 3, and 5years postoperatively. Overall, 100 (60%) patients required TV repair, while it was not indicated for 67 (40%) patients. During follow-up, 26 patients showed progression or recurrent TR≥moderate. The TR grade at 5years after MV surgery was 0.8±0.9 in patients with TV repair and 0.9±0.7 in those without TV repair (P=0.69). There were no significant differences between patients with and without TV repair in a composite endpoint of death from any cause, re-do MV or TV surgery, and recurrence or progression of TR≥moderate (P=0.46). Patient selection for TV repair considering not only the grade of TR but clinical signs representing tricuspid annular dilatation is feasible at the time of MV repair. TV repair targeting a normal systolic size in relation to the BSA is a simple and reproducible procedure. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

Quantification of mitral regurgitation by automated cardiac output measurement: experimental and clinical validation

NASA Technical Reports Server (NTRS)

Sun, J. P.; Yang, X. S.; Qin, J. X.; Greenberg, N. L.; Zhou, J.; Vazquez, C. J.; Griffin, B. P.; Stewart, W. J.; Thomas, J. D.

1998-01-01

OBJECTIVES: To develop and validate an automated noninvasive method to quantify mitral regurgitation. BACKGROUND: Automated cardiac output measurement (ACM), which integrates digital color Doppler velocities in space and in time, has been validated for the left ventricular (LV) outflow tract but has not been tested for the LV inflow tract or to assess mitral regurgitation (MR). METHODS: First, to validate ACM against a gold standard (ultrasonic flow meter), 8 dogs were studied at 40 different stages of cardiac output (CO). Second, to compare ACM to the LV outflow (ACMa) and inflow (ACMm) tracts, 50 normal volunteers without MR or aortic regurgitation (44+/-5 years, 31 male) were studied. Third, to compare ACM with the standard pulsed Doppler-two-dimensional echocardiographic (PD-2D) method for quantification of MR, 51 patients (61+/-14 years, 30 male) with MR were studied. RESULTS: In the canine studies, CO by ACM (1.32+/-0.3 liter/min, y) and flow meter (1.35+/-0.3 liter/min, x) showed good correlation (r=0.95, y=0.89x+0.11) and agreement (deltaCO(y-x)=0.03+/-0.08 [mean+/-SD] liter/min). In the normal subjects, CO measured by ACMm agreed with CO by ACMa (r=0.90, p < 0.0001, deltaCO=-0.09+/-0.42 liter/min), PD (r=0.87, p < 0.0001, deltaCO=0.12+/-0.49 liter/min) and 2D (r=0.84, p < 0.0001, deltaCO=-0.16+/-0.48 liter/min). In the patients, mitral regurgitant volume (MRV) by ACMm-ACMa agreed with PD-2D (r= 0.88, y=0.88x+6.6, p < 0.0001, deltaMRV=2.68+/-9.7 ml). CONCLUSIONS: We determined that ACM is a feasible new method for quantifying LV outflow and inflow volume to measure MRV and that ACM automatically performs calculations that are equivalent to more time-consuming Doppler and 2D measurements. Additionally, ACM should improve MR quantification in routine clinical practice.

Mechanism of valvular regurgitation.

PubMed

Khoo, Nee S; Smallhorn, Jeffery F

2011-10-01

Despite improvements in surgical techniques, valvular regurgitation results in major morbidity in children with heart disease. Functional anatomy, mechanisms of valve closure and adaptation to changing hemodynamic stress in normal mitral and tricuspid valves are complex and only partially understood. As well, pathology of atrioventricular valve regurgitation is further complicated by congenital valve abnormalities involving leaflet tissue, supporting chordal apparatus and displaced papillary muscles. This review provides a current understanding of the mechanisms that result in atrioventricular valve failure. Mitral valve leaflets have contractile elements, in addition to atrial muscle modulation of leaflet tension. When placed under mechanical tethering stress, the mitral valve adapts by leaflet expansion, which increases coaptation surface reserve and chordal thickening. Both pediatric and adult studies are increasingly reporting on the importance of subvalvar apparatus function in maintaining valve competency. The maintenance of efficient valve function is accomplished by a complex series of events involving atrial and annular contraction, annular deformation, active leaflet tension, chordal transmission of papillary muscle contractions and ventricular contraction.

Quantitation of aortic and mitral regurgitation in the pediatric population: evaluation by radionuclide angiocardiography

DOE Office of Scientific and Technical Information (OSTI.GOV)

Hurwitz, R.A.; Treves, S.; Freed, M.

The ability to quantitate aortic (AR) or mitral regurgitation (MR), or both, by radionuclide angiocardiography was evaluated in children and young adults at rest and during isometric exercise. Regurgitation was estimated by determining the ratio of left ventricular stroke volume to right ventricular stroke volume obtained during equilibrium ventriculography. The radionuclide measurement was compared with results of cineangiography, with good correlation between both studies in 47 of 48 patients. Radionuclide stroke volume ratio was used to classify severity: the group with equivocal regurgitation differed from the group with mild regurgitation (p less than 0.02); patients with mild regurgitation differed frommore » those with moderate regurgitation (p less than 0.001); and those with moderate regurgitation differed from those with severe regurgitation (p less than 0.01). The stroke volume ratio was responsive to isometric exercise, remaining constant or increasing in 16 of 18 patients. After surgery to correct regurgitation, the stroke volume ratio significantly decreased from preoperative measurements in all 7 patients evaluated. Results from the present study demonstrate that a stroke volume ratio greater than 2.0 is compatible with moderately severe regurgitation and that a ratio greater than 3.0 suggests the presence of severe regurgitation. Thus, radionuclide angiocardiography should be useful for noninvasive quantitation of AR or MR, or both, helping define the course of young patients with left-side valvular regurgitation.« less

Impact of baseline tricuspid regurgitation on long-term clinical outcomes and survival after interventional edge-to-edge repair for mitral regurgitation.

PubMed

Schueler, Robert; Öztürk, Can; Sinning, Jan-Malte; Werner, Nikos; Welz, Armin; Hammerstingl, Christoph; Nickenig, Georg

2017-05-01

Tricuspid regurgitation (TR) in patients with mitral valve disease is associated with poor outcome and mortality. Only limited data on the impact of TR on functional outcome and survival in patients undergoing MitraClip procedures are available. 261 patients (mean age 76.6 ± 10, EuroScore 15.9 ± 15.1%) with symptomatic mitral regurgitation (MR) (75.2% functional MR) undergoing MitraClip procedure were included and followed for 721 ± 19.4 days. At baseline 54.7% presented with TR grade 0/I, 29.5% with grade II, 13.4% with grade III and 2.3% with grade IV. When dividing groups according to baseline TR grades, follow-up (FU)-NYHA class was significantly improved only in patients with TR ≤ II (p = 0.05). FU-6-min walking distance increased significantly in the overall cohort (p = 0.05), in patients with TR ≤ II (p = 0.007), but not in patients with TR > II (p = 0.4). Moreover, FU-NT-pro-BNP levels were higher in patients with TR > II (p = 0.05), compared to patients with TR ≤ II. There was a higher mortality according to baseline TR > II and multivariate Cox regression revealed TR > II as the strongest independent predictor for mortality (hazard ratio 2.04). Concomitant TR at baseline negatively influences functional outcome and mortality in patients undergoing MitraClip procedures. Our results underline the need for dedicated interventional strategies for the treatment of TR in patients with symptomatic MR.

Use of signal analysis of heart sounds and murmurs to assess severity of mitral valve regurgitation attributable to myxomatous mitral valve disease in dogs.

PubMed

Ljungvall, Ingrid; Ahlstrom, Christer; Höglund, Katja; Hult, Peter; Kvart, Clarence; Borgarelli, Michele; Ask, Per; Häggström, Jens

2009-05-01

To investigate use of signal analysis of heart sounds and murmurs in assessing severity of mitral valve regurgitation (mitral regurgitation [MR]) in dogs with myxomatous mitral valve disease (MMVD). 77 client-owned dogs. Cardiac sounds were recorded from dogs evaluated by use of auscultatory and echocardiographic classification systems. Signal analysis techniques were developed to extract 7 sound variables (first frequency peak, murmur energy ratio, murmur duration > 200 Hz, sample entropy and first minimum of the auto mutual information function of the murmurs, and energy ratios of the first heart sound [S1] and second heart sound [S2]). Significant associations were detected between severity of MR and all sound variables, except the energy ratio of S1. An increase in severity of MR resulted in greater contribution of higher frequencies, increased signal irregularity, and decreased energy ratio of S2. The optimal combination of variables for distinguishing dogs with high-intensity murmurs from other dogs was energy ratio of S2 and murmur duration > 200 Hz (sensitivity, 79%; specificity, 71%) by use of the auscultatory classification. By use of the echocardiographic classification, corresponding variables were auto mutual information, first frequency peak, and energy ratio of S2 (sensitivity, 88%; specificity, 82%). Most of the investigated sound variables were significantly associated with severity of MR, which indicated a powerful diagnostic potential for monitoring MMVD. Signal analysis techniques could be valuable for clinicians when performing risk assessment or determining whether special care and more extensive examinations are required.

Surgical Strategies for Management of Mitral Regurgitation: Recent Evidence from Randomized Controlled Trials.

PubMed

Tolis, George; Sundt, Thoralf M

2015-12-01

In contrast to mitral regurgitation (MR) caused by structural abnormality of the valve ("primary" MR), about which there is increasing consensus regarding treatment, there is increasing controversy around the management of functional or "secondary" MR, of which "ischemic mitral regurgitation" (IMR) is a common cause. While the trend in the management of primary MR is increasingly aggressive, with wide agreement on the preference for repair over replacement such that debate centers on earlier and earlier repair even among asymptomatic patients, the situation is reversed in the setting of secondary MR with uncertainly beyond the mode of management (repair or replacement) to the value of intervening at all. This is, in part, because the term IMR has been somewhat loosely applied by the medical and surgical communities to include regurgitation secondary to active myocardial ischemia, as well as that resulting from a completed myocardial infarct. As a result, there is considerable variability in reported outcomes of surgical interventions for IMR. In addition, the natural history of IMR is quite adverse-more so than that of many solid organ malignancies-and its surgical treatment has traditionally carried a higher operative mortality than many cardiac surgical procedures, including similar operations for primary MR and incidental coronary artery disease. Added to this, with recent advances in both the medical and surgical treatment of heart failure improving nonoperative outcomes and simultaneously reducing operative risk compared to reports from previous decades, the landscape has been quite dynamic. Here, we review the issues surrounding surgical treatment for IMR, along with available evidence supporting different approaches, to lend an informed perspective on the divergent opinions among experts in this field and guide the appropriate management of the individual patient.

Impact of Mitral Regurgitation on Clinical Outcomes After Transcatheter Aortic Valve Implantation

PubMed Central

Tüller, David; Zbinden, Rainer; Eberli, Franz R

2016-01-01

Severe aortic stenosis (AS) and mitral regurgitation (MR) are the two most common valvular lesions referred for surgical intervention in Europe and frequently co-exist. In patients with both severe AS and significant MR referred for surgical aortic valve replacement (SAVR), a concomitant mitral valve intervention is typically performed if the MR is severe, despite the higher associated perioperative risk. The management of moderate MR among SAVR patients is controversial and depends on a number of factors including MR aetiology (i.e., organic versus functional MR), feasibility of repair and patient risk profile. Moderate or severe MR is present in up to one-third of patients undergoing transcatheter aortic valve implantation (TAVI), is mainly of functional aetiology and is typically left untreated. Although data are conflicting, a growing body of evidence suggests that significant MR exerts an adverse effect on both short- and long-term clinical outcomes after TAVI. Moderate or severe MR improves in just over half of patients following TAVI and recent data suggest MR is more likely to improve among patients receiving a balloon-expandable as compared with a self-expandable transcatheter heart valve. PMID:29588707

Criteria for Mitral Regurgitation Classification were inadequate for Dilated Cardiomyopathy

PubMed Central

Mancuso, Frederico José Neves; Moisés, Valdir Ambrosio; Almeida, Dirceu Rodrigues; Oliveira, Wercules Antonio; Poyares, Dalva; Brito, Flavio Souza; de Paola, Angelo Amato Vincenzo; Carvalho, Antonio Carlos Camargo; Campos, Orlando

2013-01-01

Background Mitral regurgitation (MR) is common in patients with dilated cardiomyopathy (DCM). It is unknown whether the criteria for MR classification are inadequate for patients with DCM. Objective We aimed to evaluate the agreement among the four most common echocardiographic methods for MR classification. Methods Ninety patients with DCM were included. Functional MR was classified using four echocardiographic methods: color flow jet area (JA), vena contracta (VC), effective regurgitant orifice area (ERO) and regurgitant volume (RV). MR was classified as mild, moderate or important according to the American Society of Echocardiography criteria and by dividing the values into terciles. The Kappa test was used to evaluate whether the methods agreed, and the Pearson correlation coefficient was used to evaluate the correlation between the absolute values of each method. Results MR classification according to each method was as follows: JA: 26 mild, 44 moderate, 20 important; VC: 12 mild, 72 moderate, 6 important; ERO: 70 mild, 15 moderate, 5 important; RV: 70 mild, 16 moderate, 4 important. The agreement was poor among methods (kappa = 0.11; p < 0.001). It was observed a strong correlation between the absolute values of each method, ranging from 0.70 to 0.95 (p < 0.01) and the agreement was higher when values were divided into terciles (kappa = 0.44; p < 0.01) Conclusion The use of conventional echocardiographic criteria for MR classification seems inadequate in patients with DCM. It is necessary to establish new cutoff values for MR classification in these patients. PMID:24100692

Impact of Residual Mitral Regurgitation on Right Ventricular Systolic Function After Left Ventricular Assist Device Implantation.

PubMed

Ertugay, Serkan; Kemal, Hatice S; Kahraman, Umit; Engin, Catagay; Nalbantgil, Sanem; Yagdi, Tahir; Ozbaran, Mustafa

2017-07-01

Significant mitral regurgitation (MR) is thought to decrease after left ventricular assist device (LVAD) implantation, and therefore repair of mitral valve is not indicated in current practice. However, residual moderate and severe MR leads to pulmonary artery pressure increase, thereby resulting in right ventricular (RV) dysfunction during follow-up. We examined the impact of residual MR on systolic function of the right ventricle by echocardiography after LVAD implantation. This study included 90 patients (mean age: 51.7 ± 10.9 years, 14.4% female) who underwent LVAD implantation (HeartMate II = 21, HeartWare = 69) in a single center between December 2010 and June 2014. Echocardiograms obtained at 3-6 months and over after implantation were analyzed retrospectively. RV systolic function was graded as normal, mild, moderate, and severely depressed. MR (≥moderate) was observed in 43 and 44% of patients at early and late period, respectively. Systolic function of the RV was severely depressed in 16 and 9% of all patients. Initial analysis (mean duration of support 174.3 ± 42.5 days) showed a statistically significant correlation between less MR and improved systolic function of RV (P = 0.01). Secondary echocardiographic analysis (following a mean duration of support of 435.1 ± 203 days) was also statistically significant for MR degree and RV systolic dysfunction (P = 0.008). Residual MR after LVAD implantation may cause deterioration of RV systolic function and cause right-sided heart failure symptoms. Repair of severe MR, in selected patients such as those with severe pulmonary hypertension and depressed RV, may be considered to improve the patient's clinical course during pump support. © 2016 International Center for Artificial Organs and Transplantation and Wiley Periodicals, Inc.

Predicting device failure after percutaneous repair of functional mitral regurgitation in advanced heart failure: Implications for patient selection.

PubMed

Stolfo, Davide; De Luca, Antonio; Morea, Gaetano; Merlo, Marco; Vitrella, Giancarlo; Caiffa, Thomas; Barbati, Giulia; Rakar, Serena; Korcova, Renata; Perkan, Andrea; Pinamonti, Bruno; Pappalardo, Aniello; Berardini, Alessandra; Biagini, Elena; Saia, Francesco; Grigioni, Francesco; Rapezzi, Claudio; Sinagra, Gianfranco

2018-04-15

Patients with heart failure (HF) and severe symptomatic functional mitral regurgitation (FMR) may benefit from MitraClip implantation. With increasing numbers of patients being treated the success of procedure becomes a key issue. We sought to investigate the pre-procedural predictors of device failure in patients with advanced HF treated with MitraClip. From April 2012 to November 2016, 76 patients with poor functional class (NYHA class III-IV) and severe left ventricular (LV) remodeling underwent MitraClip implantation at University Hospitals of Trieste and Bologna (Italy). Device failure was assessed according to MVARC criteria. Patients were subsequently followed to additionally assess the patient success after 12months. Mean age was 67±12years, the mean Log-EuroSCORE was 23.4±16.5%, and the mean LV end-diastolic volume index and ejection fraction (EF) were 112±33ml/m 2 and 30.6±8.9%, respectively. At short-term evaluation, device failure was observed in 22 (29%) patients. Univariate predictors of device failure were LVEF, LV and left atrial volumes and anteroposterior mitral annulus diameter. Annulus dimension (OR 1.153, 95% CI 1.002-1.327, p=0.043) and LV end-diastolic volume (OR 1.024, 95% CI 1.000-1.049, p=0.049) were the only variables independently associated with the risk of device failure at the multivariate model. Pre-procedural anteroposterior mitral annulus diameter accurately predicted the risk of device failure after MitraClip in the setting of advanced HF. Its assessment might aid the selection of the best candidates to percutaneous correction of FMR. Copyright © 2018 Elsevier B.V. All rights reserved.

Intra-aortic balloon pumping in acute mitral regurgitation reduces aortic impedance and regurgitant fraction.

PubMed

Dekker, André L A J; Reesink, Koen D; van der Veen, Frederik H; van Ommen, G Vincent A; Geskes, Gijs G; Soemers, A Cecilia M; Maessen, Jos G

2003-04-01

Acute mitral regurgitation (MR) is present in 10% of patients presenting with cardiogenic shock. To stabilize these patients, intra-aortic balloon pumping (IABP) is recommended, but the mechanism of IABP support in these patients is unknown. This animal study was designed to describe the hemodynamic effect of intra-aortic balloon pumping during cardiogenic shock induced by acute MR. In eight calves, left ventricular pressure-volume loops, aortic and left atrial pressure, and aortic, carotid artery, and coronary blood flow were recorded. Acute MR (range 36%-79%) was created by placing a metal cage in the mitral valve. Hemodynamic data was obtained at control, during acute MR, and during acute MR with 1:1 IABP support. Acute MR caused a decrease in cardiac output (-32%, P = 0.018), blood pressure, and carotid artery flow, whereas left ventricular output (+127%, P = 0.018), end-diastolic volume, and left atrial pressure all significantly increased. Stroke work, ejection fraction, and coronary blood flow were not significantly changed, and no signs of ischemia were seen on the ECG. The IABP raised average cardiac output by 31% (P = 0.012) and significantly raised blood pressure and flow to the brain while decreasing systemic vascular resistance. Left ventricular function and mean coronary blood flow did not change, but diastolic coronary flow became more important as shown by the increase in diastolic fraction from 64% to 95%. (P = 0.028). Average MR dropped by 7.5% (P = 0.025). In conclusion, application of the IABP during acute MR lowers aortic impedance, resulting in less MR and more output toward the aorta without changing left ventricular function.

Mitral valve repair for ischemic moderate mitral regurgitation in patients undergoing coronary artery bypass grafting

PubMed Central

Toktas, Faruk; Yavuz, Senol; Ozsin, Kadir K.; Sanri, Umut S.

2016-01-01

Objectives: To investigate whether mitral valve repair (MVR) at the time of coronary artery bypass grafting (CABG) in patients with ischemic moderate mitral regurgitation (MR) and coronary artery disease could improve short- and mid-term postoperative outcomes. Methods: Between March 2013 and December 2015, 90 patients with moderate ischemic MR underwent first-time CABG in Bursa Yuksek Ihtisas Training and Research Hospital, Bursa, Turkey. Out of 90 patients, 44 (48.9%) underwent combined CABG+MVR. The remaining 46 (51.1%) underwent CABG alone. Ventricular functions and effort capacities of patients in both groups were evaluated echocardiographically and clinically in the preoperative period, and in the first postoperative year. Results: Postoperative regurgitant volume changes according to preoperative values were -24.76±19 ml/beat in the combined CABG+MVR group, and -8.70±7.2 ml/beat in the CABG alone group (p=0.001). The change of vena contracta width was -3.40±0.2 mm in the combined CABG+MVR group whereas in the CABG alone -1.45±0.7 mm (p=0.019). The changes of left ventricular end-systolic volume index were -30.77±25.9 ml/m2 in the combined CABG+MVR group and -15.6±9.4 ml/m2 in the CABG alone group (p=0.096). Ejection fraction changes in the combined CABG+MVR group was +1.51±5.3% and in the CABG alone group was +1.15±4.3%. No statistically significant difference was found between both groups (p=0.604). Preoperative New York Heart Association class values in the combined CABG+MVR group was 2.18±0.45, and in the CABG alone group was 2.13±0.54. Conclusions: Moderate MR in patients undergoing CABG affects the outcome adversely and it does not reliably improve after CABG alone. Therefore, patients with ischemic moderate MR should undergo simultaneous MVR at the time of CABG. PMID:27464861

Assessment of left ventricular function using pulsed tissue Doppler imaging in healthy dogs and dogs with spontaneous mitral regurgitation.

PubMed

Teshima, Kenji; Asano, Kazushi; Sasaki, Yukie; Kato, Yuka; Kutara, Kenji; Edamura, Kazuya; Hasegawa, Atsuhiko; Tanaka, Shigeo

2005-12-01

Pulsed tissue Doppler imaging (pulsed TDI) has been demonstrated to be useful for the estimation of left ventricular (LV) systolic and diastolic functions in various human cardiac diseases. The objectives of this study were to investigate the relationship between pulsed TDI and LV function by using cardiac catheterization in healthy dogs and to evaluate the clinical usefulness of pulsed TDI in dogs with spontaneous mitral regurgitation (MR). The peak early diastolic velocity (E'), peak atrial systolic velocity (A'), and peak systolic velocity (S') were detectable in the velocity profiles of the mitral annulus in all the dogs. In the healthy dogs, S' and E' were correlated with LV peak +dP/dt and -dP/dt, respectively. E' was lower in dogs with MR than in dogs without cardiac diseases. E/E' in the MR dogs with decompensated heart failure was significantly increased in comparison with those with compensated heart failure. The sensitivity and specificity of the E/E' cutoff value of 13.0 for identifying decompensated heart failure were 80% and 83%, respectively. In addition, E/E' was significantly correlated with the ratio of left atrial to aortic diameter. These findings suggest that canine pulsed TDI can be applied clinically for estimation of cardiac function and detection of cardiac decompensation and left atrial volume overload in dogs with MR.

Long-Term Results of Mitral Valve Repair

PubMed Central

da Costa, Francisco Diniz Affonso; Colatusso, Daniele de Fátima Fornazari; Martin, Gustavo Luis do Santos; Parra, Kallyne Carolina Silva; Botta, Mariana Cozer; Balbi Filho, Eduardo Mendel; Veloso, Myrian; Miotto, Gabriela; Ferreira, Andreia Dumsch de Aragon; Colatusso, Claudinei

2018-01-01

Introduction Current guidelines state that patients with severe mitral regurgitation should be treated in reference centers with a high reparability rate, low mortality rate, and durable results. Objective To analyze our global experience with the treatment of organic mitral regurgitation from various etiologies operated in a single center. Methods We evaluated all surgically treated patients with organic mitral regurgitation from 2004-2017. Patients were evaluated clinically and by echocardiography every year. We determined early and late survival rates, valve related events and freedom from recurrent mitral regurgitation and tricuspid regurgitation. Valve failure was defined as any mitral regurgitation ≥ moderate degree or the need for reoperation for any reason. Results Out of 133 patients with organic mitral regurgitation, 125 (93.9%) were submitted to valve repair. Mean age was 57±15 years and 52 patients were males. The most common etiologies were degenerative disease (73 patients) and rheumatic disease (34 patients). Early mortality was 2.4% and late survival was 84.3% at 10 years, which are similar to the age- and gender-matched general population. Only two patients developed severe mitral regurgitation, and both were reoperated (95.6% at 10 years). Freedom from mitral valve failure was 84.5% at 10 years, with no difference between degenerative and rheumatic valves. Overall, late ≥ moderate tricuspid regurgitation was present in 34% of the patients, being more common in the rheumatic ones. The use of tricuspid annuloplasty abolished this complication. Conclusion We have demonstrated that mitral regurgitation due to organic mitral valve disease from various etiologies can be surgically treated with a high repair rate, low early mortality and long-term survival that are comparable to the matched general population. Concomitant treatment of atrial fibrillation and tricuspid valve may be important adjuncts to optimize long-term results. PMID:29617498

Mitral annular longitudinal function preservation after mitral valve repair: the MARTE study.

PubMed

Lisi, M; Ballo, P; Cameli, M; Gandolfo, F; Galderisi, M; Chiavarelli, M; Henein, M Y; Mondillo, S

2012-05-31

In patients with chronic mitral regurgitation (MR), undergoing surgical mitral valve repair, current Guidelines only recommend standard echocardiographic indices i.e. left ventricular (LV) ejection fraction (EF), and LV end-systolic and end-diastolic diameters as preoperative variables. However LV EF is often preserved until advanced stages of the valve disease. Aim of this study was to evaluate changes in LV systolic longitudinal function, 3 months after mitral valve repair in patients with chronic degenerative MR and normal preoperative EF. We measured M-mode mitral lateral annulus systolic excursion (MAPSE) and Tissue Doppler (TD) peak systolic annular velocity (S(m)) in 31 patients with moderate to severe MR and normal EF (59.9 ± 4.7%) candidates for mitral valve repair, preoperatively and 3 months after surgery. After mitral valve repair, S(m) increased from 7.8 ± 1.4 to 9.6 ± 2.2 cm/s (p<0.0001) and MAPSE increased from 1.33 ± 0.26 to 1.55 ± 0.25 cm (p=0.0013). EF decreased from 59.9 ± 4.7 to 51.3 ± 5.9% (p<0.0001). As expected, LV diameters and volumes, wall thicknesses, midwall fractional shortening (mFS), and left atrial (LA) size were all reduced after surgery. This study suggests that assessment of LV long axis systolic velocity and amplitude of excursion by echocardiography is more sensitive than simple determination of EF for revealing the beneficial impact of MR surgery on overall systolic function. Copyright © 2010 Elsevier Ireland Ltd. All rights reserved.

Catheter-based intervention for symptomatic patient with severe mitral regurgitation and very poor left ventricular systolic function - Safe but no room for complacency.

PubMed

Loh, Poay Huan; Bourantas, Christos V; Chan, Pak Hei; Ihlemann, Nikolaj; Gustafsson, Fin; Clark, Andrew L; Price, Susanna; Mario, Carlo Di; Moat, Neil; Alamgir, Farqad; Estevez-Loureiro, Rodrigo; Søndergaard, Lars; Franzen, Olaf

2015-11-26

Many patients with left ventricular systolic dysfunction have concomitant mitral regurgitation (MR). Their symptoms and prognosis worsen with increasing severity of MR. Percutaneous MitraClip(®) can be used safely to reduce the severity of MR even in patients with advanced heart failure and is associated with improved symptoms, quality of life and exercise tolerance. However, a few patients with very poor left ventricular systolic function may experience significant haemodynamic disturbance in the peri-procedural period. We present three such patients, highlighting some of the potential problems encountered and discuss their possible pathophysiological mechanisms and safety measures.

Catheter-based intervention for symptomatic patient with severe mitral regurgitation and very poor left ventricular systolic function - Safe but no room for complacency

PubMed Central

Loh, Poay Huan; Bourantas, Christos V; Chan, Pak Hei; Ihlemann, Nikolaj; Gustafsson, Fin; Clark, Andrew L; Price, Susanna; Mario, Carlo Di; Moat, Neil; Alamgir, Farqad; Estevez-Loureiro, Rodrigo; Søndergaard, Lars; Franzen, Olaf

2015-01-01

Many patients with left ventricular systolic dysfunction have concomitant mitral regurgitation (MR). Their symptoms and prognosis worsen with increasing severity of MR. Percutaneous MitraClip® can be used safely to reduce the severity of MR even in patients with advanced heart failure and is associated with improved symptoms, quality of life and exercise tolerance. However, a few patients with very poor left ventricular systolic function may experience significant haemodynamic disturbance in the peri-procedural period. We present three such patients, highlighting some of the potential problems encountered and discuss their possible pathophysiological mechanisms and safety measures. PMID:26635930

Early improvement in left atrial remodeling and function after mitral valve repair or replacement in organic symptomatic mitral regurgitation assessed by three-dimensional echocardiography.

PubMed

Le Bihan, David C S; Della Togna, Dorival Julio; Barretto, Rodrigo B M; Assef, Jorge Eduardo; Machado, Lúcia Romero; Ramos, Auristela Isabel de Oliveira; Abdulmassih Neto, Camilo; Moisés, Valdir Ambrosio; Sousa, Amanda G M R; Campos, Orlando

2015-07-01

Left atrial (LA) dilation is associated with worse prognosis in various clinical situations including chronic mitral regurgitation (MR). Real time three-dimensional echocardiography (3DE) has allowed a better assessment of LA volumes and function. Little is known about LA size and function in early postoperative period in symptomatic patients with chronic organic MR. We aimed to investigate these aspects. By means of 3DE, 43 patients with symptomatic chronic organic MR were prospectively studied before and 30 days after surgery (repair or bioprosthetic valve replacement). Twenty subjects were studied as controls. Maximum (Vol-max), minimum, and preatrial contraction LA volumes were measured and total, passive, and active LA emptying fractions were calculated. Before surgery patients had higher LA volumes (P < 0.001) but smaller LA emptying fractions than controls (P < 0.01). After surgery there was a reduction in all 3 LA volumes and an increase in active atrial emptying fraction (AAEF). Multivariate analysis showed that independent predictors of early postoperative Vol-max reduction were preoperative diastolic blood pressure (coefficient = -0.004; P = 0.02), lateral mitral annular early diastolic velocity (e') (coefficient = 0.023; P = 0.008), and the mean transmitral diastolic gradient increment (coefficient = -0.035; P < 0.001). Furthermore, e' was also independently associated with AAEF increase (odds ratio = 1.66, P = 0.027). Early LA reverse remodeling and functional improvement occur after successful surgery of symptomatic organic MR regardless of surgical technique. Diastolic blood pressure and transmitral mean gradient augmentation are variables negatively related to Vol-max reduction. Besides, e' is positively correlated with both Vol-max reduction and AAEF increase. © 2014, Wiley Periodicals, Inc.

Mitral regurgitation in patients with severe aortic stenosis: diagnosis and management.

PubMed

Sannino, Anna; Grayburn, Paul A

2018-01-01

Severe aortic stenosis (AS) and mitral regurgitation (MR) frequently coexist. Although some observational studies have reported that moderate or severe MR is associated with higher mortality, the optimal management of such patients is still unclear. Simultaneous replacement of both aortic and mitral valves is linked to significantly higher morbidity and mortality. Recent advances in minimally invasive surgical or transcatheter therapies for MR allow for staged procedures in which surgical or transcatheter aortic valve replacement (SAVR/TAVR) is done first and MR severity re-evaluated afterwards. Current evidence suggests MR severity improves in some patients after SAVR or TAVR, depending on several factors (MR aetiology, type of valve used for TAVR, presence/absence of atrial fibrillation, residual aortic regurgitation, etc). However, as of today, the absence of randomised clinical trials does not allow for evidence-based recommendations about whether or not MR should be addressed at the time of SAVR or TAVR. A careful patient evaluation and clinical judgement are recommended to distinguish patients who might benefit from a double valve intervention from those in which MR should be left alone. The aim of this review is to report and critique the available data on this subject in order to help guide the clinical decision making in this challenging subset of patients. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Mast cell stabilization decreases cardiomyocyte and LV function in dogs with isolated mitral regurgitation.

PubMed

Pat, Betty; Killingsworth, Cheryl; Chen, Yuanwen; Gladden, James D; Walcott, Greg; Powell, Pamela C; Denney, Thomas; Gupta, Himanshu; Desai, Ravi; Tillson, Michael; Dillon, A Ray; Dell'italia, Louis J

2010-09-01

Mast cells are increased in isolated mitral regurgitation (MR) in the dog and may mediate extracellular matrix loss and left ventricular (LV) dilatation. We tested the hypothesis that mast cell stabilization would attenuate LV remodeling and improve function in the MR dog. MR was induced in adult dogs randomized to no treatment (MR, n = 5) or to the mast cell stabilizer, ketotifen (MR + MCS, n = 4) for 4 months. LV hemodynamics were obtained at baseline and after 4 months of MR and magnetic resonance imaging (MRI) was performed at sacrifice. MRI-derived, serial, short-axis LV end-diastolic (ED) and end-systolic (ES) volumes, LVED volume/mass ratio, and LV 3-dimensional radius/wall thickness were increased in MR and MR + MCS dogs compared with normal dogs (n = 6) (P < .05). Interstitial collagen was decreased by 30% in both MR and MR + MCS versus normal dogs (P < .05). LV contractility by LV maximum time-varying elastance was significantly depressed in MR and MR + MCS dogs. Furthermore, cardiomyocyte fractional shortening was decreased in MR versus normal dogs and further depressed in MR + MCS dogs (P < .05). In vitro administration of ketotifen to normal cardiomyocytes also significantly decreased fractional shortening and calcium transients. Chronic mast cell stabilization did not attenuate eccentric LV remodeling or collagen loss in MR. However, MCS therapy had a detrimental effect on LV function because of a direct negative inotropic effect on cardiomyocyte function. Published by Elsevier Inc.

Finite Element Analysis of Patient-Specific Mitral Valve with Mitral Regurgitation.

PubMed

Pham, Thuy; Kong, Fanwei; Martin, Caitlin; Wang, Qian; Primiano, Charles; McKay, Raymond; Elefteriades, John; Sun, Wei

2017-03-01

Functional mitral regurgitation (FMR) is a significant complication of left ventricular dysfunction and strongly associated with a poor prognosis. In this study, we developed a patient-specific finite element (FE) model of the mitral apparatus in a FMR patient which included: both leaflets with thickness, annulus, chordae tendineae, and chordae insertions on the leaflets and origins on the papillary muscles. The FE model incorporated human age- and gender-matched anisotropic hyperelastic material properties, and MV closure at systole was simulated. The model was validated by comparing the FE results from valve closure simulation with the in vivo geometry of the MV at systole. It was found that the FE model could not replicate the in vivo MV geometry without the application of tethering pre-tension force in the chordae at diastole. Upon applying the pre-tension force and performing model optimization by adjusting the chordal length, position, and leaflet length, a good agreement between the FE model and the in vivo model was established. Not only were the chordal forces high at both diastole and systole, but the tethering force on the anterior papillary muscle was higher than that of the posterior papillary muscle, which resulted in an asymmetrical gap with a larger orifice area at the anterolateral commissure resulting in MR. The analyses further show that high peak stress and strain were found at the chordal insertions where large chordal tethering forces were found. This study shows that the pre-tension tethering force plays an important role in accurately simulating the MV dynamics in this FMR patient, particularly in quantifying the degree of leaflet coaptation and stress distribution. Due to the complexity of the disease, the patient-specific computational modeling procedure of FMR patients presented should be further evaluated using a large patient cohort. However, this study provides useful insights into the MV biomechanics of a FMR patient, and could serve

Exercise Dynamics in Secondary Mitral Regurgitation: Pathophysiology and Therapeutic Implications

PubMed Central

Bertrand, Philippe B.; Schwammenthal, Ehud; Levine, Robert A.; Vandervoort, Pieter M.

2016-01-01

Secondary mitral valve regurgitation (MR) remains a challenging problem in the diagnostic work-up and treatment of heart failure patients. Although secondary MR is characteristically dynamic in nature and sensitive to changes in ventricular geometry and loading, current therapy is mainly focused on resting conditions. Exercise-induced increase in secondary MR, however, is associated with impaired exercise capacity and increased mortality. In an era where a multitude of percutaneous solutions are emerging for the treatment of HF patients it becomes important to address the dynamic component of secondary MR during exercise as well. A critical reappraisal of the underlying disease mechanisms, and in particular of the dynamic component during exercise is of timely importance. This review summarizes the pathophysiologic mechanisms involved in the dynamic deterioration of secondary MR during exercise, its functional and prognostic impact, and the way current treatment options affect the dynamic lesion and exercise hemodynamics in general. PMID:28093494

Insights into the Mechanism of Severe Mitral Regurgitation: RT-3D TEE Guided Management with Pathological Correlation.

PubMed

Anand, Senthil; Hamoud, Naktal; Thompson, Jess; Janardhanan, Rajesh

2015-01-01

Mitral valve perforation is an uncommon but important complication of infective endocarditis. We report a case of a 65-year-old man who was diagnosed to have infective endocarditis of his mitral valve. Through the course of his admission he had a rapid development of hemodynamic instability and pulmonary edema secondary to acutely worsening mitral regurgitation. While the TEE demonstrated an increase in the size of his bacterial vegetation, Real Time 3D TEE was ultimately the imaging modality through which the valve perforation was identified. Through this case report we discuss the advantages that RT-3D TEE has over traditional 2D TEE in the management of valve perforation.

Characterization of Chronic Aortic and Mitral Regurgitation Undergoing Valve Surgery Using Cardiovascular Magnetic Resonance.

PubMed

Polte, Christian L; Gao, Sinsia A; Johnsson, Åse A; Lagerstrand, Kerstin M; Bech-Hanssen, Odd

2017-06-15

Grading of chronic aortic regurgitation (AR) and mitral regurgitation (MR) by cardiovascular magnetic resonance (CMR) is currently based on thresholds, which are neither modality nor quantification method specific. Accordingly, this study sought to identify CMR-specific and quantification method-specific thresholds for regurgitant volumes (RVols), RVol indexes, and regurgitant fractions (RFs), which denote severe chronic AR or MR with an indication for surgery. The study comprised patients with moderate and severe chronic AR (n = 38) and MR (n = 40). Echocardiography and CMR was performed at baseline and in all operated AR/MR patients (n = 23/25) 10 ± 1 months after surgery. CMR quantification of AR: direct (aortic flow) and indirect method (left ventricular stroke volume [LVSV] - pulmonary stroke volume [PuSV]); MR: 2 indirect methods (LVSV - aortic forward flow [AoFF]; mitral inflow [MiIF] - AoFF). All operated patients had severe regurgitation and benefited from surgery, indicated by a significant postsurgical reduction in end-diastolic volume index and improvement or relief of symptoms. The discriminatory ability between moderate and severe AR was strong for RVol >40 ml, RVol index >20 ml/m 2 , and RF >30% (direct method) and RVol >62 ml, RVol index >31 ml/m 2 , and RF >36% (LVSV-PuSV) with a negative likelihood ratio ≤ 0.2. In MR, the discriminatory ability was very strong for RVol >64 ml, RVol index >32 ml/m 2 , and RF >41% (LVSV-AoFF) and RVol >40 ml, RVol index >20 ml/m 2 , and RF >30% (MiIF-AoFF) with a negative likelihood ratio < 0.1. In conclusion, CMR grading of chronic AR and MR should be based on modality-specific and quantification method-specific thresholds, as they differ largely from recognized guideline criteria, to assure appropriate clinical decision-making and timing of surgery. Copyright © 2017 Elsevier Inc. All rights reserved.

A quantitative comparison of transesophageal and epicardial color Doppler echocardiography in the intraoperative assessment of mitral regurgitation.

PubMed

Kleinman, J P; Czer, L S; DeRobertis, M; Chaux, A; Maurer, G

1989-11-15

Epicardial and transesophageal color Doppler echocardiography are both widely used for the intraoperative assessment of mitral regurgitation (MR); however, it has not been established whether grading of regurgitation is comparable when evaluated by these 2 techniques. MR jet size was quantitatively compared in 29 hemodynamically and temporally matched open-chest epicardial and transesophageal color Doppler echocardiography studies from 22 patients (18 with native and 4 with porcine mitral valves) scheduled to undergo mitral valve repair or replacement. Jet area, jet length and left atrial area were analyzed. Comparison of jet area measurements as assessed by epicardial and transesophageal color flow mapping revealed an excellent correlation between the techniques (r = 0.95, p less than 0.001). Epicardial and transesophageal jet length measurements were also similar (r = 0.77, p less than 0.001). Left atrial area could not be measured in 18 transesophageal studies (62%) due to foreshortening, and in 5 epicardial studies (17%) due to poor image resolution. Acoustic interference with left atrial and color flow mapping signals was noted in all patients with mitral valve prostheses when imaged by epicardial echocardiography, but this did not occur with transesophageal imaging. Thus, in patients undergoing valve repair or replacement, transesophageal and epicardial color flow mapping provide similar quantitative assessment of MR jet size. Jet area to left atrial area ratios have limited applicability in transesophageal color flow mapping, due to foreshortening of the left atrial borders in transesophageal views. Transesophageal color flow mapping may be especially useful in assessing dysfunctional mitral prostheses due to the lack of left atrial acoustic interference.

Prognostic Value of Exercise Treadmill Testing in Asymptomatic Chronic Nonischemic Mitral Regurgitation

PubMed Central

Supino, Phyllis G.; Borer, Jeffrey S.; Schuleri, Karlheinz; Gupta, Anuj; Hochreiter, Clare; Kligfield, Paul; Herrold, Edmund McM.; Preibisz, Jacek J.

2007-01-01

In many heart diseases, exercise treadmill testing(ETT) has useful functional correlates and/or prognostic value. However, its predictive value in mitral regurgitation(MR) is undefined. To determine whether ETT descriptors predict death or indications for mitral valve surgery among patients with MR, we prospectively followed, for 7±3 endpoint-free years, a cohort of 38 patients with chronic severe nonischemic MR who underwent modified Bruce ETT; all lacked surgical indications at study entry. Their baseline exercise descriptors also were compared with those from 46 patients with severe MR who, at entry, already had reached surgical indications. Endpoints during follow-up among the cohort included sudden death(n=1), heart failure symptoms(n=2), atrial fibrillation(n=4), LVEF<60%(n=2), LV systolic dimensions(IDs)≥45 mm(n=12) and LVIDs>40mm(n=11), LVEF<60%+LVIDs 45 mm(n=3), and heart failure+LVIDs 45mm+LVEF<60%(n=1). In univariate analysis, exercise duration(p=.004), chronotropic response(p=.007), percent predicted peak heart rate(p=.01) and heart rate recovery(p<.02) predicted events; in multivariate analysis, only exercise duration was predictive(p<.02). Average annual event risk was 5-fold lower(4.62%) with exercise duration≥15 minutes vs. <15 minutes(average annual risk=23.48%, p=.004). Relative risks among patients with and without exercise-inducible ST segment depression were comparable(≤1.3[NS]) whether defined at entry and/or during follow-up. Exercise duration, but not prevalence of exercise-inducible ST segment depression, was lower(p<.001) among patients with surgical indications at entry vs. initially endpoint-free patients. In conclusion, among asymptomatic patients with chronic severe nonischemic MR and no objective criteria for operation, progression to surgical indications generally is rapid. However, those with excellent exercise tolerance have a relatively benign course. Exercise-inducible ST segment depression has no prognostic value in this

Prevalence and diagnostic characteristics of non-clinical mitral regurgitation murmurs in North American Whippets.

PubMed

Stepien, R L; Kellihan, H B; Luis Fuentes, V

2017-08-01

To assess the prevalence of functional ejection murmurs and murmurs of mitral regurgitation (MR) due to myxomatous mitral valve disease in healthy whippets; to assess the diagnostic value of auscultation to detect MR; and investigate the relationship between age and presence of echocardiographically documented MR (MR echo ). A total of 200 healthy client-owned Whippets, recruited at national shows between 2005 and 2009 were involved in this study. Cross-sectional study. Dogs were examined by auscultation by one examiner and Doppler echocardiography by another, and results were compared. Prevalence of types of murmurs and MR echo were calculated and correlated to age. Accuracy of auscultation to predict MR echo was calculated. Left-sided systolic heart murmurs were detected in 185/200 (93%) of dogs. Left apical systolic murmurs (L apex ) were detected in 57/200 (29%) and left basilar systolic murmurs (L base ) in 128/200 of the dogs (64%). MR echo was present in 76/200 (38%) dogs. Prevalence MR echo was correlated with age (r = 0.96, p=0.0028). Mitral regurgitation detected by echocardiography was present in 12/78 (15%) of the dogs ≤ 2 years of age and in 59% of the dogs at 7-8 years old. Detection of L apex predicted MR echo with sensitivity 65%, specificity 94%, positive predictive value 86%, and negative predictive value 81%; and accuracy improved when only dogs with more intense L apex (grade ≥ 3/6) were considered. Systolic murmurs are common in North American Whippets and this breed exhibits a high prevalence of MR echo , which may be documented at a relatively early age. Whippets with non-clinical MR echo may not be identifiable by auscultation alone; echocardiographic examination may be required to exclude a diagnosis of MR. Louder heart murmurs allow more accurate localization in this population. Copyright © 2017 Elsevier B.V. All rights reserved.

Aortic or Mitral Valve Replacement With the Biocor and Biocor Supra

ClinicalTrials.gov

2017-04-26

Aortic Valve Insufficiency; Aortic Valve Regurgitation; Aortic Valve Stenosis; Aortic Valve Incompetence; Mitral Valve Insufficiency; Mitral Valve Regurgitation; Mitral Valve Stenosis; Mitral Valve Incompetence

[Deformation of the tricuspid annulus by pericardial adhesions: a rare cause of early tricuspid regurgitation after mitral valve replacement].

PubMed

Tapia, M; Latrémouille, C; Chabert, J P; Fabiani, J N

1995-12-01

The authors report the case of major tricuspid regurgitation occurring early after mitral valve replacement. The mechanism was demonstrated at reoperation: the heart was deformed by a posterior pericardial effusion and cardiodiaphragmatic pericardial adhesions.

Transcatheter mitral direct annuloplasty: state of the art.

PubMed

Maisano, F; Kuck, K H

2014-06-01

Transcatheter mitral interventions are emerging as a novel therapy for patients with severe symptomatic mitral regurgitation who are deemed to be high risk or inoperable. Surgical treatment of mitral regurgitation includes a wide spectrum of therapies, ranging from leaflet and annular repair, to mitral valve replacement. Annuloplasty plays a fundamental role in open heart mitral valve repair, since it is associated with longer durability and higher degree of mitral regurgitation reduction. Direct annuloplasty is the interventional methodology most closely reproducing open heart annular repair. We describe the challenges and opportunities of the most promising technologies currently under development which will become available in clinical practice in the next future.

Radiographic features of cardiogenic pulmonary edema in dogs with mitral regurgitation: 61 cases (1998-2007).

PubMed

Diana, Alessia; Guglielmini, Carlo; Pivetta, Mauro; Sanacore, Antonina; Di Tommaso, Morena; Lord, Peter F; Cipone, Mario

2009-11-01

To evaluate radiographic distribution of pulmonary edema (PE) in dogs with mitral regurgitation (MR) and investigate the association between location of radiographic findings and direction of the mitral regurgitant jet (MRJ). Retrospective case series. 61 dogs with cardiogenic PE and MR resulting from mitral valve disease (MVD; 51 dogs), dilated cardiomyopathy (9), and hypertrophic cardiomyopathy (1). Thoracic radiographs of dogs with Doppler echocardiographic evidence of MR were reviewed for location (diffuse, perihilar, or focal) of PE. Also, direction (central or eccentric) of the MRJ, as evaluated by Doppler color flow mapping (DCFM), and distribution (symmetric or asymmetric) of radiographic findings were evaluated. Diffuse, perihilar, and focal increases in pulmonary opacity were observed in 11 (18.0%), 7 (11.5%), and 43 (70.5%) of 61 dogs, respectively. Radiographic evidence of asymmetric PE in a single lung lobe or 2 ipsilateral lobes was found in 21 dogs, with involvement of only the right caudal lung lobe in 17 dogs. Doppler color flow mapping of the MRJ was available for 46 dogs. Of 31 dogs with a central MRJ, 28 had radiographic findings indicative of symmetric PE. Of 15 dogs with eccentric MRJ, 11 had radiographic evidence of asymmetric PE, and all of these dogs had MVD. In dogs with cardiogenic PE, a symmetric radiographic distribution of increased pulmonary opacity was predominantly associated with a central MRJ, whereas an asymmetric radiographic distribution was usually associated with eccentric MRJ, especially in dogs with MVD.

Evolution of Functional Mitral Regurgitation and Prognosis in Medically Managed Heart Failure Patients With Reduced Ejection Fraction.

PubMed

Nasser, Riwa; Van Assche, Lauranne; Vorlat, Anne; Vermeulen, Tom; Van Craenenbroeck, Emeline; Conraads, Viviane; Van der Meiren, Vicky; Shivalkar, Bharati; Van Herck, Paul; Claeys, Marc J

2017-09-01

The purpose of this study was to assess whether medical management may alter the severity of functional mitral regurgitation (FMR) and its prognosis in patients who have heart failure with reduced ejection fraction (HFrEF). FMR in patients who have HFrEF is associated with a worse prognosis. It is uncertain to what extent medical management may alter the severity of FMR and its prognosis. The extent of FMR was assessed at baseline and after a median follow-up period of 50 months in 163 consecutive HFrEF patients (left ventricular ejection fraction <40%). Severe FMR was defined as mitral regurgitation (MR) grade 3-4. All of the patients received the maximal tolerable doses of their heart failure (HF) medications. Major adverse cardiac events were defined as a composite of all-cause death and the need for heart transplantation or hospitalization for HF and/or malignant arrhythmias. A total of 50 (31%) patients had severe MR at baseline. During the follow-up period, 38% of the severe FMR patients showed an improvement to nonsevere FMR (MR grade <3), whereas 18% of the nonsevere FMR patients developed severe FMR despite optimal HF treatment. Cox regression analysis revealed that the presence of sustained severe FMR or worsening of FMR was the most important independent prognostic determinant with an adjusted odds ratio of 2.5 (95% confidence interval: 1.5 to 4.3, major adverse cardiac events 83% vs. 43%). In addition, those patients showed a 13% increase in left ventricular end-diastolic volume index (LVEDVI), whereas the patients with improvement in their severe MR showed a 2% decrease in LVEDVI (p = 0.01). Severe FMR was successfully treated with medication in almost 40% and was associated with prevention of left ventricular adverse remodeling and with an improved long-term prognosis. Copyright © 2017 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Rate of change of heart size before congestive heart failure in dogs with mitral regurgitation.

PubMed

Lord, P; Hansson, K; Kvart, C; Häggström, J

2010-04-01

The objective of the study was to examine the changes in vertebral heart scale, and left atrial and ventricular dimensions before and at onset of congestive heart failure in cavalier King Charles spaniels with mitral regurgitation. Records and radiographs from 24 cavalier King Charles spaniels with mitral regurgitation were used. Vertebral heart scale (24 dogs), and left atrial dimension and left ventricular end diastolic and end systolic diameters (18 dogs) and their rate of increase were measured at intervals over years to the onset of congestive heart failure. They were plotted against time to onset of congestive heart failure. Dimensions and rates of change of all parameters were highest at onset of congestive heart failure, the difference between observed and chance outcome being highly significant using a two-tailed chi-square test (P<0.001). The left heart chambers increase in size rapidly only in the last year before the onset of congestive heart failure. Increasing left ventricular end systolic dimension is suggestive of myocardial failure before the onset of congestive heart failure. Rate of increase of heart dimensions may be a useful indicator of impending congestive heart failure.

Dynamics of Concomitant Functional Mitral Regurgitation in Patients with Aortic Stenosis Undergoing TAVI

PubMed Central

Sahinarslan, Asife; Vecchio, Francesco; MacCarthy, Philip; Dworakowski, Rafal; Deshpande, Ranjit; Wendler, Olaf; Monaghan, Mark

2016-01-01

Background The aim of this study was to investigate the echocardiographic features of functional mitral regurgitation (MR) in patients with aortic stenosis (AS) pre- and post-trans catheter aortic valve implantation (TAVI). Methods The study subjects consisted of 79 patients with severe AS, who underwent TAVI. The echocardiographic parameters related to MR severity prior to TAVI and the change in these parameters and MR severity within one month after implantation were retrospectively evaluated. Results The mean left ventricular ejection fraction (LVEF) was 53 ± 12%, and the mean MR severity was 1.2 ± 0.7. Among the baseline parameters, age (p = 0.019, r = 0.264), LV mass (p = 0.017, r = 0.269), deceleration time (DT) (p = 0.019, r = -0.266), left atrial diameter (p = 0.003, r = 0.325), were related to pre-procedure MR severity. After TAVI, the grade of MR (1.2 ± 0.7 vs. 0.8 ± 0.6, p < 0.001) and MR duration (43 ± 19% vs. 31 ± 23%, p < 0.001) were significantly decreased. The grade of pre-procedural MR (p < 0.001) was a predictor of residual MR after TAVI. However, there was not a significant change in the left ventricular echocardiographic parameters after TAVI [LVEF (53 ± 12 vs. 52 ± 11, p = 0.285), and LV mass (302 ± 84 vs. 306 ± 76 g, p = 0.495)]. Conclusions In patients with severe AS, functional MR is related to age, LV mass, DT and left atrial diameter. TAVI improves MR in these patients, even before LV remodelling occurs. PMID:27471361

Problem: Heart Valve Regurgitation

MedlinePlus

... should be completely closed For example: Watch an animation of mitral valve regurgitation A leaking mitral valve ... Not Alone Popular Articles 1 Understanding Blood Pressure Readings 2 Sodium and Salt 3 Heart Attack Symptoms ...

Reduction of severe mitral regurgitation with the MitraClip system improves renal function in two patients presenting with acute kidney injury and progressive renal failure due to cardio renal syndrome.

PubMed

Asdonk, T; Nickenig, G; Hammerstingl, C

2014-10-01

Mitral regurgitation (MR) is a frequent valve disorder in elderly patients, often accompanied by multiple comorbidities such as renal impairment. In these patients percutaneous mitral valve (MV) repair has become an established treatment option but the role of MR on renal dysfunction is not yet well defined. We here report on two cases presenting with severe MR and progressive renal failure caused by cardio renal syndrome, in which percutaneous MV treatment with the MitraClip system significantly improved renal function. These findings suggest that interventional MV repair can prevent progression of renal deterioration in patients suffering from combined advanced heart and renal failure. Further clinical studies are necessary to support our finding and to answer the question whether optimizing renal function by implantation of the MitraClip device is also of prognostic relevance in these patients. © 2014 Wiley Periodicals, Inc.

Does moderate tricuspid regurgitation require attention during mitral valve surgery?

PubMed

Yeates, Alexander; Marwick, Thomas; Deva, Rajeev; Mundy, Julie; Wood, Annabelle; Griffin, Rayleene; Peters, Paul; Shah, Pallav

2014-01-01

This study aims to determine whether tricuspid regurgitation (TR) ≥ 2+ requires attention during mitral valve surgery. From April 1999 to 2009, 161 patients undergoing primary, isolated mitral valve procedures were assessed. Preoperative moderate TR (≥2+) was present in 56 of 161 patients and tricuspid valve repair (TVR: ring annuloplasty) was carried out on 22 of 56 patients with TR ≥ 2+. Baseline echocardiogram included TR severity (ASE criteria), TR velocity, estimated right atrial pressure, visual assessment of right ventricular failure and strain. Follow-up was 47 ± 33 months (96% complete); 91 of 161 patients overall (57%) and 44 of 45 patients with TR ≥ 2+ had follow-up echocardiogram. Patients with moderate TR had worse baseline functional class and operative risks, both worst in the non-TVR group. Overall mortality was 15% (n = 23), comprising 2.5% (4/161) 30-day mortality and 12% (9/157) late death. Poorer preoperative TR was associated with worse survival by univariate analysis (P = 0.046), after correction for right ventricular function and pulmonary artery pressure (P = 0.049), age and diabetes (P = 0.041). Despite lower risk of TR ≥ 2+ with TVR, 5-year survival was 42%, which was less than TR < 2+ and that of non-TVR group (90%, P = 0.003). Improvement in overall functional class (NYHA) was better in the non-TVR group (TVR: preoperative 2.1 ± 1.5; post-operative 1.2 ± 1.1 (P = 0.02) versus non-TVR: preoperative 1.8 ± 1.4, post-operative 1.2 ± 0.9 (P < 0.0001)). There was no difference in quality of life (QOL) indices (SF-36 questionnaire) at follow-up between patients with TR < 2+ and TR ≥ 2+ preoperatively, or across all levels of TR before or after surgical repair. Preoperative TR ≥ 2+, non-TVR group had more favourable functional class and mid-term survival with comparable QOL and echocardiographic parameters to the TVR group. © 2013 The Authors. ANZ Journal of Surgery © 2013 Royal Australasian College of Surgeons.

Twenty-year outcome of anomalous origin of left coronary artery from pulmonary artery: management of mitral regurgitation.

PubMed

Kudumula, Vikram; Mehta, Chetan; Stumper, Oliver; Desai, Tarak; Chikermane, Ashish; Miller, Paul; Dhillon, Rami; Jones, Timothy J; De Giovanni, Joseph; Brawn, William J; Barron, David J

2014-03-01

This study is a single-center experience with surgical repair of anomalous origin of left coronary artery from pulmonary artery (ALCAPA) with focus on the management of associated mitral regurgitation (MR). We performed a retrospective analysis of cases presenting to a quaternary referral center between November 1990 and October 2011. In all, 25 patients (18 female) presented with a diagnosis of ALCAPA at a median age of 5 months (range, 1.5 to 102). Twenty-one patients (84%) had moderate to severe impairment of left ventricular function with median fractional shortening of 14% (range, 2% to 33%), and 19 patients (76%) had moderate to severe MR. Surgery was performed with direct coronary reimplantation in 16 patients (64%) and intrapulmonary tunnel (Takeuchi repair) in 9 (36%). Four patients had mitral valve repair at time of surgery, all for structural anomalies. Functional MR with a structurally normal mitral valve was not repaired. The median duration of postoperative follow-up was 93 months (range, 9 to 240). There were no early or late deaths, and no patient required mechanical support. Four patients (16%) required surgical or catheter reintervention. At last follow-up, 24 of 25 patients were asymptomatic; the left ventricular function was normal in 22 patients. Moderate MR was present in 4 patients. There was significant improvement in left ventricular function and MR (p < 0.01) during follow-up. Surgical repair of ALCAPA has good long-term results with low mortality and reintervention rates. The majority of MR is functional and will improve with reperfusion, but structural mitral valve abnormalities should be repaired at the time of surgery. Copyright © 2014 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Determinants of the development of mitral regurgitation in pacing-induced heart failure.

PubMed

Takagaki, Masami; McCarthy, Patrick M; Goormastic, Marlene; Ochiai, Yoshie; Doi, Kazuyoshi; Kopcak, Michael W; Tabata, Tomotsugu; Cardon, Lisa A; Thomas, James D; Fukamachi, Kiyotaka

2003-01-01

The pacing-induced heart failure model provides an opportunity to assess the structural and functional determinants of mitral regurgitation (MR) in dilated cardiomyopathy. This study aimed to evaluate MR to better understand the multitude of factors contributing to its development. Heart failure was induced by rapid ventricular pacing (230 beats/min) in 40 mongrel dogs. Left ventricular (LV) size and MR were evaluated echocardiographically. LV contractility was analyzed using a conductance catheter. MR increased to mild in 12 animals (regurgitant orifice area, 0.06+/-0.05 cm(2)), moderate in 15 (0.14+/-0.07 cm(2)), and severe in 13 (0.34+/-0.16 cm(2)). The grade of MR had an inverse relationships with E(max) (the slope of the end-systolic pressure-volume relationship, p<0.01) and dE/dt (the slope of the maximum rate of change of pressure-end-diastolic volume [V(ED)] relationship, p<0.01) and positive relationships with V(ED) and end-diastolic cross-sectional areas and lengths (p<0.05) by univariate analysis. The dE/dt had an independently significant (p<0.01) relationship by multivariable logistic regression. Many factors influence the development of MR and because of its similarity to the clinical situation, this model can be used to investigate MR and heart failure, as well as new surgical therapies.

Transcatheter Mitral Valve Replacement for Patients With Symptomatic Mitral Regurgitation: A Global Feasibility Trial.

PubMed

Muller, David W M; Farivar, Robert Saeid; Jansz, Paul; Bae, Richard; Walters, Darren; Clarke, Andrew; Grayburn, Paul A; Stoler, Robert C; Dahle, Gry; Rein, Kjell A; Shaw, Marty; Scalia, Gregory M; Guerrero, Mayra; Pearson, Paul; Kapadia, Samir; Gillinov, Marc; Pichard, Augusto; Corso, Paul; Popma, Jeffrey; Chuang, Michael; Blanke, Philipp; Leipsic, Jonathon; Sorajja, Paul

2017-01-31

Symptomatic mitral regurgitation (MR) is associated with high morbidity and mortality that can be ameliorated by surgical valve repair or replacement. Despite this, many patients with MR do not undergo surgery. Transcatheter mitral valve replacement (TMVR) may be an option for selected patients with severe MR. This study aimed to examine the effectiveness and safety of TMVR in a cohort of patients with native valve MR who were at high risk for cardiac surgery. Patients underwent transcatheter, transapical delivery of a self-expanding mitral valve prosthesis and were examined in a prospective registry for short-term and 30-day outcomes. Thirty patients (age 75.6 ± 9.2 years; 25 men) with grade 3 or 4 MR underwent TMVR. The MR etiology was secondary (n = 23), primary (n = 3), or mixed pathology (n = 4). The Society of Thoracic Surgeons Predicted Risk of Mortality was 7.3 ± 5.7%. Successful device implantation was achieved in 28 patients (93.3%). There were no acute deaths, strokes, or myocardial infarctions. One patient died 13 days after TMVR from hospital-acquired pneumonia. Prosthetic leaflet thrombosis was detected in 1 patient at follow-up and resolved after increased oral anticoagulation with warfarin. At 30 days, transthoracic echocardiography showed mild (1+) central MR in 1 patient, and no residual MR in the remaining 26 patients with valves in situ. The left ventricular end-diastolic volume index decreased (90.1 ± 28.2 ml/m 2 at baseline vs. 72.1 ± 19.3 ml/m 2 at follow-up; p = 0.0012), as did the left ventricular end-systolic volume index (48.4 ± 19.7 ml/m 2 vs. 43.1 ± 16.2 ml/m 2 ; p = 0.18). Seventy-five percent of the patients reported mild or no symptoms at follow-up (New York Heart Association functional class I or II). Successful device implantation free of cardiovascular mortality, stroke, and device malfunction at 30 days was 86.6%. TMVR is an effective and safe therapy for selected patients with symptomatic native MR. Further

Four decades of experience with mitral valve repair: analysis of differential indications, technical evolution, and long-term outcome.

PubMed

DiBardino, Daniel J; ElBardissi, Andrew W; McClure, R Scott; Razo-Vasquez, Ozwaldo A; Kelly, Nicole E; Cohn, Lawrence H

2010-01-01

To determine the long-term outcomes of mitral valvuloplasty for myxomatous valve disease, rheumatic valve disease, and functional mitral regurgitation. A total of 1503 patients underwent mitral valvuloplasty by a single surgeon between February 1972 and April 2008 and were retrospectively reviewed for short- and long-term results. Overall mean age was 60.3 + or - 13.7 years, and 57% were male. The cause was rheumatic in 193 patients, myxomatous in 1042 patients, and ischemic and nonischemic functional mitral regurgitation in 236 patients. Ring annuloplasty was performed in 1306 patients (87%). Commissurotomy was the primary repair for rheumatic valves, posterior leaflet resection and reconstruction was the most common repair for myxomatous valves (527/1042 [51%]), and ring reduction annuloplasty was the primary operation for functional mitral regurgitation. The 30-day mortality was 19 of 1503 patients (1.3%) and significantly higher in the functional mitral regurgitation group (11/236 patients, 4.7% vs 0.5% in the rheumatic group and 0.6% in the myxomatous group, P < .01). The 10-, 20-, and 30-year survivals were similar for the rheumatic and myxomatous groups (77%, 56%, and 39% vs 79%, 62%, and 52%, respectively) but significantly less for the functional mitral regurgitation group (44%, 4%, and 0%, respectively, log-rank P < .0001). The 10- and 20-year freedom from reoperation rates were significantly better for the myxomatous group than for the rheumatic group (90% and 82% vs 66% and 34%, log-rank P < .0001), with a 30-year freedom from reoperation of only 10% for rheumatic repair. In the myxomatous group, freedom from reoperation was lower in patients with anterior leaflet pathology (P = .0008). Follow-up data to 36 years demonstrate that cause strongly determines survival and durability of mitral valvuloplasty; patients with rheumatic valve disease who survive more than 20 years require reoperation, whereas functional mitral regurgitation carries the highest

Predictors of ischaemic mitral regurgitation recurrence in patients undergoing combined surgery: additional value of cardiovascular magnetic resonance imaging.

PubMed

Glaveckaite, Sigita; Uzdavinyte-Gateliene, Egle; Petrulioniene, Zaneta; Palionis, Darius; Valeviciene, Nomeda; Kalinauskas, Gintaras; Serpytis, Pranas; Laucevicius, Aleksandras

2018-03-09

We aimed to evaluate (i) the effectiveness of combined surgery (coronary artery bypass grafting with restrictive mitral valve annuloplasty) and (ii) the late gadolinium enhancement cardiovascular magnetic resonance-based predictors of ischaemic mitral regurgitation (IMR) recurrence. The prospective analysis included 40 patients with multivessel coronary artery disease, IMR >II° and left ventricular (LV) dysfunction undergoing combined surgery. The degree of IMR and LV parameters were assessed preoperatively by transthoracic echocardiography, 3D transoesophageal echocardiography and cardiovascular magnetic resonance and postoperatively by transthoracic echocardiography. The effective mitral valve repair group (n = 30) was defined as having recurrent ischaemic mitral regurgitation (RIMR) ≤II° at the end of follow-up (25 ± 11 months). The surgery was effective: freedom from RIMR >II° at 1 and 2 years after surgery was 80% and 75%, respectively. Using multivariable logistic regression, 2 independent predictors of RIMR >II° were identified: ≥3 non-viable LV segments (odds ratio 22, P = 0.027) and ≥1 non-viable segment in the LV posterior wall (odds ratio 11, P = 0.026). Using classification trees, the best combinations of cardiovascular magnetic resonance-based and 3D transoesophageal echocardiography-based predictors for RIMR >II° were (i) posterior mitral valve leaflet angle >40° and LV end-systolic volume index >45 ml/m2 (sensitivity 100%, specificity 89%) and (ii) scar transmurality >68% in the inferior LV wall and EuroSCORE II >8 (sensitivity 83%, specificity 78%). There is a clear relationship between the amount of non-viable LV segments, especially in the LV posterior and inferior walls, and the recurrence of IMR after the combined surgery.

Echocardiographic parameters predicting acute hemodynamically significant mitral regurgitation during transfemoral transcatheter aortic valve replacement.

PubMed

Ito, Asahiro; Iwata, Shinichi; Mizutani, Kazuki; Nonin, Shinichi; Nishimura, Shinsuke; Takahashi, Yosuke; Yamada, Tokuhiro; Murakami, Takashi; Shibata, Toshihiko; Yoshiyama, Minoru

2018-03-01

Alteration in mitral valve morphology resulting from retrograde stiff wire entanglement sometimes causes hemodynamically significant acute mitral regurgitation (MR) during transfemoral transcatheter aortic valve replacement (TAVR). Little is known about the echocardiographic parameters related to hemodynamically significant acute MR. This study population consisted of 64 consecutive patients who underwent transfemoral TAVR. We defined hemodynamically significant acute MR as changes in the severity of MR with persistent hypotension (systolic blood pressure < 80-90 mm Hg or mean arterial pressure 30 mm Hg lower than baseline). Hemodynamically significant acute MR occurred in 5 cases (7.8%). Smaller left ventricular end-systolic diameter (LVDs), larger ratios of the coiled section of stiff wire tip to LVDs (wire-width/LVDs), and higher Wilkins score were significantly associated with hemodynamically significant acute MR (P < .05), whereas the parameters of functional MR (annular area, anterior-posterior diameter, tenting area, and coaptation length) were not. Moreover, when patients were divided into 4 groups according to wire-width/LVDs and Wilkins score, the group with the larger wire-width/LVDs and higher Wilkins score improved prediction rates (P < .05). Small left ventricle or wire oversizing and calcific mitral apparatus were predictive of hemodynamically significant acute MR. These findings are important for risk stratification, and careful monitoring using intraoperative transesophageal echocardiography may improve the safety in this population. © 2017, Wiley Periodicals, Inc.

Long-term echocardiographic follow-up of untreated 2+ functional tricuspid regurgitation in patients undergoing mitral valve surgery†

PubMed Central

Kusajima, Kunio; Fujita, Tomoyuki; Hata, Hiroki; Shimahara, Yusuke; Miura, Sayaka; Kobayashi, Junjiro

2016-01-01

OBJECTIVES Concomitant tricuspid valve surgery with mitral valve surgery is recommended for patients with severe functional tricuspid regurgitation (TR). However, the treatment for 2+ TR (mild TR) remains controversial. Here, we evaluated the long-term results of untreated 2+ TR in patients undergoing mitral valve surgery. METHODS We retrospectively reviewed the records of 96 patients with untreated 2+ TR among 885 patients who underwent mitral valve surgery from 2003 to 2010. Exclusion criteria were tricuspid valve surgery (TVS), emergency surgery, primary TR and pacemaker lead through the tricuspid valve. We assessed survival and freedom from heart failure. The freedom from 3+ (moderate) or 4+ (severe) TR was investigated by echocardiographic data at pre- and postoperative week 1, then at 1, 3, 5, 7 and 10 postoperative years, which were compared with those in patients who had 2+ TR preoperatively and underwent concomitant TVS in the same period (n = 47). RESULTS The mean follow-up was 7.1 ± 2.7 years. There was no 30-day mortality. The survival rate was 97.5% at 5 years and 87.5% at 10 years. The independent risk factors for mortality were age (OR 1.2, P = 0.03) and left ventricular ejection fraction (OR 0.9, P = 0.03). Untreated 2+ TR improved transiently within the first postoperative year (P < 0.001), but progressed again in the mid- to long term. Freedom from ≥3+ TR was 64.2% at 5 years and 46.7% at 10 years, which was significantly lower than that from ≥3+ TR in patients who underwent concomitant TVS (P = 0.006). The independent risk factors for TR progression (≥3 + TR) were age (OR 1.1, P = 0.005), atrial fibrillation (OR 2.2, P = 0.04) and tricuspid annular diameter (TAD) index (mm/m2; OR 1.1, P = 0.02). Receiver operating characteristic curves showed that the optimal TAD index cut-off value was 21.0 for long-term survival [area under the curve (AUC) = 0.72] and 21.2 for TR progression (AUC = 0.64). CONCLUSIONS Although untreated, 2+ TR

Long-term echocardiographic follow-up of untreated 2+ functional tricuspid regurgitation in patients undergoing mitral valve surgery.

PubMed

Kusajima, Kunio; Fujita, Tomoyuki; Hata, Hiroki; Shimahara, Yusuke; Miura, Sayaka; Kobayashi, Junjiro

2016-07-01

Concomitant tricuspid valve surgery with mitral valve surgery is recommended for patients with severe functional tricuspid regurgitation (TR). However, the treatment for 2+ TR (mild TR) remains controversial. Here, we evaluated the long-term results of untreated 2+ TR in patients undergoing mitral valve surgery. We retrospectively reviewed the records of 96 patients with untreated 2+ TR among 885 patients who underwent mitral valve surgery from 2003 to 2010. Exclusion criteria were tricuspid valve surgery (TVS), emergency surgery, primary TR and pacemaker lead through the tricuspid valve. We assessed survival and freedom from heart failure. The freedom from 3+ (moderate) or 4+ (severe) TR was investigated by echocardiographic data at pre- and postoperative week 1, then at 1, 3, 5, 7 and 10 postoperative years, which were compared with those in patients who had 2+ TR preoperatively and underwent concomitant TVS in the same period (n = 47). The mean follow-up was 7.1 ± 2.7 years. There was no 30-day mortality. The survival rate was 97.5% at 5 years and 87.5% at 10 years. The independent risk factors for mortality were age (OR 1.2, P = 0.03) and left ventricular ejection fraction (OR 0.9, P = 0.03). Untreated 2+ TR improved transiently within the first postoperative year (P < 0.001), but progressed again in the mid- to long term. Freedom from ≥3+ TR was 64.2% at 5 years and 46.7% at 10 years, which was significantly lower than that from ≥3+ TR in patients who underwent concomitant TVS (P = 0.006). The independent risk factors for TR progression (≥3 + TR) were age (OR 1.1, P = 0.005), atrial fibrillation (OR 2.2, P = 0.04) and tricuspid annular diameter (TAD) index (mm/m(2); OR 1.1, P = 0.02). Receiver operating characteristic curves showed that the optimal TAD index cut-off value was 21.0 for long-term survival [area under the curve (AUC) = 0.72] and 21.2 for TR progression (AUC = 0.64). Although untreated, 2+ TR significantly improved after mitral valve

Pharmacokinetics of nicorandil in dogs with mild mitral regurgitation.

PubMed

Fukunaga, K; Fujii, Y; Chiba, N; Ueshima, A; Wakao, Y; Mishima, K; Fujiwara, M; Orito, K

2011-02-01

The aim of this study was to examine the pharmacokinetics of nicorandil, a hybrid of an adenosine triphosphate-sensitive potassium channel opener and a nitrate, and to estimate its clinical doses in dogs with mild mitral valve regurgitation (MR). Nicorandil (0.1, 0.3, and 1.0 mg/kg) was administered orally to normal dogs and those with experimentally-induced MR, and its plasma concentrations were analyzed using high-performance liquid chromatography. Plasma concentrations increased dose-dependently after the administration of nicorandil, and were not different between normal dogs and those with MR. Similar to the effective plasma values obtained in cardiac disease in humans, the findings of this pharmacokinetic study may indicate that a dose of 0.3-1.0 mg/kg has the same effectiveness in dogs with cardiac dysfunction. Copyright © 2010. Published by Elsevier India Pvt Ltd.

Effects of 4 classes of cardiovascular drugs on ventricular function in dogs with mitral regurgitation.

PubMed

Nakayama, Tomohiro; Nishijima, Yoshinori; Miyamoto, Mutsumi; Hamlin, Robert L

2007-01-01

There have been few trials in which dogs with mitral regurgitation (MR) have been treated with various cardioactive drugs to determine effects on left ventricular (LV) function. Four classes of cardiovascular drugs may improve LV function in dogs with MR without increasing MR. Nine mature dogs were included in the study. MR was produced in 9 dogs. Five months later under butorphanol narcosis, parameters of LV function and left atrial dimension (LAD) were monitored by LV micromanometry and echocardiography/Doppler. Dogs were given (in random order) enalaprilat, nitroglycerine, ouabain, milrinone, and placebo. Nitroglycerin produced no significant change; milrinone and ouabain increased contractility; ouabain decreased heart rate; and there was evidence that enalaprilat and milrinone decreased LAD. Milrinone and ouabain decreased isovolumetric contraction time and therefore the time available for MR. There was no evidence that a positive inotrope increased MR despite increasing LV contractility and stroke volume. This study contradicts the hypotheses that (1) strengthening the left ventricle may increase MR and (2) treatment of MR (even before symptoms of heart failure develop) may decrease LAD. It is reasonable that strengthening the force of LV contraction should increase the driving pressure for MR; however, this effect did not appear to increase MR. Although some investigators believe that treating dogs with MR with afterload reducers and decreasing hindrance to ejection of blood from the LV to aorta may lengthen life by decreasing MR, there did not appear to be a reduction in MR, at least in response to the angiotensin-converting enzyme (ACE) inhibitor.

Percutaneous transluminal mitral commissurotomy for rheumatic mitral stenosis in a 5-year-old child.

PubMed

Ullah, Maad; Sultan, Mehboob; Akbar, Hajira; Sadiq, Nadeem

2012-06-01

We report a 5-year-old boy weighing 11 kg, with severe mitral valve stenosis of rheumatic aetiology, who underwent successful percutaneous transluminal mitral commissurotomy (PTMC) with valvuloplasty balloon. Postprocedural mean pressure gradient across the mitral valve decreased to 6 mmHg from an initially recorded value of 22 mmHg. In addition to symptomatic improvement, the mitral valvular area increased from 0.4 to 0.8 cm(2) without significant change in mitral regurgitation. At 1- and 3-month follow up, transthoracic echocardiography revealed further improvement with an increase in mitral valve area to 1.0 cm(2), a decrease in pulmonary arterial pressure, and a mean mitral valve pressure gradient of 8 mmHg with trivial mitral regurgitation. To best of our knowledge, this is the first successful PTMC procedure performed in the youngest and smallest ever reported child with rheumatic mitral stenosis (MS). We conclude that PTMC with valvuloplasty balloon could be a logical alternative to surgery in young patients with rheumatic MS.

The value of assessing pulmonary venous flow velocity for predicting severity of mitral regurgitation: A quantitative assessment integrating left ventricular function

NASA Technical Reports Server (NTRS)

Pu, M.; Griffin, B. P.; Vandervoort, P. M.; Stewart, W. J.; Fan, X.; Cosgrove, D. M.; Thomas, J. D.

1999-01-01

Although alteration in pulmonary venous flow has been reported to relate to mitral regurgitant severity, it is also known to vary with left ventricular (LV) systolic and diastolic dysfunction. There are few data relating pulmonary venous flow to quantitative indexes of mitral regurgitation (MR). The object of this study was to assess quantitatively the accuracy of pulmonary venous flow for predicting MR severity by using transesophageal echocardiographic measurement in patients with variable LV dysfunction. This study consisted of 73 patients undergoing heart surgery with mild to severe MR. Regurgitant orifice area (ROA), regurgitant stroke volume (RSV), and regurgitant fraction (RF) were obtained by quantitative transesophageal echocardiography and proximal isovelocity surface area. Both left and right upper pulmonary venous flow velocities were recorded and their patterns classified by the ratio of systolic to diastolic velocity: normal (>/=1), blunted (<1), and systolic reversal (<0). Twenty-three percent of patients had discordant patterns between the left and right veins. When the most abnormal patterns either in the left or right vein were used for analysis, the ratio of peak systolic to diastolic flow velocity was negatively correlated with ROA (r = -0.74, P <.001), RSV (r = -0.70, P <.001), and RF (r = -0.66, P <.001) calculated by the Doppler thermodilution method; values were r = -0.70, r = -0.67, and r = -0.57, respectively (all P <.001), for indexes calculated by the proximal isovelocity surface area method. The sensitivity, specificity, and predictive values of the reversed pulmonary venous flow pattern for detecting a large ROA (>0.3 cm(2)) were 69%, 98%, and 97%, respectively. The sensitivity, specificity, and predictive values of the normal pulmonary venous flow pattern for detecting a small ROA (<0.3 cm(2)) were 60%, 96%, and 94%, respectively. However, the blunted pattern had low sensitivity (22%), specificity (61%), and predictive values (30

Impact of percutaneous mitral valvuloplasty on left ventricular function in patients with mitral stenosis assessed by 3D echocardiography.

PubMed

Esteves, William Antonio M; Lodi-Junqueira, Lucas; Soares, Juliana Rodrigues; Sant'Anna Athayde, Guilherme Rafael; Goebel, Gabriela Assunção; Carvalho, Lucas Amorim; Zeng, Xin; Hung, Judy; Tan, Timothy C; Nunes, Maria Carmo Pereira

2017-12-01

The status of intrinsic left ventricular (LV) contractility in patients with isolated rheumatic mitral stenosis (MS) has been debated. The acute changes in loading conditions after percutaneous mitral valvuloplasty (PMV) may affect LV performance. We aimed to examine the acute effects of PMV on LV function and identify factors associated with LV ejection fraction (LVEF) changes, and determinants of long-term events following the procedure. One hundred and forty-two patients who underwent PMV for symptomatic rheumatic MS (valve area of 0.99±0.3cm 2 ) were prospectively enrolled. LV volumes and LVEF were measured by three-dimensional (3D) echocardiography. Long-term outcome was a composite endpoint of death, mitral valve (MV) replacement, repeat PMV, new onset of atrial fibrillation, and stroke. The mean age was 42.3±12.1years, and 125 patients were women (88%). After PMV, LVEF increased significantly (51.4 vs 56.5%, p<0.001), primary due to a significant increase in LV end-diastolic volume (65.8mL vs 67.9mL, p=0.002), and resultant increase in the stroke volume (33.9mL vs 39.6mL, p<0.001). Changes in cardiac index and systolic pulmonary artery pressure were associated with LVEF changes after PMV. During a mean follow-up period of 30.8months, 28 adverse clinical events were observed. Postprocedural mitral regurgitation, MV area, and mean gradient were independent predictors of composite endpoints. In patients with rheumatic MS, PMV resulted in a significant improvement in LV end-diastolic volume, stroke volume and consequently increased in LVEF. Changes in cardiac index and systolic pulmonary artery pressure were associated with LVEF changes after PMV. The predictors of long-term adverse events following PMV were post-procedural variables, including mitral regurgitation, valve area, and mean gradient. Copyright © 2017 Elsevier B.V. All rights reserved.

Does Surgical Repair of Moderate Ischemic Mitral Regurgitation Improve Survival? A Systematic Review.

PubMed

Chatterjee, Saurav; Tripathi, Byomesh; Virk, Hafeez Ul Hassan; Ahmed, Mohammed; Bavishi, Chirag; Krishnamoorthy, Parasuram; Sardar, Partha; Giri, Jay; Omidvari, Karan; Chikwe, Joanna

2016-03-01

Mitral regurgitation (MR) is one of the common complications in myocardial infarction (MI) patients. Almost half of the post MI patients have MR (ischemic MR)(17) which is moderate to severe (grade II-IV). Whether there is a mortality benefit of performing mitral valve repair (MVR) along with coronary artery bypass grafting (CABG) in patients with post MI moderate MR remains inconclusive. Literature search was done from PubMed, Google scholar, Ovid, and Medline databases. Studies which included post MI patients with moderate ischemic MR and reported mortality outcomes of performing CABG and MVR were chosen for the systematic review. Our preliminary literature search identified 194 studies, of which 11 studies met our inclusion criteria. Nine studies showed no survival benefit of performing simultaneous MVR and CABG. One study demonstrated survival benefit of performing CABG plus MVR only in the New York Heart Association (NYHA) class III-IV, and one study suggested survival benefit of performing CABG plus MVR as compared to CABG alone in patient with ischemic MR irrespective of preoperative NYHA functional class. Review of current literature showed mixed results in terms of improvement in functional status but failed to show any survival benefit of performing MVR along with CABG. Limitations of studies include small sample size, difference in baseline demographic variables, and short follow-up period which might influence the outcome of the study. Prospective randomized studies are required to establish clear benefit of performing MVR simultaneously with CABG.

Systolic Anterior Motion of the Mitral Valve after Mitral Valve Repair

PubMed Central

Sternik, Leonid; Zehr, Kenton J.

2005-01-01

Factors predisposing patients to systolic anterior motion of the mitral valve (SAM) with left ventricular outflow tract (LVOT) obstruction after mitral valve repair are the presence of a myxomatous mitral valve with redundant leaflets, a nondilated hyperdynamic left ventricle, and a short distance between the mitral valve coaptation point and the ventricular septum after repair. From December 1999 through March 2000, we used our surgical method in 6 patients with severely myxomatous regurgitant mitral valves who were at risk of developing SAM. Leaflets were markedly redundant in all 6. Left ventricular function was hyperdynamic in 4 patients and normal in 2. Triangular or quadrangular resection of the midportion of the posterior leaflet and posterior band annuloplasty were performed. To prevent SAM and LVOT obstruction, extra, posteriorly directed, mid-posterior-leaflet secondary chordae tendineae, which would otherwise have been resected, were transferred to the underside of the middle of the mid-anterior leaflet with a small piece of associated valve as an anchoring pledget. This kept the redundant anterior leaflet edge, which extended below the coaptation point, away from the LVOT. No post-repair SAM or LVOT obstruction was observed on intraoperative or discharge echocardiography. All patients had no or trivial residual mitral regurgitation. We conclude that extra chordae tendineae, when available, can be used in mitral valve repair to tether the redundant anterior leaflet and thus prevent it from flipping into the LVOT. This will theoretically prevent SAM and LVOT obstruction in patients with risk factors for SAM. PMID:15902821

Fluid-Structure Interaction Analysis of Ruptured Mitral Chordae Tendineae.

PubMed

Toma, Milan; Bloodworth, Charles H; Pierce, Eric L; Einstein, Daniel R; Cochran, Richard P; Yoganathan, Ajit P; Kunzelman, Karyn S

2017-03-01

The chordal structure is a part of mitral valve geometry that has been commonly neglected or simplified in computational modeling due to its complexity. However, these simplifications cannot be used when investigating the roles of individual chordae tendineae in mitral valve closure. For the first time, advancements in imaging, computational techniques, and hardware technology make it possible to create models of the mitral valve without simplifications to its complex geometry, and to quickly run validated computer simulations that more realistically capture its function. Such simulations can then be used for a detailed analysis of chordae-related diseases. In this work, a comprehensive model of a subject-specific mitral valve with detailed chordal structure is used to analyze the distinct role played by individual chordae in closure of the mitral valve leaflets. Mitral closure was simulated for 51 possible chordal rupture points. Resultant regurgitant orifice area and strain change in the chordae at the papillary muscle tips were then calculated to examine the role of each ruptured chorda in the mitral valve closure. For certain subclassifications of chordae, regurgitant orifice area was found to trend positively with ruptured chordal diameter, and strain changes correlated negatively with regurgitant orifice area. Further advancements in clinical imaging modalities, coupled with the next generation of computational techniques will enable more physiologically realistic simulations.

Fluid-Structure Interaction Analysis of Ruptured Mitral Chordae Tendineae

PubMed Central

Toma, Milan; Bloodworth, Charles H.; Pierce, Eric L.; Einstein, Daniel R.; Cochran, Richard P.; Yoganathan, Ajit P.; Kunzelman, Karyn S.

2016-01-01

The chordal structure is a part of mitral valve geometry that has been commonly neglected or simplified in computational modeling due to its complexity. However, these simplifications cannot be used when investigating the roles of individual chordae tendineae in mitral valve closure. For the first time, advancements in imaging, computational techniques, and hardware technology make it possible to create models of the mitral valve without simplifications to its complex geometry, and to quickly run validated computer simulations that more realistically capture its function. Such simulations can then be used for a detailed analysis of chordae-related diseases. In this work, a comprehensive model of a subject-specific mitral valve with detailed chordal structure is used to analyze the distinct role played by individual chordae in closure of the mitral valve leaflets. Mitral closure was simulated for 51 possible chordal rupture points. Resultant regurgitant orifice area and strain change in the chordae at the papillary muscle tips were then calculated to examine the role of each ruptured chorda in the mitral valve closure. For certain subclassifications of chordae, regurgitant orifice area was found to trend positively with ruptured chordal diameter, and strain changes correlated negatively with regurgitant orifice area. Further advancements in clinical imaging modalities, coupled with the next generation of computational techniques will enable more physiologically realistic simulations. PMID:27624659

Chronic mitral regurgitation and Doppler estimation of left ventricular filling pressures in patients with heart failure

NASA Technical Reports Server (NTRS)

Temporelli, P. L.; Scapellato, F.; Corra, U.; Eleuteri, E.; Firstenberg, M. S.; Thomas, J. D.; Giannuzzi, P.

2001-01-01

Previous studies relating Doppler parameters and pulmonary capillary wedge pressures (PCWP) typically exclude patients with severe mitral regurgitation (MR). We evaluated the effects of varying degrees of chronic MR on the Doppler estimation of PCWP. PCWP and mitral Doppler profiles were obtained in 88 patients (mean age 55 +/- 8 years) with severe left ventricular (LV) dysfunction (mean ejection fraction 23% +/- 5%). Patients were classified by severity of MR. Patients with severe MR had greater left atrial areas, LV end-diastolic volumes, and mean PCWPs and lower ejection fractions (each P <.01). In patients with mild MR, multiple echocardiographic parameters correlated with PCWP; however, with worsening MR, only deceleration time strongly related to PCWP. From stepwise multivariate analysis, deceleration time was the best independent predictor of PCWP overall, and it was the only predictor in patients with moderate or severe MR. Doppler-derived early mitral deceleration time reliably predicts PCWP in patients with severe LV dysfunction irrespective of degree of MR.

Mitral leaflet geometry perturbations with papillary muscle displacement and annular dilatation: an in-vitro study of ischemic mitral regurgitation.

PubMed

He, Shengqiu; Jimenez, Jorge; He, Zhaoming; Yoganathan, Ajit P

2003-05-01

Perturbations of leaflet geometry are the final end point through which left ventricular (LV) ischemia causes incomplete mitral leaflet closure and resultant mitral regurgitation (MR). Geometric inconsistencies observed with valvular or subvalvular structural alterations raise several questions. A new in-vitro LV flexible bag model was developed in order to visualize and analyze leaflet geometric changes under simulated pathological ischemic MR conditions. Papillary muscle (PM) displacement and annular dilatation decreased leaflet coaptation length, leading to significant MR. Symmetrical PM displacement shifted the coaptation line towards the leaflet edges and created central gaps along this line. Asymmetric PM displacement generated diametrically uneven coaptation with a tent-shaped leaflet at the tethered PM side, while the leaflet bulged at the opposite side towards the left atrium. Leaflet geometry during systole is affected by subvalvular structures. Asymmetric PM displacement, which may occur in regional or acute myocardial infarction, induces irregular deformation of the leaflet's coaptation line and, as a result, MR at the tethered side. Direct visualization of leaflet perturbation under these simulated pathological conditions may promote understanding of mechanisms present in ischemic MR.

Left ventricular function quantified by myocardial strain imaging in small-breed dogs with chronic mitral regurgitation.

PubMed

Smith, Danielle N; Bonagura, John D; Culwell, Nicole M; Schober, Karsten E

2012-03-01

The presence of left ventricular (LV) systolic dysfunction may influence prognosis or therapy in dogs with chronic mitral regurgitation (MR). Assessment of LV function in MR by conventional echocardiography is confounded by altered ventricular loading. Myocardial deformation (strain) imaging might offer more sensitive estimates of LV function in this disease. Prospectively measure myocardial strain in dogs with asymptomatic MR compared to a control group. Forty healthy dogs (3.5-11.5 kg): 20 Controls; 20 dogs with MR and LV remodeling (Stage B2), were evaluated in this study. LV size and function were assessed in a short-axis plane. Segmental radial strain and strain rate and global circumferential strain were measured using a 2D echocardiographic speckle-tracking algorithm (GE EchoPAC). Groups were compared using Bonferroni t-tests. Influences of heart rate and body weight were explored with linear regression. The MR group had significantly greater mean values for heart rate, LV size, and LV systolic function. Specifically, LV diastolic diameter, diastole area, shortening fraction, averaged peak systolic and early diastolic radial strain, global circumferential strain, and averaged radial strain rate were significantly greater in the MR group (p < 0.015 to p < 0.001). Strain was unrelated to weight, but weakly correlated with heart rate. Similar to conventional indices, Stage B2 dogs with MR demonstrate hyperdynamic deformation in the short-axis plane. Short-axis strain variables measured by 2D speckle tracking are greater than for controls of similar age and weight. These results imply either preserved LV systolic function or that LV dysfunction is masked by altered ventricular loading. Copyright © 2012 Elsevier B.V. All rights reserved.

Criteria for determining the need for surgical treatment of tricuspid regurgitation during mitral valve replacement

PubMed Central

2012-01-01

Background Tricuspid regurgitation (TR) is common in patients with mitral valve disease; however, there are no straightforward, rapidly determinably criteria available for deciding whether TR repair should be performed during mitral valve replacement. The aim of our retrospective study was to identify a simple and fast criterion for determining whether TR repair should be performed in patients undergoing mitral valve replacement. Methods We reviewed the records of patients who underwent mitral valve replacement with or without (control) TR repair (DeVega or Kay procedure) from January 2005 to December 2008. Preoperative and 2-year postoperative echocardiographic measurements included right ventricular and atrial diameter, interventricular septum size, TR severity, ejection fraction, and pulmonary artery pressure. Results A total of 89 patients were included (control, n = 50; DeVega, n = 27; Kay, n = 12). Demographic and clinical characteristics were similar between groups. Cardiac variables were similar between the DeVega and Kay groups. Right atrium and ventricular diameter and ejection fraction were significantly decreased postoperatively both in the control and operation (DeVega + Kay) group (P < 0.05). Pulmonary artery pressure was significantly decreased postoperatively in-operation groups (P < 0.05). Our findings indicate that surgical intervention for TR should be considered during mitral valve replacement if any of the following preoperative criteria are met: right atrial transverse diameter > 57 mm; right ventricular end-diastolic diameter > 55 mm; pulmonary artery pressure > 58 mmHg. Conclusions Our findings suggest echocardiography may be used as a rapid and simple means of determining which patients require TR repair during mitral valve replacement. PMID:22443513

Predictors of Exercise-Induced Pulmonary Hypertension in Patients with Asymptomatic Degenerative Mitral Regurgitation: Mechanistic Insights from 2D Speckle-Tracking Echocardiography

PubMed Central

Kamijima, Ryo; Suzuki, Kengo; Izumo, Masaki; Kuwata, Shingo; Mizukoshi, Kei; Takai, Manabu; Kou, Seisyou; Hayashi, Akio; Kida, Keisuke; Harada, Tomoo; Akashi, Yoshihiro J.

2017-01-01

Presence of exercise-induced pulmonary hypertension (EIPH) in asymptomatic degenerative mitral regurgitation (DMR) determines prognosis. This study aimed to elucidate the mechanism and predictors of EIPH in asymptomatic DMR. Ninety-one consecutive asymptomatic patients with DMR who underwent exercise stress echocardiography were prospectively included. We obtained various conventional echocardiographic parameters at rest and during peak exercise, as well as left atrial (LA) function at rest using 2-dimensional speckle-tracking analysis. The 25 patients (33.3%) with EIPH were significantly older and had a greater ratio of mitral peak velocity of early filling to early diastolic mitral annular velocity during peak exercise than those without EIPH. LA strain (LAS)-s and LAS-e, indices of LA reservoir and conduit function, respectively, were significantly lower in those with EIPH than in those without EIPH. Multivariate analysis indicated that LAS-s was the only resting echocardiographic parameter that independently predicted EIPH, with a cut-off value of 26.9%. Furthermore, Kaplan-Meier curve analysis showed that symptom-free survival was markedly lower among those with reduced LAS-s. In conclusion, decreased LA reservoir function contributes to EIPH, and LAS-s at rest is a useful indicator for predicting EIPH in asymptomatic patients with DMR. PMID:28071674

Real-Time 3-Dimensional Echocardiographic Assessment of Effective Regurgitant Orifice Area in Dogs With Myxomatous Mitral Valve Disease.

PubMed

Tidholm, A; Bodegård-Westling, A; Höglund, K; Häggström, J; Ljungvall, I

2017-03-01

Effective regurgitant orifice area (EROA), calculated from the vena contracta width (VCW) as the narrowest portion of the proximal regurgitant jet, might be used to estimate severity of mitral regurgitation. However, this simplified assumption only holds when the EROA is circular, which might not be true in dogs with myxomatous mitral valve disease (MMVD). Effective regurgitant orifice area in dogs with MMVD is noncircular, and using color Doppler real-time 3-dimensional (RT3D) echocardiography, measured EROA in the en face view will be significantly different from calculated EROA. Hundred and fifty-eight privately owned dogs with naturally occurring MMVD. Prospective observational study comparing en face view of EROA with calculated EROA using VCW in 4-chamber (4Ch) and 2-chamber (2Ch) view only or combined 4Ch and 2Ch views using RT3D echocardiography. The calculated EROA using the 2Ch view showed a systematic underestimation of 17% compared with the measured en face EROA corrected for body surface area. The calculated EROA using 4Ch and 4Ch + 2Ch views showed less agreement with the en face EROA, and the difference between methods increased with increasing EROA. The difference between calculated and measured EROA showed a systematic underestimation of the calculated EROA by 36% (4Ch) and 33% (4Ch + 2Ch), respectively, compared to measured en face EROA. When replacing measured EROA with calculated EROA using VCW measurements, the 2Ch view is preferred in dogs with MMVD. Copyright © 2017 The Authors. Journal of Veterinary Internal Medicine published by Wiley Periodicals, Inc. on behalf of the American College of Veterinary Internal Medicine.

Immediate Outcome of Balloon Mitral Valvuloplasty with JOMIVA Balloon during Pregnancy

PubMed Central

Ramasamy, Ramona; Kaliappan, Tamilarasu; Gopalan, Rajendiran; Palanimuthu, Ramasmy; Anandhan, Premkrishna

2017-01-01

Introduction Rheumatic mitral stenosis is the most common Valvular Heart Disease encountered during pregnancy. Balloon Mitral Valvuloplasty (BMV) is one of the treatment option available if the symptoms are refractory to the medical management and the valve anatomy is suitable for balloon dilatation. BMV with Inoue balloon is the most common technique being followed worldwide. Over the wire BMV is a modified technique using Joseph Mitral Valvuloplasty (JOMIVA) balloon catheter which is being followed in certain centres. Aim To assess the immediate post procedure outcome of over the wire BMV with JOMIVA balloon. Materials and Methods Clinical and echocardiographic parameters of pregnant women with significant mitral stenosis who underwent elective BMV with JOMIVA balloon in our institute from 2005 to 2015 were analysed retrospectively. Severity of breathlessness (New York Heart Association Functional Class), and duration of pregnancy was included in the analysis. Pre procedural echocardiographic parameters which included severity of mitral stenosis and Wilkin’s scoring were analysed. Clinical, haemodynamic and echocardiographic outcomes immediately after the procedure were analysed. Results Among the patients who underwent BMV in our Institute 38 were pregnant women. Twenty four patients (63%) were in New York Heart Association (NYHA) Class III. All of them were in sinus rhythm except two (5%) who had atrial fibrillation. Thirty four patients (89.5%) were in second trimester of pregnancy at the time of presentation and four (10.5%) were in third trimester. Echocardiographic analysis of the mitral valve showed that the mean Wilkin’s score was 7.3. Mean mitral valve area pre procedure was 0.8 cm2. Mean gradient across the valve was 18 mmHg. Ten patients (26.5%) had mild mitral regurgitation and none had more than mild mitral regurgitation. Thirty six patients had pulmonary hypertension as assessed by tricuspid regurgitation jet velocity. All of them underwent BMV

Second diastolic pulmonary venous flow and isolated late diastolic mitral valve regurgitation in first-degree atrioventricular block.

PubMed

Leibundgut, Gregor; Bernheim, Alain M

2010-04-01

The authors report the case of a 77-year-old male patient with sinus rhythm and a first-degree atrioventricular (AV) block who was referred for echocardiographic follow-up 18 years after aortic valve replacement. Left ventricular systolic function as well as the function of the aortic prosthesis was normal. Systolic mitral regurgitation (MR) was virtually absent, but isolated late diastolic MR was detected by colour Doppler imaging. Coincidental to the occurrence of diastolic MR, a second late diastolic forward flow in the pulmonary veins was observed. Therefore, during the prolonged left atrial relaxation caused by first-degree AV block, the left atrial pressure drops below the pressure in both adjacent chambers in late diastole, resulting in both late diastolic MR and a second diastolic pulmonary venous forward flow.

Randomised trial of mitral valve repair with leaflet resection versus leaflet preservation on functional mitral stenosis (The CAMRA CardioLink-2 Trial).

PubMed

Chan, Vincent; Chu, Michael W A; Leong-Poi, Howard; Latter, David A; Hall, Judith; Thorpe, Kevin E; de Varennes, Benoit E; Quan, Adrian; Tsang, Wendy; Dhingra, Natasha; Yared, Kibar; Teoh, Hwee; Chu, F Victor; Chan, Kwan-Leung; Mesana, Thierry G; Connelly, Kim A; Ruel, Marc; Jüni, Peter; Mazer, C David; Verma, Subodh

2017-05-30

The gold-standard treatment of severe mitral regurgitation (MR) due to degenerative disease is valve repair, which is surgically performed with either a leaflet resection or leaflet preservation approach. Recent data suggest that functional mitral stenosis (MS) may occur following valve repair using a leaflet resection strategy, which adversely affects patient prognosis. A randomised comparison of these two approaches to mitral repair on functional MS has not been conducted. This is a prospective, multicentre randomised controlled trial designed to test the hypothesis that leaflet preservation leads to better preservation of mitral valve geometry, and therefore, will be superior to leaflet resection for the primary outcome of functional MS as assessed by 12-month mean mitral valve gradient at peak exercise. Eighty-eight patients with posterior leaflet prolapse will be randomised intraoperatively once deemed by the operating surgeon to feasibly undergo mitral repair using either a leaflet resection or leaflet preservation approach. Secondary end points include comparison of repair strategies with regard to mitral valve orifice area, leaflet coaptation height, 6 min walk test and a composite major adverse event end point consisting of recurrent MR ≥2+, death or hospital readmission for congestive heart failure within 12 months of surgery. Institutional ethics approval has been obtained from all enrolling sites. Overall, there remains clinical equipoise regarding the mitral valve repair strategy that is associated with the least likelihood of functional MS. This trial hopes to introduce high-quality evidence to help surgical decision making in this context. NCT02552771. © Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2017. All rights reserved. No commercial use is permitted unless otherwise expressly granted.

Practice gaps in the care of mitral valve regurgitation: Insights from the American College of Cardiology mitral regurgitation gap analysis and advisory panel.

PubMed

Wang, Andrew; Grayburn, Paul; Foster, Jill A; McCulloch, Marti L; Badhwar, Vinay; Gammie, James S; Costa, Salvatore P; Benitez, Robert Michael; Rinaldi, Michael J; Thourani, Vinod H; Martin, Randolph P

2016-02-01

The revised 2014 American College of Cardiology (ACC)/American Heart Association valvular heart disease guidelines provide evidenced-based recommendations for the management of mitral regurgitation (MR). However, knowledge gaps related to our evolving understanding of critical MR concepts may impede their implementation. The ACC conducted a multifaceted needs assessment to characterize gaps, practice patterns, and perceptions related to the diagnosis and treatment of MR. A key project element was a set of surveys distributed to primary care and cardiovascular physicians (cardiologists and cardiothoracic surgeons). Survey and other gap analysis findings were presented to a panel of 10 expert advisors from specialties of general cardiology, cardiac imaging, interventional cardiology, and cardiac surgeons with expertise in valvular heart disease, especially MR, and cardiovascular education. The panel was charged with assessing the relative importance and potential means of remedying identified gaps to improve care for patients with MR. The survey results identified several knowledge and practice gaps that may limit implementation of evidence-based recommendations for MR care. Specifically, half of primary care physicians reported uncertainty regarding timing of intervention for patients with severe primary or functional MR. Physicians in all groups reported that quantitative indices of MR severity were frequently not reported in clinical echocardiographic interpretations, and that these measurements were not consistently reviewed when provided in reports. In the treatment of MR, nearly 30% of primary care physician and general cardiologists did not know the volume of mitral valve repair surgeries by their reference cardiac surgeons and did not have a standard source to obtain this information. After review of the survey results, the expert panel summarized practice gaps into 4 thematic areas and offered proposals to address deficiencies and promote better alignment

Surgical relocation of the papillary muscles in functional ischemic mitral regurgitation: what are the forces of the relocation stitches acting on the myocardium?

PubMed

Jensen, Henrik; Jensen, Morten O; Vind-Kezunovic, Stefan; Vestergaard, Rikke; Ringgaard, Steffen; Smerup, Morten H; Hønge, Jesper L; Hasenkam, J Michael; Nielsen, Sten L

2013-07-01

In patients with chronic functional ischemic mitral regurgitation (FIMR), papillary muscle relocation has the potential to induce reverse left ventricular remodeling. However, in order to optimize function and durability, the forces imposed on the left ventricular myocardium by papillary muscle relocation should be assessed. Eight pigs with FIMR were subjected to down-sized ring annuloplasty in combination with relocation of the anterior (5 mm) and posterior (15 mm) papillary muscles towards the respective trigone. Papillary muscle relocation was obtained by a 2-0 expanded polytetrafluoroethylene stitch fixed to the trigone, exteriorized through the myocardium overlying the papillary muscle, and fixed to an epicardial disc. Tension in these stitches was measured at a systolic blood pressure > 80 mmHg using a custom-made sliding caliper with a strain gauge mounted in line. This allowed assessment of the cyclic change from minimal diastolic to maximum systolic papillary muscle relocation stitch tension. Maximum cyclic change in the posterior papillary muscle (PPM) stitch tension was 1.1 N at 15 mm relocation. In comparison, the anterior papillary muscle (APM) tension was increased to a maximum of 1.4 N with only 5 mm relocation. Surprisingly, during each step of isolated PPM relocation, the APM stitch tension increased concomitantly, but in contrast APM relocation did not influence the magnitude of PPM stitch tension. There was no statistically significant difference between cyclic changes in APM and PPM stitch tension at any step of relocation. Papillary muscle relocation using stitches attached between epicardial discs and respective trigones induced a cyclic change in papillary muscle relocation stitch tension of 1.1-1.4 N. These values were in the range of normal tension in the mitral valve apparatus, and equivalent to only 19-24% of the total papillary muscle forces. Therefore, this technique does not appear to induce a non-physiologically high cyclic load on

Role of parietal pericardium in acute, severe mitral regurgitation in dogs.

PubMed

Freeman, G L; LeWinter, M M

1984-07-01

Mitral regurgitation (MR) resulting from acute disruption of the mitral valve apparatus leads to serious hemodynamic sequelae. The lesion produces major elevation of left atrial (LA) and pulmonary artery pressures and decreases forward cardiac output. Clinical studies have shown hemodynamic patterns in acute MR similar to those seen in constrictive pericardial disease, suggesting that the pericardium serves to importantly limit cardiac filling in this condition. This hypothesis has not been tested in an animal model in which the intrapericardial pressure can be directly measured. In the present study intrapericardial and intracardiac pressures were measured in 8 dogs before and after the production of acute MR. After production of MR, mean LA pressure increased from 8 +/- 3 to 20 +/- 7 mm Hg (p = 0.004) and the peak LA V wave averaged 31 +/- 13 mm Hg. Mean right atrial pressure increased slightly, from 4 +/- 2 to 5 +/- 1 mm Hg (p less than 0.008). Intrapericardial pressure increased in each dog, but the increment was invariably small (1 +/- 2 to 3 +/- 2 mm Hg, p = 0.001) and there was no tendency to equalization of pressure between right- and left-sided cardiac chambers. Thus, the role of the pericardium in the immediate hemodynamic response to acute, severe MR is minor.

Percutaneous transfemoral-transseptal implantation of a second-generation CardiAQ mitral valve bioprosthesis: first procedure description and 30-day follow-up.

PubMed

Ussia, Gian Paolo; Quadri, Arshad; Cammalleri, Valeria; De Vico, Pasquale; Muscoli, Saverio; Marchei, Massimo; Ruvolo, Giovanni; Sondergaard, Lars; Romeo, Francesco

2016-02-01

Transcatheter mitral valve implantation for mitral valve regurgitation is in the very early phase of development because of challenging anatomy and device dimensions. We describe the procedure of a transfemoral-transseptal implantation of the second-generation CardiAQ mitral valve bioprosthesis and 30-day follow-up. The procedure was performed percutaneously, without any left extracorporeal circulatory support. The patient had severe mitral regurgitation with severely depressed ventricular function and other comorbidities. The patient was deemed extreme high risk for conventional cardiac surgery by a multidisciplinary team. The main procedural steps were the creation of an arteriovenous loop with an exchange nitinol wire, and the use of a customised "steerable snare system" to facilitate the catheter delivery system into the mitral annulus. Transoesophageal echocardiography and fluoroscopy were utilised for device positioning and deployment. The mitral valve prosthesis was implanted with mild mitral regurgitation. The postoperative course was uneventful and at 30-day follow-up the patient is in NYHA Class I, with good function of the mitral valve bioprosthesis. This procedure shows that percutaneous transfemoral transcatheter mitral valve implantation is feasible, safe and successful. Further experience is needed to render this procedure clinically available.

Mitral Transcatheter Technologies

PubMed Central

Maisano, Francesco; Buzzatti, Nicola; Taramasso, Maurizio; Alfieri, Ottavio

2013-01-01

Mitral valve regurgitation (MR) is often diagnosed in patients with heart failure and is associated with worsening of symptoms and reduced survival. While surgery remains the gold standard treatment in low-risk patients with degenerative MR, in high-risk patients and in those with functional MR, transcatheter procedures are emerging as an alternative therapeutic option. MitraClip® is the device with which the largest clinical experience has been gained to date, as it offers sustained clinical benefit in selected patients. Further to MitraClip implantation, several additional approaches are developing, to better match with the extreme variability of mitral valve disease. Not only repair is evolving, initial steps towards percutaneous mitral valve implantation have already been undertaken, and initial clinical experience has just started. PMID:23908865

[A case of systemic lupus erythematosus discovered from left heart failure due to lupus induced mitral regurgitation].

PubMed

Ueno, K; Fujimoto, S; Fujimoto, T; Nakano, H; Nakajima, T; Yamano, S; Shiiki, H; Hashimoto, T; Imoto, K; Miyagawa, S; Dohi, K

1999-10-01

A 50-year-old female was admitted to a local hospital because of dyspnea, and diagnosed as having left heart failure secondary to mitral regurgitation. After the improvement of congestive heart failure, polyarthralgia, fever, and positive anti-nuclear antibody were pointed out. She was referred to our hospital for the further evaluation. Serological test showed anti-double stranded DNA antibodies, anti-SS-A antibodies, anti-beta 2-GPI antibodies and biological false positive for syphilis. The diagnosis of SLE has been made from the clinical signs and the serology. Therefore mitral valvular lesion of this patient was considered to be one of the symptoms of SLE. We reported a rare case in which left heart failure was a initial clinical manifestation of SLE.

Hemorrhagic Tamponade as Initial Manifestation of Systemic Lupus with Subsequent Refractory and Progressive Lupus Myocarditis Resulting in Cardiomyopathy and Mitral Regurgitation.

PubMed

Marijanovich, Nicole; Halalau, Alexandra

2018-01-01

Systemic lupus erythematosus (SLE) is a heterogeneous autoimmune disease with a wide range of clinical and serological manifestations. Cardiac disease among patients with SLE is common and can involve the pericardium, myocardium, valves, conduction system, and coronary arteries. We are reporting a case of SLE in a young woman that is unique is unique in that initial symptoms consisted of pericarditis and hemorrhagic tamponade which remained progressive and resistant to aggressive immunosuppressive treatment and led to severe cardiomyopathy (ejection fraction of 25%) and severe (+4) mitral regurgitation. Her immunosuppressive treatment included hydroxychloroquine, high-dose steroids, intravenous immunoglobulins, azathioprine, and mycophenolate mofetil. Her disease progression was felt to be due to underlying uncontrolled SLE because the complement levels remained persistently low throughout the entire course and PET Myocardial Perfusion and Viability study showed stable persistent active inflammation. Eventually, she was treated with cyclophosphamide which led to improvement in ejection fraction to 55% with only mild mitral regurgitation.

Hemorrhagic Tamponade as Initial Manifestation of Systemic Lupus with Subsequent Refractory and Progressive Lupus Myocarditis Resulting in Cardiomyopathy and Mitral Regurgitation

PubMed Central

Marijanovich, Nicole

2018-01-01

Systemic lupus erythematosus (SLE) is a heterogeneous autoimmune disease with a wide range of clinical and serological manifestations. Cardiac disease among patients with SLE is common and can involve the pericardium, myocardium, valves, conduction system, and coronary arteries. We are reporting a case of SLE in a young woman that is unique is unique in that initial symptoms consisted of pericarditis and hemorrhagic tamponade which remained progressive and resistant to aggressive immunosuppressive treatment and led to severe cardiomyopathy (ejection fraction of 25%) and severe (+4) mitral regurgitation. Her immunosuppressive treatment included hydroxychloroquine, high-dose steroids, intravenous immunoglobulins, azathioprine, and mycophenolate mofetil. Her disease progression was felt to be due to underlying uncontrolled SLE because the complement levels remained persistently low throughout the entire course and PET Myocardial Perfusion and Viability study showed stable persistent active inflammation. Eventually, she was treated with cyclophosphamide which led to improvement in ejection fraction to 55% with only mild mitral regurgitation. PMID:29610699

Impact of concomitant mitral valve repair for severe mitral regurgitation at the time of continuous-flow left ventricular assist device insertion.

PubMed

Sandoval, Elena; Singh, Steve K; Carillo, Julius A; Baldwin, Andrew C W; Ono, Masahiro; Anand, Jatin; Frazier, O H; Mallidi, Hari R

2017-10-01

Mitral regurgitation (MR) is common in patients with end-stage heart failure. We assessed the effect of performing concomitant mitral valve repair during continuous-flow left ventricular assist device (CF-LVAD) implantation in patients with severe preoperative MR. We performed a single-centre, retrospective review of all patients who underwent CF-LVAD implantation between December 1999 and December 2013 (n = 469). Patients with severe preoperative MR (n = 78) were identified and then stratified according to whether they underwent concomitant valve repair. Univariate and survival analyses were performed, and multivariable regression was used to determine predictors of survival. Of the 78 patients with severe MR, 21 underwent valve repair at the time of CF-LVAD implantation (repair group) and 57 did not (non-repair group). A comparison of the 2 groups showed significant differences between groups: INTERMACS I 16.985 vs 9.52%, (P = 0.039), cardiopulmonary bypass time 82.09 vs 109.4 min (P = 0.0042) and the use of HeartMate II 63.16 vs 100% (P = 0.001). Survival analysis suggested trends towards improved survival and a lower incidence of heart failure-related readmissions in the repair group. Multivariable regression analysis showed no significant independent predictors of survival (mitral valve repair: odds ratio 0.4, 95% confidence interval 0.8-1.5; P = 0.2). Despite the lack of statistical significance, trends towards improved survival and a lower incidence of heart failure events suggest that mitral valve repair may be beneficial in patients undergoing CF-LVAD implantation. Given the known relationship between severe MR and mortality, further study is encouraged to confirm the value of mitral valve repair in these patients. © The Author 2017. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Mitral Valve Repair Using ePTFE Sutures for Ruptured Mitral Chordae Tendineae: A Computational Simulation Study

PubMed Central

Rim, Yonghoon; Laing, Susan T.; McPherson, David D.; Kim, Hyunggun

2013-01-01

Mitral valve repair using expanded polytetrafluoroethylene (ePTFE) sutures is an established and preferred interventional method to resolve the complex pathophysiologic problems associated with chordal rupture. We developed a novel computational evaluation protocol to determine the effect of the artificial sutures on restoring mitral valve function following valve repair. A virtual mitral valve was created using three-dimensional echocardiographic data in a patient with ruptured mitral chordae tendineae. Virtual repairs were designed by adding artificial sutures between the papillary muscles and the posterior leaflet where the native chordae were ruptured. Dynamic finite element simulations were performed to evaluate pre- and post-repair mitral valve function. Abnormal posterior leaflet prolapse and mitral regurgitation was clearly demonstrated in the mitral valve with ruptured chordae. Following virtual repair to reconstruct ruptured chordae, the severity of the posterior leaflet prolapse decreased and stress concentration was markedly reduced both in the leaflet tissue and the intact native chordae. Complete leaflet coaptation was restored when four or six sutures were utilized. Computational simulations provided quantitative information of functional improvement following mitral valve repair. This novel simulation strategy may provide a powerful tool for evaluation and prediction of interventional treatment for ruptured mitral chordae tendineae. PMID:24072489

Changes in mitral annular and left ventricular dimensions and left ventricular pressure-volume relations after off-pump treatment of mitral regurgitation with the Coapsys device.

PubMed

Fukamachi, Kiyotaka; Popović, Zoran B; Inoue, Masahiro; Doi, Kazuyoshi; Schenk, Soren; Ootaki, Yoshio; Kopcak, Michael W; McCarthy, Patrick M

2004-03-01

The objective of this study was to evaluate the changes in mitral annular and left ventricular dimensions and left ventricular pressure-volume relations produced by the Myocor Coapsys device that has been developed to treat functional mitral regurgitation (MR) off-pump. The Coapsys device, which consists of anterior and posterior epicardial pads connected by a sub-valvular chord, was implanted in seven dogs with functional MR resulting from pacing induced cardiomyopathy. The Coapsys device was then sized by drawing the posterior leaflet and annulus toward the anterior leaflet. During sizing, MR grade was assessed using color flow Doppler echocardiography. Final device size was selected when MR was eliminated or minimized. Following implantation, heart failure was maintained by continued pacing for a period of 8 weeks. Mitral annular and left ventricular dimensions and left ventricular pressure-volume relations were evaluated by two-dimensional echocardiography and a conductance catheter, respectively, at pre-sizing, post-sizing, and after 8 weeks. All implants were performed on beating hearts without cardiopulmonary bypass. Mean MR grade was reduced from 2.9+/-0.7 at pre-sizing to 0.7+/-0.8 at post-sizing (P<0.001), and was maintained at 0.8+/-0.8 after 8 weeks (P<0.01). The septal-lateral dimensions were significantly reduced at both mitral annular level [2.4+/-0.2 cm at pre-sizing, 1.5+/-0.3 cm at post-sizing (P<0.001) and 1.8+/-0.3 cm after 8 weeks (P<0.05)] and mid-papillary level [4.1+/-0.4 cm at pre-sizing, 2.4+/-0.2 cm at post-sizing (P<0.001) and 3.3+/-0.4 cm after 8 weeks (P<0.001)]. The end-systolic pressure-volume relation shifted leftward at post-sizing with a significantly steeper slope (P=0.03). There was a significant (P=0.03) leftward shift of the end-diastolic pressure-volume relation at post-sizing. After 8 weeks, these changes in pressure-volume relations tended to return to pre-sizing relations. The Coapsys device significantly reduced MR by

Adult patent ductus arteriosus: successful surgery with mitral valvuloplasty.

PubMed

Hobo, Kyoko; Hanayama, Naoji; Umezu, Kentaro; Shimada, Naohiro; Toyama, Akihiko; Takazawa, Arihumi

2009-06-01

The development of left ventricular dysfunction is a serious complication of longstanding patent ductus arteriosus. An 80-year-old woman who underwent patent ductus arteriosus ligation 13 years previously developed congestive heart failure and mitral regurgitation. She underwent surgical repair with transpulmonary ductus closure and mitral valve annuloplasty under cardiopulmonary bypass. She made a full recovery with improved left ventricular function.

Feasibility of Ultrasound-Based Computational Fluid Dynamics as a Mitral Valve Regurgitation Quantification Technique: Comparison with 2-D and 3-D Proximal Isovelocity Surface Area-Based Methods.

PubMed

Jamil, Muhammad; Ahmad, Omar; Poh, Kian Keong; Yap, Choon Hwai

2017-07-01

Current Doppler echocardiography quantification of mitral regurgitation (MR) severity has shortcomings. Proximal isovelocity surface area (PISA)-based methods, for example, are unable to account for the fact that ultrasound Doppler can measure only one velocity component: toward or away from the transducer. In the present study, we used ultrasound-based computational fluid dynamics (Ub-CFD) to quantify mitral regurgitation and study its advantages and disadvantages compared with 2-D and 3-D PISA methods. For Ub-CFD, patient-specific mitral valve geometry and velocity data were obtained from clinical ultrasound followed by 3-D CFD simulations at an assumed flow rate. We then obtained the average ratio of the ultrasound Doppler velocities to CFD velocities in the flow convergence region, and scaled CFD flow rate with this ratio as the final measured flow rate. We evaluated Ub-CFD, 2-D PISA and 3-D PISA with an in vitro flow loop, which featured regurgitation flow through (i) a simplified flat plate with round orifice and (ii) a 3-D printed realistic mitral valve and regurgitation orifice. The Ub-CFD and 3-D PISA methods had higher precision than the 2-D PISA method. Ub-CFD had consistent accuracy under all conditions tested, whereas 2-D PISA had the lowest overall accuracy. In vitro investigations indicated that the accuracy of 2-D and 3-D PISA depended significantly on the choice of aliasing velocity. Evaluation of these techniques was also performed for two clinical cases, and the dependency of PISA on aliasing velocity was similarly observed. Ub-CFD was robustly accurate and precise and has promise for future translation to clinical practice. Copyright © 2017 World Federation for Ultrasound in Medicine & Biology. Published by Elsevier Inc. All rights reserved.

The MitraClip Asia-Pacific registry: Differences in outcomes between functional and degenerative mitral regurgitation.

PubMed

Tay, Edgar; Muda, Nasir; Yap, Jonathan; Muller, David W M; Santoso, Teguh; Walters, Darren L; Liu, Xianbao; Yamen, Eric; Jansz, Paul; Yip, James; Zambahari, Robaayah; Passage, Jurgen; Ding, Zee Pin; Wang, Jian'an; Scalia, Gregory; Soesanto, Amiliana M; Yeo, Khung Keong

2016-06-01

The objective of this study is to describe and compare the use of the MitraClip therapy in mitral regurgitation (MR) patients with degenerative MR (DMR) and functional MR (FMR). Percutaneous edge-to-edge repair of severe MR using the MitraClip device is approved for use in the USA for high risk DMR while European guidelines include its use in FMR patients as well. The MitraClip in the Asia-Pacific Registry (MARS) is a multicenter retrospective registry, involving eight sites in five Asia-Pacific countries. Clinical and echocardiographic characteristics, procedural outcomes and 1-month outcomes [death and major adverse events (MAE)] were compared between FMR and DMR patients treated with the MitraClip. A total of 163 patients were included from 2011 to 2014. The acute procedural success rates for FMR (95.5%, n = 84) and DMR (92%, n = 69) were similar (P = 0.515). 45% of FMR had ≥2 clips inserted compared to 60% of those with DMR (P = 0.064).The 30-day mortality rate for FMR and DMR was similar at 4.5% and 6.7% respectively (P = 0.555). The 30-day MAE rate was 9.2% for FMR and 14.7% for DMR (P = 0.281). Both FMR and DMR patients had significant improvements in the severity of MR and NYHA class after 30 days. There was a significantly greater reduction in left ventricular end-diastolic diameter (P = 0.002) and end systolic diameter (P = 0.017) in DMR than in FMR. The MitraClip therapy is a safe and efficacious treatment option for both FMR and DMR. Although, there is a significantly greater reduction in LV volumes in DMR, patients in both groups report clinical benefit with improvement in functional class. © 2015 Wiley Periodicals, Inc. © 2015 Wiley Periodicals, Inc.

Atrial myocardial nox2 containing NADPH oxidase activity contribution to oxidative stress in mitral regurgitation: potential mechanism for atrial remodeling.

PubMed

Chang, Jen-Ping; Chen, Mien-Cheng; Liu, Wen-Hao; Yang, Cheng-Hsu; Chen, Chien-Jen; Chen, Yung-Lung; Pan, Kuo-Li; Tsai, Tzu-Hsien; Chang, Hsueh-Wen

2011-01-01

Oxidative stress is linked with several cardiovascular diseases. However, the NADPH oxidase activity in severe mitral regurgitation patients with and without atrial fibrillation has not yet been explored. This study involved 16 adult patients (eight patients with persistent atrial fibrillation and eight with sinus rhythm) with severe mitral and moderate-to-severe tricuspid regurgitation and five control patients without mitral and tricuspid disease. Atrial tissues of the right and left atrial appendages were obtained during surgery. Superoxide anion production was measured by lucigenin-enhanced chemiluminescence, and the expression of nox2 containing NADPH oxidase mRNA was measured by quantitative real-time RT-PCR. Additionally, immunohistochemical study was performed. NADPH-stimulated superoxide release was significantly higher than basal superoxide production from right [5671.9±3498.7 vs. 232.7±70.0 relative light units per second per milligram of protein (RLU s(-1) mg protein(-1)), P=.008) and left atrial homogenates (6475.1±1890.8 vs. 229.0±79.6 RLU s(-1) mg protein(-1), P=.008) in atrial fibrillation patients. The NADPH-stimulated superoxide release from right atrial homogenates was also significantly higher than basal superoxide production in sinus patients (6809.1±1327.1 vs. 244.2±65.5 RLU s(-1) mg protein(-1), P=.008). Additionally, there was a borderline significant correlation between NADPH-stimulated superoxide production from left atrial homogenates and left atrial sizes (r=0.683, P=.062) in atrial fibrillation patients. Membrane-bound nox2 containing NADPH oxidase mRNA expression was increased and was similar in both the atrial fibrillation patients and sinus patients. The NADPH-stimulated superoxide production in right atrial homogenates in control atrial samples was 1863.7±137.2 RLU s(-1) mg protein(-1). Immunohistochemical study demonstrated increased expression of nox2 in myocytes with moderate-to-severe myolysis and hypertrophy. Results of

Follow-Up of the Novel Free Margin Running Suture Technique for Mitral Valve Repair.

PubMed

Agnino, Alfonso; Lanzone, Alberto Maria; Albertini, Andrea; Anselmi, Amedeo

2018-06-13

The free margin running suture (FMRS) is a novel technique for nonresection correction of degenerative mitral regurgitation. It was employed in 37 minimally invasive mitral repair cases. We performed a retrospective collection of in-hospital data and a clinical/echocardiographic follow-up. All patients were discharged with none or mild mitral regurgitation, except one who had mild-to-moderate (2+) regurgitation. At follow-up (average: 2.1 years), all patients were alive; there were no instances of recurrent regurgitation, one case of 2+ regurgitation, and no valve-related complications. Average mitral valve area, mean gradient, and coaptation length were 2.9 cm 2  ±0.1, 3.5 mm Hg ±0.9, and 1.1 cm ±0.2. Georg Thieme Verlag KG Stuttgart · New York.

Preoperative left ventricular ejection fraction and left atrium reverse remodeling after mitral regurgitation surgery.

PubMed

Machado, Lucia R; Meneghelo, Zilda M; Le Bihan, David C S; Barretto, Rodrigo B M; Carvalho, Antonio C; Moises, Valdir A

2014-11-06

Left atrium enlargement has been associated with cardiac events in patients with mitral regurgitation (MR). Left atrium reverse remodeling (LARR) occur after surgical correction of MR, but the preoperative predictors of this phenomenon are not well known. It is therefore important to identify preoperative predictors for postoperative LARR. We enrolled 62 patients with chronic severe MR (prolapse or flail leaflet) who underwent successful mitral valve surgery (repair or replacement); all with pre- and postoperative echocardiography. LARR was defined as a reduction in left atrium volume index (LAVI) of ≥ 25%. Stepwise multiple regression analysis was used to identify independent predictors of LARR. LARR occurred in 46 patients (74.2%), with the mean LAVI decreasing from 85.5 mL/m2 to 49.7 mL/m2 (p <0.001). These patients had a smaller preoperative left ventricular systolic volume (p =0.022) and a higher left ventricular ejection fraction (LVEF) (p =0.034). LVEF was identified as the only preoperative variable significantly associated with LARR (odds ratio, 1.086; 95% confidence interval, 1.002-1.178). A LVEF cutoff value of 63.5% identified patients with LARR of ≥ 25% with a sensitivity of 71.7% and a specificity of 56.3%. LARR occurs frequently after mitral valve surgery and is associated with preoperative LVEF higher than 63.5%.

Partial external mitral annuloplasty in dogs with myxomatous mitral valve degeneration and congestive heart failure: outcome in 9 cases.

PubMed

de Andrade, James N B M; Christopher Orton, E; Boon, June; Nishimori, Celina T D; Olivaes, Claudio; Camacho, Aparecido A

2011-09-01

To report the outcome of partial external mitral annuloplasty in dogs with congestive heart failure (CHF) due to mitral regurgitation caused by myxomatous mitral valve degeneration (MMVD). Nine client-owned dogs with CHF due to mitral regurgitation caused by MMVD. Surgery consisted of a double row of pledget-butressed continuous suture lines placed into the left ventricle parallel and just ventral to the atrioventricular groove between the subsinuosal branch of the left circumflex coronary artery and the paraconal branch of the left coronary artery. Two dogs died during surgery because of severe hemorrhage. Two dogs died 12 and 36 h after surgery because of acute myocardial infarction. Three dogs were euthanized 2 and 4 weeks after surgery because of progression of CHF, 1 was euthanized 30 days after surgery for non-cardiac disease, and 1 survived for 48 months. In the 5 dogs that survived to discharge there was no significant change in the left atrium to aortic ratio with surgery (3.6 ± 0.56 before surgery; 3.1 ± 0.4 after surgery; p = 0.182), and no significant change in mitral regurgitant fraction in 4 dogs in which this measurement was made (78.7 ± 2.0% before surgery; 68.7 ± 7.5% after surgery; p = 0.09). Partial external mitral annuloplasty in dogs with CHF due to MMVD was associated with high perioperative mortality and most dogs that survived to discharge failed to show clinically relevant palliation from this procedure. Consequently, partial external mitral annuloplasty is not a viable option for dogs with mitral regurgitation due to MMVD that has progressed to the stage of CHF. Copyright © 2011 Elsevier B.V. All rights reserved.

Application of Percutaneous Balloon Mitral Valvuloplasty in Patients of Rheumatic Heart Disease Mitral Stenosis Combined with Tricuspid Regurgitation

PubMed Central

Chen, Zhang-Qiang; Hong, Lang; Wang, Hong; Lu, Lin-Xiang; Yin, Qiu-Lin; Lai, Heng-Li; Li, Hua-Tai; Wang, Xiang

2015-01-01

Background: Tricuspid regurgitation (TR) is frequently associated with severe mitral stenosis (MS), the importance of significant TR was often neglected. However, TR influences the outcome of patients. The aim of this study was to investigate the efficacy and safety of percutaneous balloon mitral valvuloplasty (PBMV) procedure in rheumatic heart disease patients with mitral valve (MV) stenosis and tricuspid valve regurgitation. Methods: Two hundred and twenty patients were enrolled in this study due to rheumatic heart disease with MS combined with TR. Mitral balloon catheter made in China was used to expand MV. The following parameters were measured before and after PBMV: MV area (MVA), TR area (TRA), atrial pressure and diameter, and pulmonary artery pressure (PAP). The patients were followed for 6 months to 9 years. Results: After PBMV, the MVAs increased significantly (1.7 ± 0.3 cm2 vs. 0.9 ± 0.3 cm2, P < 0.01); TRA significantly decreased (6.3 ± 1.7 cm2 vs. 14.2 ± 6.5 cm2, P < 0.01), right atrial area (RAA) decreased significantly (21.5 ± 4.5 cm2 vs. 25.4 ± 4.3 cm2, P < 0.05), TRA/RAA (%) decreased significantly (29.3 ± 3.2% vs. 44.2 ± 3.6%, P < 0.01). TR velocity (TRV) and TR continue time (TRT) as well as TRV × TRT decreased significantly (183.4 ± 9.4 cm/s vs. 254.5 ± 10.7 cm/s, P < 0.01; 185.7 ± 13.6 ms vs. 238.6 ± 11.3 ms, P < 0.01; 34.2 ± 5.6 cm vs. 60.7 ± 8.5 cm, P < 0.01, respectively). The postoperative left atrial diameter (LAD) significantly reduced (41.3 ± 6.2 mm vs. 49.8 ± 6.8 mm, P < 0.01) and the postoperative right atrial diameter (RAD) significantly reduced (28.7 ± 5.6 mm vs. 46.5 ± 6.3 mm, P < 0.01); the postoperative left atrium pressure significantly reduced (15.6 ± 6.1 mmHg vs. 26.5 ± 6.6 mmHg, P < 0.01), the postoperative right atrial pressure decreased significantly (13.2 ± 2.4 mmHg vs. 18.5 ± 4.3 mmHg, P < 0.01). The pulmonary arterial pressure decreased significantly after PBMV (48.2 ± 10.3 mmHg vs. 60.6 ± 15

Isolated Effect of Geometry on Mitral Valve Function for In-Silico Model Development

PubMed Central

Siefert, Andrew William; Rabbah, Jean-Pierre Michel; Saikrishnan, Neelakantan; Kunzelman, Karyn Susanne; Yoganathan, Ajit Prithivaraj

2013-01-01

Computational models for the heart’s mitral valve (MV) exhibit several uncertainties which may be reduced by further developing these models using ground-truth data sets. The present study generated a ground-truth data set by quantifying the effects of isolated mitral annular flattening, symmetric annular dilatation, symmetric papillary muscle displacement, and asymmetric papillary muscle displacement on leaflet coaptation, mitral regurgitation (MR), and anterior leaflet strain. MVs were mounted in an in vitro left heart simulator and tested under pulsatile hemodynamics. Mitral leaflet coaptation length, coaptation depth, tenting area, MR volume, MR jet direction, and anterior leaflet strain in the radial and circumferential directions were successfully quantified for increasing levels of geometric distortion. From these data, increasing levels of isolated papillary muscle displacement resulted in the greatest mean change in coaptation depth (70% increase), tenting area (150% increase), and radial leaflet strain (37% increase) while annular dilatation resulted in the largest mean change in coaptation length (50% decrease) and regurgitation volume (134% increase). Regurgitant jets were centrally located for symmetric annular dilatation and symmetric papillary muscle displacement. Asymmetric papillary muscle displacement resulted in asymmetrically directed jets. Peak changes in anterior leaflet strain in the circumferential direction were smaller and exhibited non-significant differences across the tested conditions. When used together, this ground-truth data may be used to parametrically evaluate and develop modeling assumptions for both the MV leaflets and subvalvular apparatus. This novel data may improve MV computational models and provide a platform for the development of future surgical planning tools. PMID:24059354

Isolated effect of geometry on mitral valve function for in silico model development.

PubMed

Siefert, Andrew William; Rabbah, Jean-Pierre Michel; Saikrishnan, Neelakantan; Kunzelman, Karyn Susanne; Yoganathan, Ajit Prithivaraj

2015-01-01

Computational models for the heart's mitral valve (MV) exhibit several uncertainties that may be reduced by further developing these models using ground-truth data-sets. This study generated a ground-truth data-set by quantifying the effects of isolated mitral annular flattening, symmetric annular dilatation, symmetric papillary muscle (PM) displacement and asymmetric PM displacement on leaflet coaptation, mitral regurgitation (MR) and anterior leaflet strain. MVs were mounted in an in vitro left heart simulator and tested under pulsatile haemodynamics. Mitral leaflet coaptation length, coaptation depth, tenting area, MR volume, MR jet direction and anterior leaflet strain in the radial and circumferential directions were successfully quantified at increasing levels of geometric distortion. From these data, increase in the levels of isolated PM displacement resulted in the greatest mean change in coaptation depth (70% increase), tenting area (150% increase) and radial leaflet strain (37% increase) while annular dilatation resulted in the largest mean change in coaptation length (50% decrease) and regurgitation volume (134% increase). Regurgitant jets were centrally located for symmetric annular dilatation and symmetric PM displacement. Asymmetric PM displacement resulted in asymmetrically directed jets. Peak changes in anterior leaflet strain in the circumferential direction were smaller and exhibited non-significant differences across the tested conditions. When used together, this ground-truth data-set may be used to parametrically evaluate and develop modelling assumptions for both the MV leaflets and subvalvular apparatus. This novel data may improve MV computational models and provide a platform for the development of future surgical planning tools.

The mechanobiology of mitral valve function, degeneration, and repair

PubMed Central

Richards, Jennifer M.; Farrar, Emily J.; Kornreich, Bruce G.; Moïse, N. Sydney; Butcher, Jonathan T.

2013-01-01

In degenerative valve disease, the highly organized mitral valve leaflet matrix stratification is progressively destroyed and replaced with proteoglycan rich, mechanically inadequate tissue. This is driven by the actions of originally quiescent valve interstitial cells that become active contractile and migratory myofibroblasts. While treatment for myxomatous mitral valve disease in humans ranges from repair to total replacement, therapies in dogs focus on treating the consequences of the resulting mitral regurgitation. The fundamental gap in our understanding is how the resident valve cells respond to altered mechanical signals to drive tissue remodeling. Despite the pathological similarities and high clinical occurrence, surprisingly little mechanistic insight has been gleaned from the dog. This review presents what is known about mitral valve mechanobiology from clinical, in vivo, and in vitro data. There are a number of experimental strategies already available to pursue this significant opportunity, but success requires the collaboration between veterinary clinicians, scientists, and engineers. PMID:22366572

Review of mitral valve insufficiency: repair or replacement

PubMed Central

Madesis, Athanasios; Tsakiridis, Kosmas; Katsikogiannis, Nikolaos; Machairiotis, Nikolaos; Kougioumtzi, Ioanna; Kesisis, George; Tsiouda, Theodora; Beleveslis, Thomas; Koletas, Alexander; Zarogoulidis, Konstantinos

2014-01-01

Mitral valve (MV) dysfunction is the second-most common clinically significant form of valvular defect in adults. MV regurgitation occurs with the increasing frequency of degenerative changes of the aging process. Moreover, other causes of clinically significant MV regurgitation include cardiac ischemia, infective endocarditis and rhematic disease more frequently in less developed countries. Recent evidence suggests that the best outcomes after repair of severe degenerative mitral regurgitation (MR) are achieved in asymptomatic or minimally symptomatic patients, who are selected for surgery soon after diagnosis on the basis of echocardiography. This review will focus on the surgical management of mitral insufficiency according to its aetiology today and will give insight to some of the perspectives that lay in the future. PMID:24672698

Long-term outcome in dogs undergoing mitral valve repair with suture annuloplasty and chordae tendinae replacement.

PubMed

Mizuno, T; Mizukoshi, T; Uechi, M

2013-02-01

Mitral valve repair under cardiopulmonary bypass was performed in three dogs with clinical signs associated with mitral regurgitation that were not controlled by medication. Mitral valve repair comprised circumferential annuloplasty and chordal replacement with expanded polytetrafluoroethylene. One dog died 2 years after surgery because of severe mitral regurgitation resulting from partial circumferential suture detachment. The others survived for over 5 years, but mild mitral valve stenosis persisted in one. The replaced chordae did not rupture in any dog. Mitral valve repair appears to be an effective treatment for mitral regurgitation in dogs. Chordal replacement with expanded polytetrafluoroethylene is a feasible technique, demonstrating long-term durability in dogs. However, mitral annuloplasty techniques need improvement. © 2012 British Small Animal Veterinary Association.

Beating heart mitral valve replacement with a bovine pericardial bioprosthesis for treatment of mitral valve dysplasia in a Bull Terrier.

PubMed

Behr, Luc; Chetboul, Valérie; Sampedrano, Carolina Carlos; Vassiliki, Gouni; Pouchelon, Jean-Louis; Laborde, François; Borenstein, Nicolas

2007-04-01

To describe an open, beating heart surgical technique and use of a bovine pericardial prosthetic valve for mitral valve replacement (MVR) in the dog. Clinical case report. Male Bull Terrier (17-month-old, 26 kg) with mitral valve dysplasia and severe regurgitation. A bovine pericardial bioprosthesis was used to replace the mitral valve using an open beating heart surgical technique and cardiopulmonary bypass. Successful MVR was achieved using a beating heart technique. Mitral regurgitation resolved and cardiac performances improved (left ventricular end-diastolic diameter decreased from 57.6 to 48.7 mm, and left atrium/aorta ratio returned to almost normal, from 1.62 to 1.19). Cardiopulmonary by-pass time and total surgical duration were decreased compared with standard cardioplegic techniques. Surgical recovery was uneventful and on echocardiography 6 months later valve function was excellent. Considering the technique advantages (no cardiac arrest, ischemic reperfusion injury, and hypothermia, or the need for aortic dissection and cannulation for administration of cardioplegic solution), short-term mortality and morbidity may be reduced compared with standard cardioplegic techniques. Based on experience in this dog, beating heart mitral valvular replacement is a seemingly safe and viable option for the dog and bovine pericardial prosthesis may provide better long-term survival than mechanical prostheses.

Mitral valve repair under cardiopulmonary bypass in small-breed dogs: 48 cases (2006-2009).

PubMed

Uechi, Masami; Mizukoshi, Takahiro; Mizuno, Takeshi; Mizuno, Masashi; Harada, Kayoko; Ebisawa, Takashi; Takeuchi, Junichirou; Sawada, Tamotsu; Uchida, Shuhei; Shinoda, Asako; Kasuya, Arane; Endo, Masaaki; Nishida, Miki; Kono, Shota; Fujiwara, Megumi; Nakamura, Takashi

2012-05-15

To determine whether mitral valve repair (MVR) under cardiopulmonary bypass would be an effective treatment for mitral regurgitation in small-breed dogs. Retrospective case series. 48 small-breed dogs (body weight, 1.88 to 4.65 kg [4.11 to 10.25 lb]; age, 5 to 15 years) with mitral regurgitation that underwent surgery between August 2006 and August 2009. Cardiopulmonary bypass was performed with a cardiopulmonary bypass circuit. After induction of cardiac arrest, a mitral annuloplasty was performed, and the chordae tendineae were replaced with expanded polytetrafluoroethylene chordal prostheses. After closure of the left atrium and declamping to restart the heart, the thorax was closed. Preoperatively, cardiac murmur was grade 3 of 6 to 6 of 6, thoracic radiography showed cardiac enlargement (median vertebral heart size, 12.0 vertebrae; range, 9.5 to 14.5 vertebrae), and echocardiography showed severe mitral regurgitation and left atrial enlargement (median left atrium-to-aortic root ratio, 2.6; range, 1.7 to 4.0). 45 of 48 dogs survived to discharge. Three months after surgery, cardiac murmur grade was reduced to 0/6 to 3/6, and the heart shadow was reduced (median vertebral heart size, 11.1 vertebrae, range, 9.2 to 13.0 vertebrae) on thoracic radiographs. Echocardiography confirmed a marked reduction in mitral regurgitation and left atrium-to-aortic root ratio (median, 1.7; range, 1.0 to 3.0). We successfully performed MVR under cardiopulmonary bypass in small-breed dogs, suggesting this may be an effective surgical treatment for dogs with mitral regurgitation. Mitral valve repair with cardiopulmonary bypass can be beneficial for the treatment of mitral regurgitation in small-breed dogs.

[Surgical treatment of ishemic mitral regurgitation: repair, replacement or revascularization alone?].

PubMed

Vrenes, Mile; Velinović, Milos; Kocica, Mladen; Mikić, Aleksandar; Putnik, Svetozar; Djukić, Petar; Djordjević, Aleksandar

2010-01-01

Treatment of ischemic mitral regurgitation in patients that require revascularization of myocardium is still debatable. The aim of this study was to compare three surgical approaches: valve repair and revascularization; valve replacement and revascularization, and revascularization alone. In 2006 and 2007 at the Institute for Cardiovascular Diseases, Clinical Centre of Serbia, Belgrade, 1,040 patients with coronary disease underwent surgery. Forty-three patients (4.3%) had also mitral insufficiency 3-4+. The patients were examined clinically, echocardiographically and haemodynamically. In group I there were 14 (32.3%) patients, in group II 16 (37.2%) patients and in group III 3 (30.5%) patients. Ninety-three per cent of patients were classified as New York Heart Association (NYHA) class III and IV, and three (7%) patients had congestive heart weakness with ejection fraction < or =30%. The decision as to surgical procedure was made by the surgeon. Postoperatively, patients were checked clinically and echocardiographically after 3, 6 and 12 months. The follow-up period was approximately 15 months (8-20). Hospital mortality for the whole group was 6.9% (3 patients). In group I mortality was 14.2% (2 patients), in group II 6.25% and in group III there was no mortality. Long term results, up to 15 months, showed 100% survival in groups I and II, and in group III one patient died (7.7%). Short term results upto 30 days were best in group III, but longer term results were better in groups I and II.

Relationship between systolic and diastolic function with improvements in forward stroke volume following reduction in mitral regurgitation

NASA Technical Reports Server (NTRS)

Firstenberg, M. S.; Greenberg, N. L.; Smedira, N. G.; McCarthy, P. M.; Garcia, M. J.; Thomas, J. D.

2001-01-01

Efforts to improve mitral regurgitation (MR) are often performed in conjunction with coronary revascularization. However, the independent effects of a reduced MR area (MRa) are difficult to quantify. Using a previously developed cardiovascular model, ventricular contractility (elastance 1-8 mmHg/ml) and relaxation (tau: 40-150 msec) were independently adjusted for four grades of MR orifice areas (0.0 to 0.8 cm2). Improvements in forward stroke volume (fSV) were determined for the permutations of reduced MRa. For all conditions, LV end-diastolic pressure and volumes ranged from 7.3-24.2 mmHg and 64.8-174.3 ml, respectively. Overall, fSV ranged from 36.0-89.4 (mean: 64.2 +/- 12.8) ml, improved between 6.4 and 35.3% (mean: 15.6 +/- 8.1%), and was best predicted by (r=0.97, p<0.01) %delta(fSV)[correction of fVS]=34[MRa initial] - 46[MRa final] -0.5[elastance]. Reduced MRa, independent of relaxation and minimally influence by contractility, yield improved fSVs.

Comparison of outcomes of tricuspid annuloplasty with 3D-rigid versus flexible prosthetic ring for functional tricuspid regurgitation secondary to rheumatic mitral valve disease.

PubMed

Wang, Haiping; Liu, Xiancheng; Wang, Xin; Lv, Zhenqian; Liu, Xiaojun; Xu, Ping

2016-11-01

Annuloplasty bands and rings are widely used for repairing functional tricuspid regurgitation (FTR). However, the question regarding which is the ideal annuloplasty device remains unclear. The aim of this study was to compare the efficacy and mid-term durability of tricuspid ring annuloplasty for FTR secondary to rheumatic mitral valve disease using flexible Cosgrove-Edwards band and the rigid Edwards MC3 ring (Edwards Lifesciences, LLC, Irvine, CA, USA). We retrospectively collected the clinical data of those who underwent mitral valve replacement (MVR) in concomitant with tricuspid ring annuloplasty from 2009 to 2013. The flexible band was used in 46 patients (flexible group), and the 3D rigid ring was used in 60 patients (rigid group). Echocardiographic evaluation of tricuspid function was performed preoperatively and postoperatively. The grade of TR was significantly improved compared to preoperative values in two groups. There was no significant difference regarding postoperative TR grade between the two groups at 1 week and 2-3 months but there was statistical significant difference at postoperative 6-12 months, and 2-3 years. During the follow up period, 25 of 46 patients (54.3%) in flexible group and 22 of 60 patients (30.3%) in rigid group developed recurrent TR. Freedom from recurrent TR in flexible group is significant lower than rigid group in each postoperative follow up period. These findings suggest that 3D rigid ring annuloplasty might be more effective for tricuspid ring annuloplasty in FTR in mid-term postoperative periods when compared to flexible band.

Comparison of outcomes of tricuspid annuloplasty with 3D-rigid versus flexible prosthetic ring for functional tricuspid regurgitation secondary to rheumatic mitral valve disease

PubMed Central

Wang, Haiping; Wang, Xin; Lv, Zhenqian; Liu, Xiaojun

2016-01-01

Background Annuloplasty bands and rings are widely used for repairing functional tricuspid regurgitation (FTR). However, the question regarding which is the ideal annuloplasty device remains unclear. The aim of this study was to compare the efficacy and mid-term durability of tricuspid ring annuloplasty for FTR secondary to rheumatic mitral valve disease using flexible Cosgrove-Edwards band and the rigid Edwards MC3 ring (Edwards Lifesciences, LLC, Irvine, CA, USA). Methods We retrospectively collected the clinical data of those who underwent mitral valve replacement (MVR) in concomitant with tricuspid ring annuloplasty from 2009 to 2013. The flexible band was used in 46 patients (flexible group), and the 3D rigid ring was used in 60 patients (rigid group). Echocardiographic evaluation of tricuspid function was performed preoperatively and postoperatively. Results The grade of TR was significantly improved compared to preoperative values in two groups. There was no significant difference regarding postoperative TR grade between the two groups at 1 week and 2–3 months but there was statistical significant difference at postoperative 6–12 months, and 2–3 years. During the follow up period, 25 of 46 patients (54.3%) in flexible group and 22 of 60 patients (30.3%) in rigid group developed recurrent TR. Freedom from recurrent TR in flexible group is significant lower than rigid group in each postoperative follow up period. Conclusions These findings suggest that 3D rigid ring annuloplasty might be more effective for tricuspid ring annuloplasty in FTR in mid-term postoperative periods when compared to flexible band. PMID:28066587

Insufficient Leaflet Remodeling in Patients With Atrial Fibrillation: Association With the Severity of Mitral Regurgitation.

PubMed

Kagiyama, Nobuyuki; Hayashida, Akihiro; Toki, Misako; Fukuda, Shota; Ohara, Minako; Hirohata, Atsushi; Yamamoto, Keizo; Isobe, Mitsuaki; Yoshida, Kiyoshi

2017-03-01

The relationship between annular dilatation caused by atrial fibrillation (AF) and mitral regurgitation (MR) remains controversial. We hypothesized that the small ratio of total leaflet area/annulus area (TLA/AA), reflecting insufficient leaflet remodeling to annular dilatation, is a main component of MR in patients with AF. Three-dimensional transesophageal echocardiographic data of the mitral valve were analyzed in 28 AF patients with moderate or severe MR (MR group), age- and sex-matched 56 AF patients with mild or less MR (non-MR group), and 16 control subjects. AA was significantly greater in both the MR (645±126 mm 2 /m 2 , P <0.001) and non-MR groups (568±121 mm 2 /m 2 , P =0.001) compared with control subjects (444±108 mm 2 /m 2 ). However, TLA/AA was significantly smaller in the MR (1.29±0.10, P <0.001), but not in the non-MR group (1.65±0.24, P >0.99), compared with control subjects (1.70±0.29). In linear regression analysis, TLA/AA was inversely associated with the effective regurgitant orifice ( r =-0.73, P <0.001). The area under the receiver-operating-characteristics curve of TLA/AA was significantly greater than that of AA (0.95 versus 0.72, P <0.001). Multivariable analysis revealed that small TLA/AA ( P <0.001) was independently associated with significant MR, while AA was not ( P =0.26). In patients with AF, insufficient leaflet remodeling to annular dilatation, rather than crude annular dilatation, was strongly associated with the severity of MR. © 2017 American Heart Association, Inc.

Development of Mitral Stenosis After Mitral Valve Repair: Importance of Mitral Valve Area.

PubMed

Chan, Kwan Leung; Chen, Shin-Yee; Mesana, Thierry; Lam, Buu Khanh

2017-12-01

The development of mitral stenosis (MS) is not uncommon after mitral valve (MV) repair for degenerative mitral regurgitation (MR), but the significance of MS in this setting has not been defined. We prospectively studied 110 such patients who underwent supine bicycle exercise testing to assess intracardiac hemodynamics at rest and at peak exercise. B-type natriuretic peptide (BNP) levels were measured at rest and after the exercise test. The patients also performed the 6-minute walk test and completed the 36-Item Short Form Survey (SF-36). Follow-up was performed by a review of the medical record and telephone interview. Of 110 patients, 22 had MS defined by a mitral valve area (MVA) ≤ 1.5 cm 2 . The resting and peak exercise mitral gradients and pulmonary artery systolic pressure were significantly higher in patients with MS compared with patients with an MVA > 1.5 cm 2 . BNP levels at rest and after exercise were also higher in the patients with MS, who also had lower exercise capacity and worse perception of well-being in 3 domains (physical function, vitality, and social function) on the SF-36. MVA had higher specificity and positive predictive value in predicting outcome events compared with a mean gradient of 3 or 5 mm Hg. In patients who had MV repair for degenerative MR, an MVA ≤ 1.5 cm 2 occurs in about one-fifth of patients and is associated with adverse intracardiac hemodynamics, lower exercise capacity, and adverse outcomes. Copyright © 2017 Canadian Cardiovascular Society. Published by Elsevier Inc. All rights reserved.

Changes in Left Ventricular Morphology and Function After Mitral Valve Surgery

PubMed Central

Shafii, Alexis E.; Gillinov, A. Marc; Mihaljevic, Tomislav; Stewart, William; Batizy, Lillian H.; Blackstone, Eugene H.

2015-01-01

Degenerative mitral valve disease is the leading cause of mitral regurgitation in North America. Surgical intervention has hinged on symptoms and ventricular changes that develop as compensatory ventricular remodeling takes place. In this study, we sought to characterize the temporal response of left ventricular (LV) morphology and function to mitral valve surgery for degenerative disease, and identify preoperative factors that influence reverse remodeling. From 1986–2007, 2,778 patients with isolated degenerative mitral valve disease underwent valve repair (n=2,607/94%) or replacement (n=171/6%) and had at least 1 postoperative transthoracic echocardiogram (TTE); 5,336 TTEs were available for analysis. Multivariable longitudinal repeated-measures analysis was performed to identify factors associated with reverse remodeling. LV dimensions decreased in the first year after surgery (end-diastolic from 5.7±0.80 to 4.9±1.4 cm; end-systolic from 3.4±0.71 to 3.1±1.4 cm). LV mass index decreased from 139±44 to 112±73 g·m−2. Reduction of LV hypertrophy was less pronounced in patients with greater preoperative left heart enlargement (P<.0001) and greater preoperative LV mass (P<.0001). Postoperative LV ejection fraction initially decreased from 58±7.0 to 53±20, increased slightly over the first postoperative year, and was negatively influenced by preoperative heart failure symptoms (P<.0001) and lower preoperative LV ejection fraction (P<.0001). Risk-adjusted response of LV morphology and function to valve repair and replacement was similar (P>.2). In conclusion, a positive response toward normalization of LV morphology and function after mitral valve surgery is greatest in the first year. The best response occurs when surgery is performed before left heart dilatation, LV hypertrophy, or LV dysfunction develop. PMID:22534055

Impact of moderate functional mitral insufficiency in patients undergoing surgical revascularization.

PubMed

Grossi, Eugene A; Crooke, Gregory A; DiGiorgi, Paul L; Schwartz, Charles F; Jorde, Ulrich; Applebaum, Robert M; Ribakove, Greg H; Galloway, Aubrey C; Grau, Juan B; Colvin, Stephen B

2006-07-04

Mild and moderate functional ischemic mitral insufficiency present at the time of surgical revascularization present clinical uncertainty. It is unclear whether the relatively poor outcomes in this cohort are dependent on valvular function or related to left ventricular dysfunction. The purpose of this study was to examine the early and late outcomes in patients with less-than-severe functional ischemic mitral insufficiency at the time of isolated coronary artery bypass grafting (CABG). From 1996 through 2004, 2242 consecutive patients undergoing isolated CABG were identified as having none to moderate mitral regurgitation (MR) and no valve leaflet pathology. All of the patients at this single institution routinely had an intraoperative transesophageal echocardiography, prospectively quantified MR, and ejection fraction (EF). The New York State Cardiac Surgery Reporting System infrastructure was used to prospectively collect in-hospital patient variables and outcomes. Social Security Death Benefit Index was used to determine long-term survival. Odds ratio and significance (P value) are presented for each determined risk factor. There were 841 patients (37.5%) with no MR, 1137 (50.7%) with mild MR, and 264 (11.8%) with moderate MR. The patients with moderate MR were more likely to be older, female, and have more renal disease, previous MI, congestive heart failure, previous cardiac surgery, and lower EFs. Hospital mortality was independently and significantly associated with renal disease, decreasing EF, increasing age, previous cardiac operation, and cerebral vascular disease. Multivariable analysis revealed decreased survival with increasing age, previous operation, congestive heart failure, diabetes, nonelective operation, decreasing EF, and the presence of moderate MR (expbeta = 1.49; P=0.007) and mild MR (expbeta = 1.34; P=0.033). Independent of ventricular function, mild and moderate functional mitral insufficiency are associated with significantly decreased

Clinical Outcome of Degenerative Mitral Regurgitation: Critical Importance of Echocardiographic Quantitative Assessment in Routine Practice.

PubMed

Antoine, Clemence; Benfari, Giovanni; Michelena, Hector I; Malouf, Joseph F; Nkomo, Vuyisile T; Thapa, Prabin; Enriquez-Sarano, Maurice

2018-05-31

Background -Echocardiographic quantitation of degenerative mitral regurgitation (DMR) is recommended whenever possible in clinical guidelines but is criticized and its scalability to routine clinical practice doubted. We hypothesized that echocardiographic DMR quantitation, performed in routine clinical practice by multiple practitioners predicts independently long-term survival, and thus is essential to DMR management. Methods -We included patients diagnosed with isolated mitral-valve-prolapse 2003-2011 and any degree of MR quantified by any physician/sonographer in routine clinical practice. Clinical/echocardiographic data acquired at diagnosis were retrieved electronically. Endpoint was mortality under medical treatment analyzed by Kaplan-Meir method and Proportional-Hazard models. Results -The cohort included 3914 patients (55% male) aged 62±17 years, with left ventricular ejection fraction (LVEF) 63±8% and routinely measured effective regurgitant orifice area (EROA) 19[0-40] mm 2 During follow-up (6.7±3.1 years) 696 patients died under medical management and 1263 underwent mitral surgery. In multivariate analysis, routinely measured EROA was associated with mortality (adjusted-hazard-ratio 1.19[1.13-1.24] p<0.0001 per-10mm 2 ) independently of LVEF and end-systolic diameter, symptoms and age/comorbidities. The association between routinely measured EROA and mortality persisted with competitive risk modeling (adjusted hazard-ratio 1.15[1.10-1.20] per 10mm 2 p<0.0001), or in patients without guideline-based Class I/II surgical triggers (adjusted hazard ratio 1.19[1.10-1.28] per 10mm 2 p<0.0001) and in all subgroups examined (all p<0.01). Spline curve analysis showed that, compared with general population mortality, excess mortality appears for moderate DMR (EROA ≥20mm 2 ) becomes notable ≥EROA 30mm 2 and steadily increases with higher EROA levels, > 40 mm 2 threshold. Conclusions -Echocardiographic DMR quantitation is scalable to routine practice and is

Impact of timing and surgical approach on outcomes after mitral valve regurgitation operations.

PubMed

Stevens, Louis-Mathieu; Rodriguez, Evelio; Lehr, Eric J; Kindell, Linda C; Nifong, L Wiley; Ferguson, T Bruce; Chitwood, W Randolph

2012-05-01

This study investigated whether the timing of mitral valve (MV) repair or surgical approach affects outcomes in patients with MV regurgitation. Between 1992 and 2009, 2,255 patients underwent MV operations, including 1,305 with isolated MV regurgitation operations (1,054 repairs, 251 replacements). Surgical approaches were sternotomy in 377, video-assisted right minithoracotomy in 481, or robot-assisted in 447. Mean follow-up was 6.4±4.5 years (maximum, 19 years). Sternotomy MV repairs decreased during the study while minimally invasive MV repairs increased. Robotic MV repair patients were younger, with fewer women, had better left ventricular ejection fractions, and were more likely to have myxomatous degeneration (all p<0.001). The robotic approach led to a higher MV repair rate and increased use of leaflet/chordal procedures but had longer cardiopulmonary bypass and aortic cross-clamp times (all p<0.001). The 30-day mortality for isolated MV repair was similar for all approaches (p=0.409). Fewer neurological events were observed in the videoscopic and robotic groups (p=0.013). Adjusted survival was similar for all approaches (p=0.357). Survival in patients in New York Heart Association class I to II with myxomatous degeneration or annular dilatation was similar to a matched population but was worse for patients in class III to IV or undergoing MV replacement. MV repair in patients with severe MV regurgitation should be performed before New York Heart Association class III to IV symptoms develop. Minimally invasive MV repair techniques render similar outcomes as the sternotomy approach. Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

Balloon mitral valvuloplasty during pregnancy--our experience.

PubMed

Salomé, Nuno; Dias, Carla C; Ribeiro, José; Gonçalves, Manuel; Fonseca, Conceição; Ribeiro, Vasco Gama

2002-12-01

Mitral stenosis is the most common valvular heart lesion found in pregnancy. When severe, it leads to significant maternal and fetal morbidity and mortality, since the hemodynamic adaptations to pregnancy are badly tolerated. Pregnancy can lead to development of heart failure in patients with asymptomatic or even unknown mitral stenosis, as a result of the increased mitral valve pressure gradient caused by the physiologic increase in heart rate and blood volume in pregnancy. When symptoms persist despite optimal medical therapy, the poor prognosis justifies the correction of mitral stenosis during pregnancy. To present our experience in treating severe mitral stenosis in women who develop severe heart failure during pregnancy, using percutaneous balloon mitral valvuloplasty. From 1996 to March 2002, in our department, 47 balloon mitral valvuloplasties were successfully performed in women, three of them pregnant. These were patients with congestive heart failure, New York Heart Association (NYHA) functional class III or IV, at the end of the second trimester of pregnancy, who did not respond positively to drug treatment with diuretics and digitalis. We performed percutaneous balloon mitral valvuloplasty using the Inoue technique in the three pregnant patients, with success, at around 25 weeks of gestation. After the procedure, the patients showed clinical improvement, returning to the NYHA functional class that they were in before becoming pregnant (I-II). The previous mitral valve area was 0.9-1.2 cm2, nearly doubling after valvuloplasty. Mean left atrial pressure decreased on average by 42%, and the maximum pressure (V wave) decreased on average by 40%. The mitral valve pressure gradient decreased from 15, 10 and 28 mmHg to 7, 5 and 5 mmHg after valvuloplasty. During the procedure there were no maternal or fetal complications. All patients were discharged 24 to 48 h after valvuloplasty, continuing their pregnancies without complications. One woman had vaginal

In Vitro Validation of Real-Time Three-Dimensional Color Doppler Echocardiography for Direct Measurement of Proximal Isovelocity Surface Area in Mitral Regurgitation

PubMed Central

Little, Stephen H.; Igo, Stephen R.; Pirat, Bahar; McCulloch, Marti; Hartley, Craig J.; Nosé, Yukihiko; Zoghbi, William A.

2012-01-01

The 2-dimensional (2D) color Doppler (2D-CD) proximal isovelocity surface area (PISA) method assumes a hemispheric flow convergence zone to estimate transvalvular flow. Recently developed 3-dimensional (3D)-CD can directly visualize PISA shape and surface area without geometric assumptions. To validate a novel method to directly measure PISA using real-time 3D-CD echocardiography, a circulatory loop with an ultrasound imaging chamber was created to model mitral regurgitation (MR). Thirty-two different regurgitant flow conditions were tested using symmetric and asymmetric flow orifices. Three-dimensional–PISA was reconstructed from a hand-held real-time 3D-CD data set. Regurgitant volume was derived using both 2D-CD and 3D-CD PISA methods, and each was compared against a flowmeter standard. The circulatory loop achieved regurgitant volume within the clinical range of MR (11 to 84 ml). Three-dimensional–PISA geometry reflected the 2D geometry of the regurgitant orifice. Correlation between the 2D-PISA method regurgitant volume and actual regurgitant volume was significant (r2 = 0.47, p <0.001). Mean 2D-PISA regurgitant volume underestimate was 19.1 ± 25 ml (2 SDs). For the 3D-PISA method, correlation with actual regurgitant volume was significant (r2 = 0.92, p <0.001), with a mean regurgitant volume underestimate of 2.7 ± 10 ml (2 SDs). The 3D-PISA method showed less regurgitant volume underestimation for all orifice shapes and regurgitant volumes tested. In conclusion, in an in vitro model of MR, 3D-CD was used to directly measure PISA without geometric assumption. Compared with conventional 2D-PISA, regurgitant volume was more accurate when derived from 3D-PISA across symmetric and asymmetric orifices within a broad range of hemodynamic flow conditions. PMID:17493476

Mid-term results of mitral valve repair using flexible bands versus complete rings in patients with degenerative mitral valve disease: a prospective, randomized study.

PubMed

Bogachev-Prokophiev, Alexandr V; Afanasyev, Alexandr V; Zheleznev, Sergei I; Nazarov, Vladimir M; Sharifulin, Ravil M; Karaskov, Alexandr M

2017-12-13

We aimed to compare the outcomes of mitral valve repair with flexible band (FB) versus complete semirigid ring (SR) in degenerative mitral valve disease patients. From September 2011 to 2014, 171 patients were randomized and underwent successful mitral valve repair using a SR (n = 85) or FB (n = 86). There were no significant between-group differences at baseline. There were no early mortalities. The mean follow up was 24.7 months. The 2-year survival was 96.0 ± 2.3% (95% confidence interval [CI], 88.6-98.7%) and 94.3 ± 2.8% (95% CI, 85.5-97.9%) in the SR and FB groups, respectively (p = 0.899). The left ventricle remodeling was similar between the groups. Higher transmitral peak (8.5 [3.9-17] vs. 6 [2.1-18] mmHg, p < 0.001), mean pressure gradients (3.7 [1.3-8] vs. 2.8 [0.6-6.8] mmHg, p = 0.001), and systolic pulmonary artery pressure (34.5 [20-68] vs. 29.5 [8-48] mmHg, p < 0.001) was observed in the SR group. The 2-year freedom from recurrence of significant mitral regurgitation was significantly higher in the FB group than the SR group (p = 0.002). Residual mitral regurgitation was an independent prognostic factor of recurrence of mitral regurgitation. The 3-year freedom from reoperation was significantly higher in the FB group than the SR group (p = 0.044). Patients with degenerative mitral valve disease may benefit from valve repair with FBs. Residual mitral regurgitation before discharge is an independent risk factor of late insufficiency recurrence. ClinicalTrials.gov NCT03278574 , retrospectively registered on 06.09.2017.

Tricuspid and mitral regurgitation detected by color flow Doppler in the acute phase of Kawasaki disease

DOE Office of Scientific and Technical Information (OSTI.GOV)

Suzuki, A.; Kamiya, T.; Tsuchiya, K.

Valvular lesions in the acute phase of Kawasaki disease were studied in 19 children. The patients were intensively observed by color flow Doppler every day from the day of hospitalization up to 12 days after the onset of the disease and 2 or more times a week thereafter, for up to 28 days. Mitral regurgitation (MR) was found in 9 patients (47%) and tricuspid regurgitation (TR) in 10 (53%). MRs were of transient type and confirmed from 7.5 +/- 1.6 (mean +/- standard deviation) to 13.1 +/- 6.5 days after the onset of the disease. Both types of valvular regurgitationmore » were mild. The direction of regurgitation was from the center of valvular coaptation toward the posterior wall of the atrium. Neither valvular prolapse nor valvular deformity was noted. In patients with MR, left ventricular ejection fraction on M-mode echocardiography was significantly lower in the acute phase than in the convalescent phase of the disease (p less than 0.05). Using gallium-67 scintigram, the positive uptake of the isotope was noted in 7 (88%) of 8 patients with MR, but not found at all in 8 patients free of MR. These results suggest that MR and TR are often transient in the acute phase of Kawasaki disease and could be attributed to myocarditis.« less

Functional and Biomechanical Effects of the Edge-to-Edge Repair in the Setting of Mitral Regurgitation: Consolidated Knowledge and Novel Tools to Gain Insight into Its Percutaneous Implementation.

PubMed

Sturla, Francesco; Redaelli, Alberto; Puppini, Giovanni; Onorati, Francesco; Faggian, Giuseppe; Votta, Emiliano

2015-06-01

Mitral regurgitation is the most prevalent heart valve disease in the western population. When severe, it requires surgical treatment, repair being the preferred option. The edge-to-edge repair technique treats mitral regurgitation by suturing the leaflets together and creating a double-orifice valve. Due to its relative simplicity and versatility, it has become progressively more widespread. Recently, its percutaneous version has become feasible, and has raised interest thanks to the positive results of the Mitraclip(®) device. Edge-to-edge features and evolution have stimulated debate and multidisciplinary research by both clinicians and engineers. After providing an overview of representative studies in the field, here we propose a novel computational approach to the most recent percutaneous evolution of the edge-to-edge technique. Image-based structural finite element models of three mitral valves affected by posterior prolapse were derived from cine-cardiac magnetic resonance imaging. The models accounted for the patient-specific 3D geometry of the valve, including leaflet compound curvature pattern, patient-specific motion of annulus and papillary muscles, and hyperelastic and anisotropic mechanical properties of tissues. The biomechanics of the three valves throughout the entire cardiac cycle was simulated before and after Mitraclip(®) implantation, assessing the biomechanical impact of the procedure. For all three simulated MVs, Mitraclip(®) implantation significantly improved systolic leaflets coaptation, without inducing major alterations in systolic peak stresses. Diastolic orifice area was decreased, by up to 58.9%, and leaflets diastolic stresses became comparable, although lower, to systolic ones. Despite established knowledge on the edge-to-edge surgical repair, latest technological advances make its percutanoues implementation a challenging field of research. The modeling approach herein proposed may be expanded to analyze clinical scenarios that

Design considerations and quantitative assessment for the development of percutaneous mitral valve stent.

PubMed

Kumar, Gideon Praveen; Cui, Fangsen; Phang, Hui Qun; Su, Boyang; Leo, Hwa Liang; Hon, Jimmy Kim Fatt

2014-07-01

Percutaneous heart valve replacement is gaining popularity, as more positive reports of satisfactory early clinical experiences are published. However this technique is mostly used for the replacement of pulmonary and aortic valves and less often for the repair and replacement of atrioventricular valves mainly due to their anatomical complexity. While the challenges posed by the complexity of the mitral annulus anatomy cannot be mitigated, it is possible to design mitral stents that could offer good anchorage and support to the valve prosthesis. This paper describes four new Nitinol based mitral valve designs with specific features intended to address migration and paravalvular leaks associated with mitral valve designs. The paper also describes maximum possible crimpability assessment of these mitral stent designs using a crimpability index formulation based on the various stent design parameters. The actual crimpability of the designs was further evaluated using finite element analysis (FEA). Furthermore, fatigue modeling and analysis was also done on these designs. One of the models was then coated with polytetrafluoroethylene (PTFE) with leaflets sutured and put to: (i) leaflet functional tests to check for proper coaptation of the leaflet and regurgitation leakages on a phantom model and (ii) anchorage test where the stented valve was deployed in an explanted pig heart. Simulations results showed that all the stents designs could be crimped to 18F without mechanical failure. Leaflet functional test results showed that the valve leaflets in the fabricated stented valve coapted properly and the regurgitation leakage being within acceptable limits. Deployment of the stented valve in the explanted heart showed that it anchors well in the mitral annulus. Based on these promising results of the one design tested, the other stent models proposed here were also considered to be promising for percutaneous replacement of mitral valves for the treatment of mitral

Increased NT-proANP predicts risk of congestive heart failure in Cavalier King Charles spaniels with mitral regurgitation caused by myxomatous valve disease.

PubMed

Eriksson, Anders S; Häggström, Jens; Pedersen, Henrik Duelund; Hansson, Kerstin; Järvinen, Anna-Kaisa; Haukka, Jari; Kvart, Clarence

2014-09-01

To evaluate the predictive value of plasma N-terminal pro-atrial natriuretic peptide (NT-proANP) and nitric oxide end-products (NOx) as markers for progression of mitral regurgitation caused by myxomatous mitral valve disease. Seventy-eight privately owned Cavalier King Charles spaniels with naturally occurring myxomatous mitral valve disease. Prospective longitudinal study comprising 312 measurements over a 4.5 year period. Clinical values were recorded, NT-proANP concentrations were measured by radioimmunoassay, and NOx were analyzed colorimetrically. To predict congestive heart failure (CHF), Cox proportional hazards models with time-varying covariates were constructed. The hazard ratio for NT-proANP (per 1000 pmol/l increase) to predict future CHF was 6.7 (95% confidence interval, 3.6-12.5; p < 0.001). The median time to CHF for dogs with NT-proANP levels >1000 pmol/l was 11 months (95% confidence interval, 5.6-12.6 months), compared to 54 months (46 - infinity) for dogs with concentrations ≤ 1000 pmol/l (p < 0.001). Due to intra- and inter-individual variability, most corresponding analyses for NOx were insignificant but dogs reaching CHF had a lower mean NOx concentration than dogs not reaching CHF (23 vs. 28 μmol/l, p = 0.016). Risk of CHF increased with increase in heart rate (>130 beats per minute) and grade of murmur (≥ 3/6). The risk of CHF due to mitral regurgitation is increased in dogs with blood NT-proANP concentrations above 1000 pmol/l. Measurement of NT-proANP can be a valuable tool to identify dogs that may develop CHF within months. Copyright © 2014 Elsevier B.V. All rights reserved.

R-R interval variations influence the degree of mitral regurgitation in dogs with myxomatous mitral valve disease.

PubMed

Reimann, M J; Møller, J E; Häggström, J; Markussen, B; Holen, A E W; Falk, T; Olsen, L H

2014-03-01

Mitral regurgitation (MR) due to myxomatous mitral valve disease (MMVD) is a frequent finding in Cavalier King Charles Spaniels (CKCSs). Sinus arrhythmia and atrial premature complexes leading to R-R interval variations occur in dogs. The aim of the study was to evaluate whether the duration of the R-R interval immediately influences the degree of MR assessed by echocardiography in dogs. Clinical examination including echocardiography was performed in 103 privately-owned dogs: 16 control Beagles, 70 CKCSs with different degree of MR and 17 dogs of different breeds with clinical signs of congestive heart failure due to MMVD. The severity of MR was evaluated in apical four-chamber view using colour Doppler flow mapping (maximum % of the left atrium area) and colour Doppler M-mode (duration in ms). The influence of the ratio between present and preceding R-R interval on MR severity was evaluated in 10 consecutive R-R intervals using a linear mixed model for repeated measurements. MR severity was increased when a short R-R interval was followed by a long R-R interval in CKCSs with different degrees of MR (P<0.005 when adjusted for multiple testing). The relationship was not significant in control dogs with minimal MR and in dogs with severe MR and clinical signs of heart failure. In conclusion, MR severity increases in long R-R intervals when these follow a short R-R interval in CKCSs with different degrees of MR due to asymptomatic MMVD. Thus, R-R interval variations may affect the echocardiographic grading of MR in CKCSs. Copyright © 2014 Elsevier Ltd. All rights reserved.

Association of plasma N-terminal pro-B-type natriuretic peptide concentration with mitral regurgitation severity and outcome in dogs with asymptomatic degenerative mitral valve disease.

PubMed

Chetboul, V; Serres, F; Tissier, R; Lefebvre, H P; Sampedrano, C Carlos; Gouni, V; Poujol, L; Hawa, G; Pouchelon, J -L

2009-01-01

The clinical outcome of dogs affected by degenerative mitral valve disease (MVD) without overt clinical signs is still poorly defined, and criteria for identification of animals that are at a higher risk of early decompensation have not yet been determined. N-terminal pro-B-type natriuretic peptide plasma concentration (NT-proBNP) is correlated with mitral regurgitation (MR) severity and can predict disease progression in dogs with asymptomatic MVD. Seventy-two dogs with asymptomatic MVD, with or without heart enlargement (International Small Animal Cardiac Health Council: ISACHC classes 1a and 1b), and a control group of 22 dogs were prospectively recruited. Severity of MR was quantitatively assessed from the regurgitation fraction (RF) by the proximal isovelocity surface area method. Consequences of MR were evaluated from measurements of the left atrium/aorta ratio (LA/Ao), fractional shortening (FS), end-diastolic and end-systolic left ventricular volumes indexed to body surface area (EDVI and ESVI). The relevance of these echo-Doppler indices and NT-proBNP for prediction of outcome at 12 months was studied. A significant correlation was found between NT-proBNP and RF, LA/Ao, FS, and EDVI (P < .05). NT-proBNP was higher in dogs with MVD (ISACHC classes 1a and 1b) compared with the control group (P= .025 and < .001, respectively). The difference was not significant when only dogs from ISACHC class 1a with RF < 30% were considered. Lastly, NT-proBNP was higher in dogs that underwent MVD decompensation at 12 months (P < .05). NT-proBNP is correlated with MVD severity and prognosis in dogs with asymptomatic MVD.

Mitral stenosis due to pannus overgrowth after rigid ring annuloplasty.

PubMed

Oda, Takeshi; Kato, Seiya; Tayama, Eiki; Fukunaga, Shuji; Akashi, Hidetoshi; Aoyagi, Shigeaki

2010-03-01

Although mitral stenosis (MS) due to pannus overgrowth after mitral valve repair for rheumatic mitral regurgitation (MR) is not uncommon, it is extremely rare in relation to non-rheumatic mitral regurgitation. Whilst it has been suggested that the rigid annuloplasty ring induces pannus overgrowth in the same manner as the flexible ring, to date only in cases using the flexible ring has pannus formation been confirmed by a pathological examination after redo surgery. The case is described of a woman who had undergone mitral valve repair using a 28 mm rigid ring three years previously because of non-rheumatic MR, and subsequently suffered from MS due to pannus formation over the annuloplasty ring. To the present authors' knowledge, this is the first report of MS due to pannus formation after mitral valve repair using a rigid annuloplasty ring to treat non-rheumatic MR documented at reoperation.

Biocompatibility and Systemic Safety of a Novel Implantable Annuloplasty Ring for the Treatment of Mitral Regurgitation in a Minipig Model.

PubMed

Ramot, Yuval; Rousselle, Serge D; Yellin, Nadav; Willenz, Udi; Sabag, Itai; Avner, Avi; Nyska, Abraham

2016-07-01

Prosthetic annuloplasty rings are a common treatment modality for mitral regurgitation, and recently, percutaneous implantation techniques have gained popularity due to their favorable safety profile. Although in common use, biocompatibility of annuloplasty rings has been reported only sparsely in the literature, and none of these reports used the percutaneous technique of implantation. We report on the biocompatibility and the systemic safety of a novel transcatheter mitral valve annuloplasty ring (AMEND™) in 6 minipigs. This device is composed of a nitinol tube surrounded by a braided polyethylene terephthalate fabric tube. The device produced no adverse inflammatory response, showing gradual integration between the metal ring and the fabric by normal host fibrocellular response, leading to complete neoendocardium coverage. There was no evidence for adverse reactions, rejection, or intolerance in the valvular structure. In 2 animals, hemopericardium resulted from the implantation procedure, leading to right-sided cardiac insufficiency with pulmonary edema and liver congestion. The findings reported herein can serve as a case study for the expected healing pathology reactions after implantation of transcatheter mitral valve annuloplasty rings. © The Author(s) 2016.

An uncommon cause of tricuspid regurgitation: three-dimensional echocardiographic incremental value, surgical and genetic insights.

PubMed

Theron, Alexis; Pinard, Amélie; Riberi, Alberto; Zaffran, Stéphane

2016-07-01

Congenital tricuspid valve disease is a rare defect that includes regurgitation, stenosis and Ebstein's anomaly. We report a case of severe tricuspid regurgitation associated with functional mitral regurgitation in a 47-year-old man with congestive heart failure. Transthoracic echocardiography (TTE) ruled out any Ebstein's anomaly. Three-dimensional TTE revealed a 'tricuspid hole' into the anterior leaflet that was only attached to the tricuspid annulus next to both anteroseptal and anteroposterior commissures. There was no sign of leaflet tear or perforation. The surgical repair of the tricuspid and mitral valves was performed with an optimal result. No sign of endocarditis or rheumatic disease was observed during the intervention. Sequence analysis of GATA4, HEY2 and ZFPM2 genes was performed, but no causative mutation was identified. © The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Unusual Giant Right Atrium in Rheumatic Mitral Stenosis and Tricuspid Insufficiency

PubMed Central

Anzouan-Kacou, Jean Baptiste; Konin, Christophe; Coulibaly, Iklo; N'guetta, Roland; Adoubi, Anicet; Soya, Esaïe; Boka, Bénédicte

2011-01-01

Dilation and hypertrophy of the atria occur in patients with valvular heart disease especially in mitral regurgitation, mitral stenosis or tricuspid abnormalities. In sub-saharan Africa, rheumatic fever is still the leading cause of valvular heart disease. We report a case of an unusual giant right atrium in context of rheumatic stenosis and severe tricuspid regurgitation in a 58-year-old woman. PMID:24826228

Pathology of myxomatous mitral valve disease in the dog.

PubMed

Fox, Philip R

2012-03-01

Mitral valve competence requires complex interplay between structures that comprise the mitral apparatus - the mitral annulus, mitral valve leaflets, chordae tendineae, papillary muscles, and left atrial and left ventricular myocardium. Myxomatous mitral valve degeneration is prevalent in the canine, and most adult dogs develop some degree of mitral valve disease as they age, highlighting the apparent vulnerability of canine heart valves to injury. Myxomatous valvular remodeling is associated with characteristic histopathologic features. Changes include expansion of extracellular matrix with glycosaminoglycans and proteoglycans; valvular interstitial cell alteration; and attenuation or loss of the collagen-laden fibrosa layer. These lead to malformation of the mitral apparatus, biomechanical dysfunction, and mitral incompetence. Mitral regurgitation is the most common manifestation of myxomatous valve disease and in advanced stages, associated volume overload promotes progressive valvular regurgitation, left atrial and left ventricular remodeling, atrial tears, chordal rupture, and congestive heart failure. Future studies are necessary to identify clinical-pathologic correlates that track disease severity and progression, detect valve dysfunction, and facilitate risk stratification. It remains unresolved whether, or to what extent, the pathobiology of myxomatous mitral valve degeneration is the same between breeds of dogs, between canines and humans, and how these features are related to aging and genetics. Copyright © 2012 Elsevier B.V. All rights reserved.

Mitral valve replacement with preservation of the subvalvular apparatus.

PubMed

Reardon, M J; David, T E

1999-03-01

The introduction of the Starr-Edwards valve allowed complete replacement of diseased left-sided heart valves. With improved cardiopulmonary bypass, myocardial protection, and surgical techniques the mortality rate from aortic valve replacement decreased substantially, whereas the mortality rate from mitral valve replacement remained high, largely because of low cardiac output syndrome. Increasing use of mitral valve repair techniques resulted in a marked decrease in short-term and long-term morbidity and mortality when treating patients with mitral regurgitation. Some believed that this resulted from maintenance of the mitral annular papillary muscle continuity during mitral valve repair. Subsequent experimental and clinical studies have validated the positive short-term and long-term effects of maintaining the integrity of the mitral valve subvalvular apparatus. This article considers the history of the clinical use of preservation of the subvalvular apparatus, the physiologic studies examining this concept, and the clinical data available on its use. It also examines the following: 1) mitral stenosis versus mitral regurgitation and the preservation of the subvalvular apparatus; 2) whether the anterior, posterior, or both areas of the subvalvular apparatus should be preserved; and 3) the surgical techniques for the preservation of the subvalvular apparatus and valve implantation.

Relationship between valve calcification and long-term results of percutaneous mitral commissurotomy for rheumatic mitral stenosis.

PubMed

Bouleti, Claire; Iung, Bernard; Himbert, Dominique; Messika-Zeitoun, David; Brochet, Eric; Garbarz, Eric; Cormier, Bertrand; Vahanian, Alec

2014-06-01

Indications of percutaneous mitral commissurotomy (PMC) remain debated in calcific mitral stenosis. We analyzed long-term results of PMC for calcific mitral stenosis and the factors associated with late functional results. We compared the characteristics and outcome of 314 patients undergoing PMC for calcific mitral stenosis with 710 patients with noncalcified valves followed up to 20 years. Calcification was defined by fluoroscopy, and its extent was graded from 1 to 4. Good immediate results (valve area ≥ 1.5 cm(2) with mitral regurgitation ≤ 2/4) were obtained in 251 patients (80%) with calcified valves and 661 (93%) with noncalcified valves (P < 0.001). The hazard ratio for good functional results (survival without cardiovascular death, without mitral reintervention, and in New York Heart Association class I or II) was 2.5 (95% confidence interval [2.1-2.9]; P < 0.0001) in patients with calcified valves (12 ± 3% at 20 years) relative to the noncalcified group (38 ± 2% at 20 years). In the 251 patients with calcified valves who had good immediate results, 15-year rates of good functional results were 35 ± 4% for minor (grade 1) calcification, 24 ± 6% for grade 2, and 10 ± 6% for severe (grades 3-4) calcification. Factors associated with poor late functional results on multivariable analysis were calcification extent, older age, higher New York Heart Association class, atrial fibrillation, and higher mean gradient after PMC. Although late results of PMC are less satisfying in calcific mitral stenosis, long-term functional outcome depends on calcification extent, patient characteristics, and immediate results of PMC. These findings support the use of PMC as first-line treatment in selected patients with calcific mitral stenosis. © 2014 American Heart Association, Inc.

Echocardiographic estimation of left atrial pressure in beagle dogs with experimentally-induced mitral valve regurgitation.

PubMed

Ishikawa, Taisuke; Fukushima, Ryuji; Suzuki, Shuji; Miyaishi, Yuka; Nishimura, Taiki; Hira, Satoshi; Hamabe, Lina; Tanaka, Ryou

2011-08-01

Non-invasive and immediate estimation of left atrial pressure (LAP) is very useful for the management of mitral regurgitation (MR), and many reports have assessed echocardiographic estimations of LAP to date. However, it has been unclear of which examination and evaluate article possess the best accuracy for the MR severity. The present research aims to establish the echocardiographic estimation equation of LAP that is well applicable for clinical MR dogs. After the chordae tendineae rupture was experimentally induced via left atriotomy in six healthy beagle dogs (three males and three females, two years old, weighing between 9.8 to 12.8 kg), a radio telemetry transmitter catheter was inserted, which allows the continuous recordings of LAP without the use of sedation. Approximately 5 weeks after the surgery, echocardiographic examination, indirect blood pressure measurement, measurement of plasma atrial natriuretic peptide (ANP) and LAP measurement by way of the radio telemetry system was performed simultaneously. Subsequently, simple linear regression equations between LAP and each variable were obtained, and the equations were evaluated whether to be applicable for clinical MR dogs. As a result, the ratio of early diastolic mitral flow to early diastolic lateral mitral annulus velocity (E/Ea) had the strongest correlation as maximum LAP=7.03*(E/Ea)-54.86 (r=0.74), and as mean LAP=4.94*(E/Ea)-40.37 (r=0.70) among the all variables. Therefore, these two equations associated with E/Ea should bring more precise and instant estimations of maximum and mean LAP in clinical MR dogs.

Dissociation between cardiomyocyte function and remodeling with beta-adrenergic receptor blockade in isolated canine mitral regurgitation.

PubMed

Pat, Betty; Killingsworth, Cheryl; Denney, Thomas; Zheng, Junying; Powell, Pamela; Tillson, Michael; Dillon, A Ray; Dell'Italia, Louis J

2008-12-01

The low-pressure volume overload of isolated mitral regurgitation (MR) is associated with increased adrenergic drive, left ventricular (LV) dilatation, and loss of interstitial collagen. We tested the hypothesis that beta1-adrenergic receptor blockade (beta1-RB) would attenuate LV remodeling after 4 mo of MR in the dog. beta1-RB did not attenuate collagen loss or the increase in LV mass in MR dogs. Using MRI and three-dimensional (3-D) analysis, there was a 70% increase in the LV end-diastolic (LVED) volume-to-LV mass ratio, a 23% decrease in LVED midwall circumferential curvature, and a >50% increase in LVED 3-D radius/wall thickness in MR dogs that was not attenuated by beta1-RB. However, beta1-RB caused a significant increase in LVED length from the base to apex compared with untreated MR dogs. This was associated with an increase in isolated cardiomyocyte length (171+/-5 microm, P<0.05) compared with normal (156+/-3 microm) and MR (165+/-4 microm) dogs. Isolated cardiomyocyte fractional shortening was significantly depressed in MR dogs compared with normal dogs (3.73+/-0.31 vs. 5.02+/-0.26%, P<0.05) and normalized with beta1-RB (4.73+/-0.48%). In addition, stimulation with the beta-adrenergic receptor agonist isoproterenol (25 nM) increased cardiomyocyte fractional shortening by 215% (P<0.05) in beta1-RB dogs compared with normal (56%) and MR (50%) dogs. In summary, beta1-RB improved LV cardiomyocyte function and beta-adrenergic receptor responsiveness despite further cell elongation. The failure to attenuate LV remodeling associated with MR could be due to a failure to improve ultrastructural changes in extracellular matrix organization.

Ischaemic mitral regurgitation: The effects of ring annuloplasty and suture annuloplasty repair techniques on left ventricular re-remodeling

PubMed Central

Aydin, Cemalettin; Kara, Ibrahim; Ay, Yasin; Inan, Bekir; Basel, Halil; Yanartas, Mehmet; Zeybek, Rahmi

2013-01-01

Objective: To examine the mid-term results of patients on whom a coronary revascularization as well as a mitral ring and suture annuloplasty have been performed due to coronary artery disease (CAD) and ischaemic mitral regurgitation (IMR). Methodology: Totally 73 patients on whom a revascularization and a mitral valve repair due to CAD and IMR had been performed in our clinic between 2000-2008 were included in the study. Patients were divided into two groups one of which included 38 patients (52.05%) on whom a coronary artery bypass graft (CABG) and a ring annuloplasty on the mitral valve had been performed (Group 1) and the other one 35 patients (47.95%) on whom only suture annuloplasty as well as a CABG had been performed (Group 2). The study was planned retrospectively and study data have been obtained by screening the hospital registries retrospectively. In the mid-term, patients were invited for a check and their intragroup and intergroup echocardiographic parameters and functional capacities were assessed statistically. Results: In pre-operational and post-operational intragroup assessment in terms of echocardiographic findings; although LVEDD, LVESD, EDV, PAP and the degree of recurrent MR have been decreased in both groups, the decrease in LVESD and PAP and the low degree of recurrent MR were statistically significant in Group 1 patients (p=0.047, p=0.023, p=0.01, respectively). When the mid-term intergroup echocardiograpic findings were assessed; PAP and recurrent MR have been determined statistically lower in Group 1 patients (p=0.005, p=0.08, respectively). The length of intensive care unit stay, length of hospitalization and length of detachment from respiratory support were statistically significantly longer in ring annuloplasty performed group (p=0.012, p=0.033, p=0.029, respectively). Conclusions: In moderate to severe IMR patients, a positive contribution can be provided to ventricular remodeling by a ring annuloplasty through a significant decrease

Dynamic left ventricular dyssynchrony and severe mitral regurgitation caused by exercise: should we go beyond the guidelines?

PubMed

Laflamme, Emilie; Philippon, François; O'Connor, Kim; Sarrazin, Jean-François; Auffret, Vincent; Chauvette, Vincent; Dubois, Michelle; Voisine, Pierre; Bergeron, Sébastien; Sénéchal, Mario

2018-01-01

Guidelines for cardiac resynchronization therapy (CRT) have been established, but there may be a subgroup of patients not identified in these guidelines who may benefit from this therapy. We report a patient with a dynamic left ventricular dyssynchrony and severe mitral regurgitation caused by exercise successfully treated with CRT. Exercise testing should be considered in patients with left ventricular ejection fraction <35% and QRS <130 ms with severe heart failure symptoms that are unexplained by rest echocardiography evaluation in order to rule out ischemia and/or dynamic left ventricular dyssynchrony. In the presence of exercise-induced left ventricular bundle branch block, the implantation of CRT should be contemplated.

Effect of varying ventricular function by extrasystolic potentiation on closure of the mitral valve.

NASA Technical Reports Server (NTRS)

Vandenberg, R. A.; Williams, J. C. P.; Sturm, R. E.; Wood , E. H.

1971-01-01

Mitral regurgitant indexes were measured by roentgen videodensitometry in anesthetized dogs without thoracotomy before, during and after extrasystolic potentiation of ventricular contraction while the atria and ventricles were driven in normal temporal sequence simultaneously or in such a way as to induce atrial fibrillation. Small amounts of mitral reflux were observed with simultaneous atrial and ventricular driving and with atrial fibrillation in the control measurements before initiation of extrasystolic potentiation. Reflux became negligible during extrasystolic potentiation and increased beyond control levels after termination of extrasystolic potentiation.

Efficacy of spironolactone on survival in dogs with naturally occurring mitral regurgitation caused by myxomatous mitral valve disease.

PubMed

Bernay, F; Bland, J M; Häggström, J; Baduel, L; Combes, B; Lopez, A; Kaltsatos, V

2010-01-01

Spironolactone, an aldosterone antagonist, has been demonstrated to decrease mortality in human patients when added to other cardiac therapies. Spironolactone in addition to conventional therapy increases survival compared with conventional therapy in dogs with naturally occurring myxomatous mitral valve disease (MMVD). Between February 2003 and March 2005, 221 dogs were recruited in Europe. Nine dogs were excluded from analysis, leaving 212 dogs with moderate to severe mitral regurgitation (MR) caused by MMVD (International Small Animal Cardiac Health Council classification classes II [n = 190] and III [n = 21]). Double-blinded, field study conducted with dogs randomized to receive either spironolactone (2 mg/kg once a day) or placebo in addition to conventional therapy (angiotensin converting enzyme inhibitor, plus furosemide and digoxin if needed). Primary endpoint was a composite of cardiac-related death, euthanasia, or severe worsening of MR. Primary endpoint reached by 11/102 dogs (10.8%) in the spironolactone group (6 deaths, 5 worsening) versus 28/110 (25.5%) in control group (14 deaths, 8 euthanasia, 6 worsening). Risk of reaching the composite endpoint significantly decreased by 55% (hazard ratio [HR] = 0.45; 95% confidence limits [CL], 0.22-0.90; log rank test, P = .017). Risk of cardiac-related death or euthanasia significantly reduced by 69% (HR = 0.31; 95% CL, 0.13-0.76; P = .0071). Number of dogs not completing the study for cardiac and other miscellaneous reasons similar in spironolactone (67/102) and control groups (66/110). Spironolactone added to conventional cardiac therapy decreases the risk of reaching the primary endpoint (ie, cardiac-related death, euthanasia, or severe worsening) in dogs with moderate to severe MR caused by MMVD.

Transcatheter Mitral Valve Replacement for Native and Failed Bioprosthetic Mitral Valves

PubMed Central

Sarkar, Kunal; Reardon, Michael J.; Little, Stephen H.; Barker, Colin M.; Kleiman, Neal S.

2017-01-01

Transcatheter mitral valve replacement (TMVR) is a novel approach for treatment of severe mitral regurgitation. A number of TMVR devices are currently undergoing feasibility trials using both transseptal and transapical routes for device delivery. Overall experience worldwide is limited to fewer than 200 cases. At present, the 30-day mortality exceeds 30% and is attributable to both patient- and device-related factors. TMVR has been successfully used to treat patients with degenerative mitral stenosis (DMS) as well as failed mitral bioprosthesis and mitral repair using transcatheter mitral valve-in-valve (TMViV)/valve-in-ring (ViR) repair. These patients are currently treated with devices designed for transcatheter aortic valve replacement. Multicenter registries have been initiated to collect outcomes data on patients currently undergoing TMViV/ViR and TMVR for DMS and have confirmed the feasibility of TMVR in these patients. However, the high periprocedural and 30-day event rates underscore the need for further improvements in device design and multicenter randomized studies to delineate the role of these technologies in patients with mitral valve disease. PMID:29743999

Alterations in left ventricular curvature and principal strains in dilated cardiomyopathy with functional mitral regurgitation.

PubMed

Tibayan, Frederick A; Lai, David T M; Timek, Tomasz A; Dagum, Paul; Liang, David; Zasio, Mary K; Daughters, George T; Miller, D Craig; Ingels, Neil B

2003-05-01

Functional mitral regurgitation (FMR) is increasingly recognized as a left ventricular (LV) disease. Dilated cardiomyopathy (DCM) is commonly accompanied by FMR and reduction of LV torsion. Therapeutic targets for DCM include LV size reduction, altered LV shape, elimination of MR, and increasing LV torsion. It was hypothesized that, in addition to increasing LV size, DCM with FMR would alter normal LV shape and reduce and alter the direction of principal strains across the LV wall. This hypothesis was tested by measuring changes in epicardial and endocardial 2-D principal strains and regional radii of curvature accompanying tachycardia-induced cardiomyopathy in ovine hearts. Radio-opaque marker arrays were implanted into the left ventricle of eight sheep, including one subepicardial triangle and one subendocardial triangle in the anterior wall of the left ventricle. At one week postoperatively, biplane videofluoroscopy was used to determine marker dynamics. Rapid ventricular pacing was then instituted until FMR and signs of heart failure developed, and fluoroscopy was repeated. Circumferential LV radii of curvature were determined from marker triplets. DCM changed the normal epicardial oval LV cross-section to a more circular configuration. The endocardium maintained its normal circular shape as the left ventricle dilated. Deformations of the triangles from end-diastole to end-systole were determined, and the magnitude and direction of 2-D principal strains calculated. DCM was associated with decreased magnitude of both epicardial (-0.095 +/- 0.055 versus -0.040 +/- 0.032, p = 0.006) and endocardial (-0.117 +/- 0.047 versus -0.073 +/- 0.037, p = 0.023) principal strains. DCM reduced the angle of epicardial but not endocardial principal strain. DCM with FMR is associated with LV dilation, circularization of the normally oval equatorial circumferential LV epicardium, transmural reduction in principal strain, and decrease in angle of principal epicardial strain. These

Intermediate outcomes of rheumatic mitral stenosis post-balloon mitral valvotomy.

PubMed

Sharma, Jugal; Goel, Pravin K; Pandey, Chandra Mani; Awasthi, Ashish; Kapoor, Aditya; Tewari, Satyendra; Garg, Naveen; Kumar, Sudeep; Khanna, Roopali

2015-10-01

Balloon mitral valvotomy is a standard therapeutic modality for managing rheumatic mitral stenosis. Data on intermediate outcomes of this procedure are limited. Thus we investigated the intermediate outcome after balloon mitral valvotomy performed at a large tertiary center in India. Case records and follow-up data of 2330 patients who underwent valvotomy from June 1999 to December 2005 were retrieved from the hospital information system and analyzed. The median age of the patients was 32 ± 11 years, 1363 were female including 36 who were pregnant, and 379 were in atrial fibrillation. Follow-up ranged from 1 to 14 years (mean 4.5 years, median 4.0 years). The procedural success rate was 93%. Atrial fibrillation, higher functional class, and worse valve morphology were independent predictors of a poor procedural outcome. Patients with sinus rhythm had better event-free survival (10.43 years, 95% confidence interval: 10.1-10.7) compared to those with atrial fibrillation (8.17 years, 95% confidence interval: 7.5-8.8). Patients who achieved a valve area >1.75 cm(2) had a better event-free survival (11.7 years, 95% confidence interval: 11.4-12.0) than those with a valve area of 1.5-1.74 cm(2) (9.3 years, 95% confidence interval: 9.0-9.7). On multivariate analysis, higher functional class, worse valve morphology, and new significant mitral regurgitation were predictors of a poor outcome. Achieved mitral valve area >1.75 cm(2) was an independent predictor of a good outcome. Patients with sinus rhythm, less gross valve deformity, and a post-balloon mitral valvotomy area >1.75 cm(2) had better intermediate outcomes. © The Author(s) 2015.

Gargantuan left atrium: a sequela of mitral regurgitation and mitral stenosis.

PubMed

Omslaer, Brian T; Biederman, Robert W W

2015-06-01

Cardiac magnetic resonance imaging and echocardiography revealed a gargantuan left atrium measuring 18.9 cm × 15.7 cm × 11.3 cm in a 56-year-old patient diagnosed with severe rheumatic mitral stenosis, severe pulmonary hypertension, and permanent atrial fibrillation. A chest x-ray also revealed a cardiothoracic ratio approaching 1.0 and a transthoracic echocardiogram measured diameters as large as 19.2 cm. The patient then underwent mitral valve replacement and left atrial reduction surgery and has had no further admissions or complications. © 2015, Wiley Periodicals, Inc.

Correction of anterior mitral prolapse: the parachute technique.

PubMed

Zannis, Konstantinos; Mitchell-Heggs, Laurens; Di Nitto, Valentina; Kirsch, Matthias E W; Noghin, Milena; Ghorayeb, Gabriel; Lessana, Arrigo

2012-04-01

To evaluate a new surgical technique for the correction of anterior mitral leaflet prolapse. From October 2006 to November 2011, 44 consecutive patients (28 males, mean age 55 ± 13 years) underwent mitral valve repair because of anterior mitral leaflet prolapse. Echocardiography was performed to evaluate the distance from the tip of each papillary muscle to the annular plane. A specially designed caliper was used to manufacture a parachute-like device, by looping a 4-0 polytetrafluoroethylene suture between a Dacron strip and Teflon felt pledget, according to the preoperative echocardiographic measurements. This parachute was then used to resuspend the anterior mitral leaflet to the corresponding papillary muscle. Of the 44 patients, 35 (80%) required concomitant posterior leaflet repair. Additional procedures were required in 16 patients (36%). The preoperative logistic European System for Cardiac Operative Risk Evaluation was 4.3 ± 6.9. The clinical and echocardiographic follow-up were complete. The total follow-up was 1031 patient-months and averaged 23.4 ± 17.2 months per patient. The overall mortality rate was 4.5% (n = 2). Also, 2 patients (4.5%) with recurrent mitral regurgitation required mitral valve replacement, 1 on the first postoperative day and 1 after 13 months. In the latter patient, histologic analysis showed complete endothelialization of the Dacron strip. At follow-up, all non-reoperated survivors (n = 40) were in New York Heart Association class I, with no regurgitation in 40 patients (93%) and grade 2+ mitral regurgitation in 3 (7%). This technique offers a simple and reproducible solution for correction of anterior leaflet prolapse. Echocardiography can reliably evaluate the length of the chordae. However, the long-term results must be evaluated and compared with other surgical strategies. Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

Ecocardiografía tridimensional. Nuevas perspectivas sobre la caracterización de la válvula mitral

PubMed Central

Solis, Jorge; Sitges, Marta; Levine, Robert A.; Hung, Judy

2010-01-01

Recent developments in three-dimensional echocardiography have made it possible to obtain images in real time, without the need for off-line reconstruction. These developments have enabled the technique to become an important tool for both research and daily clinical practice. A substantial proportion of the studies carried out using three-dimensional echocardiography have focused on the mitral valve, the pathophysiology of mitral valve disease and, in particular, functional mitral regurgitation. The aims of this article were to review the contribution of three-dimensional echocardiography to understanding of the functional anatomy of the mitral valve and to summarize the resulting clinical applications and therapeutic implications. PMID:19232192

Baseline mitral regurgitation predicts outcome in patients referred for dobutamine stress echocardiography.

PubMed

O'Driscoll, Jamie M; Gargallo-Fernandez, Paula; Araco, Marco; Perez-Lopez, Manuel; Sharma, Rajan

2017-11-01

A number of parameters recorded during dobutamine stress echocardiography (DSE) are associated with worse outcome. However, the relative importance of baseline mitral regurgitation (MR) is unknown. The aim of this study was to assess the prevalence and associated implications of functional MR with long-term mortality in a large cohort of patients referred for DSE. 6745 patients (mean age 64.9 ± 12.2 years) were studied. Demographic, baseline and peak DSE data were collected. All-cause mortality was retrospectively analyzed. DSE was successfully completed in all patients with no adverse outcomes. MR was present in 1019 (15.1%) patients. During a mean follow up of 5.1 ± 1.8 years, 1642 (24.3%) patients died and MR was significantly associated with increased all-cause mortality (p < 0.001). With Kaplan-Meier analysis, survival was significantly worse for patients with moderate and severe MR (p < 0.001). With multivariate Cox regression analysis, moderate and severe MR (HR 2.78; 95% CI 2.17-3.57 and HR 3.62; 95% CI 2.89-4.53, respectively) were independently associated with all-cause mortality. The addition of MR to C statistic models significantly improved discrimination. MR is associated with all-cause mortality and adds incremental prognostic information among patients referred for DSE. The presence of MR should be taken into account when evaluating the prognostic significance of DSE results.

Clinical outcomes and economic impact of transcatheter mitral leaflet repair in heart failure patients.

PubMed

Asgar, Anita W; Khairy, Paul; Guertin, Marie-Claude; Cournoyer, Daniel; Ducharme, Anique; Bonan, Raoul; Basmadjian, Arsene; Tardif, Jean-Claude; Cohen, David J

2017-01-01

Mitral regurgitation (MR) is a common valvular heart disorder requiring intervention once it becomes severe. Transcatheter mitral repair with the MitraClip device is a safe and effective therapy for selected patients denied surgery. The authors sought to evaluate the clinical outcomes and economic impact of this therapy compared to medical management in heart-failure patients with symptomatic mitral regurgitation. The study was comprised of two phases; an observational study of patients with heart failure and mitral regurgitation treated with either medical therapy or the MitraClip, and an economic model. Results of the observational study were used to estimate parameters for the decision model, which estimated costs, and benefits in a hypothetical cohort of patients with heart failure and moderate-to-severe mitral regurgitation treated with either standard medical therapy or MitraClip. The cohort of patients treated with the MitraClip was propensity matched to a population of heart failure patients, and their outcomes compared. At a mean follow-up of 22 months, all-cause mortality was 21% in the MitraClip cohort and 42% in the medical management cohort (p = .007). The decision model demonstrated that MitraClip increased life expectancy from 1.87-3.60 years and quality-adjusted life years (QALY) from 1.13-2.76 years. The incremental cost was $52,500 Canadian dollars, corresponding to an incremental cost-effectiveness ratio (ICER) of $32,300.00 per QALY gained. Results were sensitive to the survival benefit. In heart failure patients with symptomatic moderate-severe mitral regurgitation, therapy with the MitraClip is associated with superior survival and is cost-effective compared to medical therapy.

Early beneficial effect of preservation of papillo-annular continuity in mitral valve replacement on left ventricular function.

PubMed

Dilip, D; Chandra, A; Rajashekhar, D; Padmanabhan, M

2001-05-01

Impairment of left ventricular (LV) function after mitral valve replacement (MVR) has been the most important factor to determine morbidity and mortality. With this in mind, LV performance in the postoperative period was assessed with and without preservation of papillo-annular continuity in MVR. Between March 1994 and August 1998, a total of 383 valve prostheses (202 MVR, 65 AVR, 58 MVR+AVR) were implanted in 325 patients, 177 of whom underwent MVR with Starr Edwards ball cage prostheses (the study group). Of these 177 patients, 105 had MVR with preservation of the posterior mitral leaflet (group I), and 72 had conventional MVR (group II). Predominant lesions were mitral stenosis in 81, mitral regurgitation in 42, and mixed mitral lesion (MS/MR) in 54. Concomitant tricuspid valve annuloplasty was performed in 13, and atrial septal defect repair in five. Sixteen patients underwent MVR for mitral restenosis. In-vivo performance of the prostheses and LV function was evaluated by M-mode and Doppler echocardiography. At 3-6 months clinical improvement was seen in NYHA class, with reduction in cardiothoracic ratio among patients with preserved papillo-annular continuity, irrespective of lesion type. Significant reductions (p <0.05) were seen in left atrial dimensions (54.10 +/- 8.79 preop. versus 44.64 +/- 8.54 postop.; p <0.05), left ventricular end-diastolic dimensions (LVEDD) (50.84 +/- 10.42 preop. versus 41.21 +/- 7.16 postop.; p <0.05) and end-systolic dimensions (LVESD) (34.76 +/- 7.94 preop. versus 28.81 +/- 5.79 postop.; p <0.05) in patients who had their posterior mitral leaflet preserved with significant improvement in ejection fraction (60.31 +/- 8.22 versus 64.47 +/- 7.93; p <0.05). Further analysis of data in group I patients showed significant reductions in left atrial dimensions, LVESD and peak gradient, along with improved ejection fraction compared with conventional (group II) patients. Deterioration in LV function in patients undergoing conventional

Circulating concentrations of insulin-like growth factor-1 in dogs with naturally occurring mitral regurgitation.

PubMed

Pedersen, Henrik D; Falk, Torkel; Häggström, Jens; Tarnow, Inge; Olsen, Lisbeth H; Kvart, Clarence; Nielsen, Mette O

2005-01-01

Insulin-like growth factor-1 (IGF-1), which mediates most effects of growth hormone, has effects on cardiac mass and function, and plays an important role in the regulation of vascular tone. In humans, an inverse relationship between degree of heart failure (HF) and circulating IGF-1 concentrations has been found in several studies. In dogs with HF, few studies have focused on IGF-1. We examined circulating IGF-1 concentrations in dogs with mitral regurgitation (MR) caused by myxomatous mitral valve disease. Study 1 included 88 Cavalier King Charles Spaniels (CKCSs) with a broad range of asymptomatic MR (median serum IGF-1: 76.7 microg/L; 25-75 percentile, 59.8-104.9 microg/L). As expected, standard body weight and percentage under- or overweight correlated directly with IGF-1. MR (assessed in 4 different ways) did not correlate with IGF-1. In study 2, 28 dogs with severe MR and stable, treated congestive HF had similar serum IGF-1 concentrations (median, 100.8 g/L; 25-75 percentile, 74.9-156.5 microg/L) as 11 control dogs (79.6 microg/L; 25-75 percentile, 64.1-187.4 microg/L; P = .84). In study 3, the plasma IGF-1 concentration of 15 untreated CKCSs with severe MR was 16.4 +/- 24.2 microg/L lower (P = .02) at the examination when decompensated HF had developed (80.8 +/- 30.9 microg/L) than at a visit 1-12 months earlier (97.2 +/- 39.8 microg/L), possibly in part due to an altered state of nutrition. The studies document that circulating IGF-1 concentrations are not altered before development of congestive HF in dogs with naturally occurring MR, but decrease by approximately 20% with the development of untreated HE In treated HF, circulating IGF-1 concentrations apparently return to within the reference range.

Afterload mismatch in aortic and mitral valve disease: implications for surgical therapy.

PubMed

Ross, J

1985-04-01

In the management of patients with valvular heart disease, an understanding of the effects of altered loading conditions on the left ventricle is important in reaching a proper decision concerning the timing of corrective operation. In acquired valvular aortic stenosis, concentric hypertrophy generally maintains left ventricular chamber size and ejection fraction within normal limits, but in late stage disease function can deteriorate as preload reserve is lost and aortic stenosis progresses. In this setting, even when the ejection fraction is markedly reduced (less than 25%), it can improve to normal after aortic valve replacement, suggesting that afterload mismatch rather than irreversibly depressed myocardial contractility was responsible for left ventricular failure. Therefore, patients with severe aortic stenosis and symptoms should not be denied operation because of impaired cardiac function. In chronic severe aortic and mitral regurgitation, operation is generally recommended when symptoms are present, but whether to recommend operation to prevent irreversible myocardial damage in patients with few or no symptoms has remained controversial. In aortic regurgitation, left ventricular function generally improves postoperatively, even if it is moderately impaired preoperatively, indicating correction of afterload mismatch. Most such patients can be carefully followed by echocardiography. However, in some patients, severe left ventricular dysfunction fails to improve postoperatively. Therefore, when echocardiographic studies in the patient with severe aortic regurgitation show an ejection fraction of less than 40% (fractional shortening less than 25%) plus enlarging left ventricular end-diastolic diameter (approaching 38 mm/m2 body surface area) and end-systolic diameter (approaching 50 mm or 26 mm/m2), confirmation of these findings by cardiac catheterization and consideration of operation are advisable even in patients with minimal symptoms. In chronic mitral

Mitral valve repair using ePTFE sutures for ruptured mitral chordae tendineae: a computational simulation study.

PubMed

Rim, Yonghoon; Laing, Susan T; McPherson, David D; Kim, Hyunggun

2014-01-01

Mitral valve (MV) repair using expanded polytetrafluoroethylene sutures is an established and preferred interventional method to resolve the complex pathophysiologic problems associated with chordal rupture. We developed a novel computational evaluation protocol to determine the effect of the artificial sutures on restoring MV function following valve repair. A virtual MV was created using three-dimensional echocardiographic data in a patient with ruptured mitral chordae tendineae (RMCT). Virtual repairs were designed by adding artificial sutures between the papillary muscles and the posterior leaflet where the native chordae were ruptured. Dynamic finite element simulations were performed to evaluate pre- and post-repair MV function. Abnormal posterior leaflet prolapse and mitral regurgitation was clearly demonstrated in the MV with ruptured chordae. Following virtual repair to reconstruct ruptured chordae, the severity of the posterior leaflet prolapse decreased and stress concentration was markedly reduced both in the leaflet tissue and the intact native chordae. Complete leaflet coaptation was restored when four or six sutures were utilized. Computational simulations provided quantitative information of functional improvement following MV repair. This novel simulation strategy may provide a powerful tool for evaluation and prediction of interventional treatment for RMCT.

Ex Vivo Methods for Informing Computational Models of the Mitral Valve

PubMed Central

Bloodworth, Charles H.; Pierce, Eric L.; Easley, Thomas F.; Drach, Andrew; Khalighi, Amir H.; Toma, Milan; Jensen, Morten O.; Sacks, Michael S.; Yoganathan, Ajit P.

2016-01-01

Computational modeling of the mitral valve (MV) has potential applications for determining optimal MV repair techniques and risk of recurrent mitral regurgitation. Two key concerns for informing these models are (1) sensitivity of model performance to the accuracy of the input geometry, and, (2) acquisition of comprehensive data sets against which the simulation can be validated across clinically relevant geometries. Addressing the first concern, ex vivo micro-computed tomography (microCT) was used to image MVs at high resolution (~40 micron voxel size). Because MVs distorted substantially during static imaging, glutaraldehyde fixation was used prior to microCT. After fixation, MV leaflet distortions were significantly smaller (p<0.005), and detail of the chordal tree was appreciably greater. Addressing the second concern, a left heart simulator was designed to reproduce MV geometric perturbations seen in vivo in functional mitral regurgitation and after subsequent repair, and maintain compatibility with microCT. By permuting individual excised ovine MVs (n=5) through each state (healthy, diseased and repaired), and imaging with microCT in each state, a comprehensive data set was produced. Using this data set, work is ongoing to construct and validate high-fidelity MV biomechanical models. These models will seek to link MV function across clinically relevant states. PMID:27699507

Transfemoral aortic valve implantation in severe aortic stenosis patients with prior mitral valve prosthesis

PubMed Central

Sarı, Cenk; Baştuğ, Serdal; Kasapkara, Hacı Ahmet; Durmaz, Tahir; Keleş, Telat; Akçay, Murat; Aslan, Abdullah Nabi; Bayram, Nihal Akar; Bozkurt, Engin

2015-01-01

Introduction Transcatheter aortic valve implantation for severe symptomatic aortic stenosis in patients with a previous mitral valve prosthesis is technically challenging, and pre-procedural comprehensive assessment of these patients before transcatheter aortic valve implantation is vital for an uncomplicated and successful procedure. Aim We want to share our experience with transcatheter aortic valve implantation in patients with a preexisting functional mitral valve prosthesis and describe a series of important technical and pre-procedural details. Material and methods At our center, 135 patients with symptomatic severe aortic stenosis were treated with transcatheter aortic valve implantation. Six of them with a preexisting mitral valve prosthesis received an Edwards SAPIEN XT valve through the transfemoral route. Results Transcatheter aortic valve implantation was performed successfully in all 6 patients without any deformation of the cobalt-chromium/steel stents of the aortic valve bioprosthesis. Also no distortion or malfunction in the mitral valve prosthesis was observed after the procedure. There were no complications during the hospitalization period. Post-procedural echocardiography revealed no or mild aortic paravalvular regurgitation and normal valve function in all the patients. In addition, serial echocardiographic examination demonstrated that both the stability and function of the aortic and mitral prosthetic valves were normal without any deterioration in the gradients and the degree of the regurgitation at long-term follow-ups. Conclusions Our experience confirms that transcatheter aortic valve implantation is technically feasible in patients with previous mitral valve replacement but comprehensive evaluation of patients by multimodal imaging techniques such as transesophageal echocardiography and multislice computed tomography is mandatory for a successful and safe procedure. PMID:26677380

A Ruptured Mitral Valve Aneurysm as Complication of a Bicuspid Aortic Valve Endocarditis.

PubMed

Muscente, Francesca; Scarano, Michele; Clemente, Daniela; Pezzuoli, Franco; Parato, Vito Maurizio

2017-01-01

We present a case of a ruptured mitral valve (MV) aneurysm as a complication of a bicuspid aortic valve (BAV) endocarditis. It is about a young 35-year-old man, admitted to Cardiology Unit because of unexpected heart failure picture. We found a BAV endocarditis complicated by anterior MV-anterior leaflet aneurysm formation and subsequent severe MV regurgitation caused by aneurysm perforation. It was a particular and rare situation characterized by an infection of anterior mitral leaflet secondary to an infected regurgitant jet of a primary aortic infective endocarditis due to a BAV. A resulting aneurysm formation on the atrial side of the mitral anterior leaflet leads later to mitral perforation. In this article, we review the more relevant medical literature on this topic.

Early and late outcomes in minimally invasive mitral valve repair: an eleven-year experience in 707 patients.

PubMed

McClure, R Scott; Cohn, Lawrence H; Wiegerinck, Esther; Couper, Gregory S; Aranki, Sary F; Bolman, R Morton; Davidson, Michael J; Chen, Frederick Y

2009-01-01

This study analyzes a single institution experience with minimally invasive mitral valve repair and evaluates long-term surgical outcomes of morbidity, mortality, and rates of reoperation. Late follow-up of mitral regurgitation and left ventricular function were also assessed. Between August 1996 and October 2007, minimally invasive mitral valve repair was performed in 713 patients (mean follow-up 5.7 years). Excluding 6 repairs with robotic assistance, an perspective analysis of the remaining 707 patients was carried forth. Mean age was 57 +/- 13 years. Mean preoperative ejection fraction was 60% +/- 10%. Surgical access was through a lower ministernotomy (74%), right parasternal incision (24%), right thoracotomy (1.4%), or upper ministernotomy (0.7%). Exposure of the mitral valve was through the left atrium in 58% of the cases and transeptal in 42%. A ring annuloplasty was incorporated into 680 (96%) of 707 repairs. The Kaplan-Meier and Student t test for paired samples were used for statistical analysis. There were 3 (0.4%) operative deaths. Perioperative morbidity included new-onset atrial fibrillation (20%), reoperation for bleeding (2%), stroke (1.9%), permanent pacemaker implantation (1.7%), deep sternal wound infection (0.7%), and aortic dissection (0.4%). Median hospital stay was 5 days. Only 31% of patients required blood transfusion during the hospital course. There were 49 (6.9%) late deaths and 34 (4.8%) failed repairs necessitating reoperation. At 11.2 years, survival was 83% (95% confidence intervals, 76.5-88.1); freedom from reoperation was 92% (95% confidence intervals, 86.2-94.9). Nine (1.3%) patients were lost to follow-up. A total of 2369 patient-years of echocardiography time were obtained in 544 patients (mean 4.36 years, range 0.47-11.09). Mean grade of mitral regurgitation decreased from 3.80 to 1.42 (P < .0001) Mean left ventricular ejection fraction decreased from 60.7% to 56.3% (P < .0001). Combined risk of death, reoperation, and

[Aortic stenosis and mitral regurgitation complicated by hemolytic anemia and positive Direct Coombs test: a case report].

PubMed

Tamura, Shinjiro; Kitaoka, Hiroaki; Yamasaki, Naohito; Okawa, Makoto; Kubo, Toru; Matsumura, Yoshihisa; Furuno, Takashi; Takata, Jun; Nishinaga, Masanori; Sasaguri, Shiro; Doi, Yoshinori

2005-09-01

A 83-year-old man was admitted because of heart failure due to severe aortic stenosis and mitral regurgitation secondary to chordal rupture of the anterior leaflet. Mild anemia and elevated serum lactate dehydrogenase were present with reticulocytosis and haptoglobinemia. Direct Coombs test was positive. Coexistence of autoimmune hemolytic anemia was identified, but the main cause of his hemolysis was thought to be mechanical hemolysis due to stenotic valve and/or ruptured chordae because of the presence of red cell fragmentation. The patient successfully underwent double valve replacement. Improvement of anemia was coupled with reduction of the serum lactate dehydrogenase level. Valvular shear stress on the red cells and reduction of red cell deformability secondary to autoimmune hemolytic anemia were thought to be responsible for his hemolysis.

Biologic variability in NT-proBNP and cardiac troponin-I in healthy dogs and dogs with mitral valve degeneration.

PubMed

Ruaux, Craig; Scollan, Katherine; Suchodolski, Jan S; Steiner, Jörg M; Sisson, D David

2015-09-01

The N-terminal fragment of the prohormone B-type natriuretic peptide (NT-proBNP) and cardiac troponin-I are candidate biomarkers for cardiac disease in dogs. The degree of biologic variation in these biomarkers has not previously been reported in healthy dogs or dogs with mitral regurgitation. The purpose of the study was to derive estimates of intrinsic biologic variability and reference change values for NT-proBNP and cardiac troponin-I in healthy dogs and dogs with mitral regurgitation grade IB and II according to the International Small Animal Cardiac Health Council (ISACHC) grading system. Plasma and sera were collected weekly for up to 7 weeks from 12 control dogs and 9 dogs with mitral regurgitation. NT-proBNP and troponin-I (C-TnI) concentrations were determined. Indices of biologic variation such as reciprocal index of individuality (r-IoI) and reference change values (RCV) were calculated in both the groups. Individuality was high in control dogs and dogs with grade IB and II mitral valve regurgitation for both C-TnI (r-IoI 1.6 and 2) and NT-proBNP (1.5 and 2.7), while the 2-sided RCV for NT-proBNP was significantly lower in dogs with mitral regurgitation (52.5% vs 99.4%, P<0.01.). High individuality of these cardiac biomarkers suggests that, following diagnosis, these assays are best interpreted by serial determination in individual canine patients rather than by comparison to a population-based reference interval. The smaller RCV values for dogs with mitral regurgitation suggest that smaller relative changes in NT-proBNP are clinically meaningful in these patients. © 2015 American Society for Veterinary Clinical Pathology.

Effect of balloon mitral valvotomy on left ventricular function in rheumatic mitral stenosis.

PubMed

Rajesh, Gopalan Nair; Sreekumar, Pradeep; Haridasan, Vellani; Sajeev, C G; Bastian, Cicy; Vinayakumar, D; Kadermuneer, P; Mathew, Dolly; George, Biju; Krishnan, M N

Mitral stenosis (MS) is found to produce left ventricular (LV) dysfunction in some studies. We sought to study the left ventricular function in patients with rheumatic MS undergoing balloon mitral valvotomy (BMV). Ours is the first study to analyze effect of BMV on mitral annular plane systolic excursion (MAPSE), and to quantify prevalence of longitudinal left ventricular dysfunction in rheumatic MS. In this prospective cohort study, we included 43 patients with severe rheumatic mitral stenosis undergoing BMV. They were compared to twenty controls whose distribution of age and gender were similar to that of patients. The parameters compared were LV ejection fraction (EF) by modified Simpson's method, mitral annular systolic velocity (MASV), MAPSE, mitral annular early diastolic velocity (E'), and myocardial performance index (MPI). These parameters were reassessed immediately following BMV and after 3 months of procedure. MASV, MAPSE, E', and EF were significantly lower and MPI was higher in mitral stenosis group compared to controls. Impaired longitudinal LV function was present in 77% of study group. MAPSE and EF did not show significant change after BMV while MPI, MASV, and E' improved significantly. MASV and E' showed improvement immediately after BMV, while MPI decreased only at 3 months follow-up. There were significantly lower mitral annular motion parameters including MAPSE in patients with rheumatic mitral stenosis. Those with atrial fibrillation had higher MPI. Immediately after BMV, there was improvement in LV long axis function with a gradual improvement in global LV function. There was no significant change of MAPSE after BMV. Copyright © 2015 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.

Calculation of Mitral Valve Area in Mitral Stenosis: Comparison of Continuity Equation and Pressure Half Time With Two-Dimensional Planimetry in Patients With and Without Associated Aortic or Mitral Regurgitation or Atrial Fibrillation.

PubMed

Sattarzadeh, Roya; Tavoosi, Anahita; Saadat, Mohammad; Derakhshan, Leila; Khosravi, Bakhtyar; Geraiely, Babak

2017-11-01

Accurate measurement of Mitral Valve Area (MVA) is essential to determining the Mitral Stenosis (MS) severity and to achieving the best management strategies for this disease. The goal of the present study is to compare mitral valve area (MVA) measurement by Continuity Equation (CE) and Pressure Half-Time (PHT) methods with that of 2D-Planimetry (PL) in patients with moderate to severe mitral stenosis (MS). This comparison also was performed in subgroups of patients with significant Aortic Insufficiency (AI), Mitral Regurgitation (MR) and Atrial Fibrillation (AF). We studied 70 patients with moderate to severe MS who were referred to echocardiography clinic. MVA was determined by PL, CE and PHT methods. The agreement and correlations between MVA's obtained from various methods were determined by kappa index, Bland-Altman analysis, and linear regression analysis. The mean values for MVA calculated by CE was 0.81 cm (±0.27) and showed good correlation with those calculated by PL (0.95 cm, ±0.26 ) in whole population (r=0.771, P<0.001) and MR subgroup (r=0.763, P<0.001) and normal sinus rhythm and normal valve subgroups (r=0.858, P<0.001 and r=0.867, P<0.001, respectively). But CE methods didn't show any correlation in AF and AI subgroups. MVA measured by PHT had a good correlation with that measured by PL in whole population (r=0.770, P<0.001) and also in NSR (r=0.814, P<0.001) and normal valve subgroup (r=0.781, P<0.001). Subgroup with significant AI and those with significant MR showed moderate correlation (r=0.625, P=0.017 and r=0.595, P=0.041, respectively). Bland Altman Analysis showed that CE would estimate MVA smaller in comparison with PL in the whole population and all subgroups and PHT would estimate MVA larger in comparison with PL in the whole population and all subgroups. The mean bias for CE and PHT are 0.14 cm and -0.06 cm respectively. In patients with moderate to severe mitral stenosis, in the absence of concomitant AF, AI or MR, the accuracy of CE

PREVALENCE OF VALVULAR REGURGITATIONS IN CLINICALLY HEALTHY CAPTIVE LEOPARDS AND CHEETAHS: A PROSPECTIVE STUDY FROM THE WILDLIFE CARDIOLOGY (WLC) GROUP (2008-2013).

PubMed

Chai, Norin; Petit, Thierry; Kohl, Muriel; Bourgeois, Aude; Gouni, Vassiliki; Trehiou-Sechi, Emilie; Misbach, Charlotte; Petit, Amandine; Damoiseaux, Cécile; Garrigou, Audrey; Guepin, Raphaëlle; Pouchelon, Jean Louis; Chetboul, Valérie

2015-09-01

The purpose of this prospective study was to evaluate transthoracic echocardiograms from clinically healthy large felids for the presence of valvular regurgitations (VR). Physiologic VR commonly occur in normal dogs and cats, but the percentage of large felids with VR has not been previously reported. During a 5-yr study period (2008-2013), 28 healthy animals were evaluated under general anesthesia: 16 cheetahs (Acinonyx jubatus soemmeringuii) with a mean age of 1.5±0.8 yr (range 0.7-3.5 yr), 5 Amur leopards (Panthera pardus orientalis), 1 snow leopard (Uncia uncia), and 6 clouded leopards (Neofelis nebulosa). For this study, all the leopards were gathered in one so-called "leopards group" with a mean age of 2.8±3.4 yr (range 0.3-10.7 yr). All valves observed in each view were examined for evidence of regurgitant jets and turbulent blood flow using the color-flow Doppler mode. Valves were also examined for structural changes. Mitral valve and aortic cusp abnormalities were considered to be of congenital origin. Mitral valve lesions led to mitral insufficiency in all the felids. Aortic cusp abnormalities led to aortic regurgitation in 94% of the cheetahs and 67% of the leopards. Leopards showed a predominance of early systolic mitral regurgitations, whereas all the mitral regurgitation jets in cheetahs were holosystolic. Tricuspid regurgitation was found in 81% of the cheetahs and in 50% of the leopards, whereas pulmonic regurgitation was detected in 44% of the cheetahs and 33% of the leopards. Interestingly, none of these tricuspid and pulmonic regurgitations were associated with two-dimensional structural valve abnormalities, thus suggesting their physiologic origin, as described in humans, cats, and dogs. In conclusion, subclinical valvular diseases are common in apparently healthy leopards and cheetahs. Longitudinal follow-up of affected animals is therefore required to assess their clinical outcome.

Advanced mitral-tricuspid disease with severe right ventricular dysfunction: the double-staged approach.

PubMed

Jouan, Jérôme; Achouh, Paul; Besson, Laila; Carpentier, Alain; Fabiani, Jean-Noël

2012-09-01

Tricuspid valve surgery in the presence of severe right ventricular dysfunction and pulmonary hypertension secondary to mitral valve stenosis is associated with poor early outcomes. We report the case of a young patient, presenting with severe chronic mitral-tricuspid disease responsible for long-lasting pulmonary hypertension and altered right ventricular function, who initially underwent mitral valve replacement and 7 days later the correction of her tricuspid insufficiency. This 2-staged approach permitted progressive reduction of pulmonary pressure and partial right ventricular remodeling before closing the systolic release valve of the right ventricle represented by tricuspid regurgitation. Copyright © 2012 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.

COMPARISON OF ARTIFICIAL NEOCHORDAE AND NATIVE CHORDAL TRANSFER IN THE REPAIR OF A FLAIL POSTERIOR MITRAL LEAFLET: AN EXPERIMENTAL STUDY

PubMed Central

Padala, Muralidhar; Cardinau, Benedicte; Gyoneva, Lazarina I.; Thourani, Vinod H.

2013-01-01

BACKGROUND Surgical reconstruction of a flail posterior leaflet is a routine mitral valve repair, the techniques for which have evolved from leaflet resection to leaflet preservation. Artificial ePTFE neochordae are frequently used to stabilize the flail leaflet, and seldom translocation of the native secondary chordae of the valve to the leaflet free edge is used. In this study, we sought to investigate the efficacy of the two techniques to correct posterior leaflet prolapse and reduce mitral regurgitation, and quantify the acute post-repair leaflet kinematics. METHODS Adult porcine mitral valves (N =7) were studied in a pulsatile left heart experimental model in which isolated P2 flail was mimicked by marginal chordal transection. Baseline conditions were established in each valve under normal conditions (control), and followed by induction of isolated P2 flail by transecting the two marginal chordae on the posterior leaflet free edge (disease). The flail posterior leaflet was reconstructed using artificial neochordae (repair 1) and then native chordal translocation (repair 2). Reduction in leaflet flail, changes in mitral regurgitation fraction, leaflet coaptation length, and posterior leaflet mobility were measured using B-mode echocardiography or color doppler. RESULTS At baseline, all the valves were competent with no mitral regurgitation. After transection of the marginal chordae on the posterior leaflet, isolated P2 flail was evident with 13.7±13% regurgitation. Reconstruction with artificial neochordae eliminated leaflet flail and reduced mitral regurgitation to 3.2± 2.8%, and with chordal translocation leaflet flail was corrected and mitral regurgitation was measured at 2.3±2.6%. Using either repair techniques, leaflet coaptation and mobility of the repaired leaflets were adequate and comparable to the baseline measurements. CONCLUSIONS Comparable reduction leaflet flail and regurgitation, and restoration of physiological leaflet coaptation with the

Maternal and fetal outcomes in pregnant women undergoing balloon mitral valvotomy for rheumatic mitral stenosis.

PubMed

Vinayakumar, Desabandhu; Vinod, G V; Madhavan, Suresh; Krishnan, Mangalath Narayanan

Rheumatic mitral stenosis constitutes a major cause of acquired heart disease complicating pregnancy in India. In the present study, we have studied the fetal and maternal outcomes of women undergoing balloon mitral valvotomy during pregnancy. 49 pregnant ladies were included in this study in whom balloon mitral valvotomy was performed. The mean age of these patients was 25.7±3.1 years. The mean gestational age was 23.5±5.2 weeks (12-36 weeks). The procedure was successful in 48 patients (95.9%). Mean two-dimensional MVA increased from baseline value of 0.93±0.17cm 2 to 1.75±0.27cm 2 (p value <0.0001). Pre-procedure peak pulmonary artery pressure was 43.05±15.88mmHg, which decreased to 22.31±6.36mmHg (p value <0.0001). Hemodynamic data showed pre-BMV left atrial mean pressure of 29.6±6.6mmHg, which decreased to 13.7±4.8mmHg after the procedure (p value <0.0001). Mean fluoroscopy time was 6.4±1.2min. There was no maternal mortality in our study. One procedure had to be abandoned, because of failed septal puncture. One of the patients developed cardiac tamponade and another patient developed severe mitral regurgitation, which were managed medically. The patient who developed severe mitral regurgitation later underwent mitral valve replacement. Post-procedure follow-up showed an improvement in NYHA status by at least one class in 81.3% of patients. Thirty-nine (81.3%) patients had a term normal vaginal delivery and 8 (16.7%) underwent cesarean section for obstetric indications. One of the patients had abortion on the second day of the procedure. Percutaneous mitral valvotomy during pregnancy is safe and provides excellent symptomatic relief and hemodynamic improvement. This should be considered as the treatment of choice when managing pregnant women with severe mitral stenosis. Copyright © 2016 Cardiological Society of India. Published by Elsevier B.V. All rights reserved.

Mitral Perivalvular Leak after Blunt Chest Trauma: A Rare Cause of Severe Subacute Mitral Regurgitation.

PubMed

Marchese, Nicola; Facciorusso, Antonio; Vigna, Carlo

2015-12-01

Blunt chest trauma is a very rare cause of valve disorder. Moreover, mitral valve involvement is less frequent than is aortic or tricuspid valve involvement, and the clinical course is usually acute. In the present report, we describe the case of a 49-year-old man with a perivalvular mitral injury that became clinically manifest one year after a violent, nonpenetrating chest injury. This case is atypical in regard to the valve involved (isolated mitral damage), the injury type (perivalvular leak in the absence of subvalvular abnormalities), and the clinical course (interval of one year between trauma and symptoms).

Anatomic characteristics of bileaflet mitral valve prolapse--Barlow disease--in patients undergoing mitral valve repair.

PubMed

Rostagno, Carlo; Droandi, Ginevra; Rossi, Alessandra; Bevilacqua, Sergio; Romagnoli, Stefano; Montesi, Gian Franco; Stefàno, Pier Luigi

2014-01-01

Barlow disease is a still challenging pathology for the surgeon. Aim of the present study is to report anatomic abnormalities of mitral valve in patients undergoing mitral valve repair. Between January 1st, 2007, and December 31st, 2010, 85 consecutive patients (54 men and 31 women, mean age 59 +/- 14 years--range: 28-85 years) with the features of a Barlow mitral valve disease underwent mitral repair Forty seven percent of patients were in New York Heart Association functional class III or IV. Preoperative transesophageal echocardiography was compared with anatomical findings at the moment of surgery. Transthoracic echocardiography diagnosis of Barlow disease according to the criteria described by Carpentier was confirmed at anatomical inspection. Annular calcifications were found in 28 patients while 7 patients presented single or multiple clefts. A flail posterior mitral leaflet was detected in 32 subjects, while a flail anterior leaflet in 8. Elongation of chordae tendineae was demonstrated in 45 patients and chordal rupture in 31. All patients showed at trans esophageal echocardiography the typical features of Barlow disease. Seventy-seven (90.6%) patients had severe mitral valve regurgitation, in the remaining 9.4% it was moderate to severe. Transesophageal echocardiography failed to identify clefts in 2/7 and chordal rupture in 4/31. bileaflet prolapse > 2 mm, billowing valve with excess tissue and thickened leaflets > or = 3 mm, and severe annular dilatation, are characteristics of Barlow disease, however the identification of the associated and complex abnormalities of mitral valve is necessary to obtain optimal valve repair.

The geometrical effect of different annuloplasty rings on mitral valve annulus.

PubMed

Al-Maisary, Sameer; Graser, Bastian; Engelhardt, Sandy; Wolf, Ivo; Karck, Matthias; DE Simone, Raffaele

2017-06-01

Different types of mitral annuloplasty rings are commercially available. The aim of this study was to investigate the effect of implantation of six types of annuloplasty rings on the geometry and dynamics of the mitral valve. Three-dimensional echocardiography images of 42 patients were acquired to visualize the mitral valve annulus. Virtual representations of six commercially available annuloplasty rings were matched to anatomical mitral annuli of each patient according to anterolateral-posteromedial diameter. The virtual displacement of each annuloplasty ring after the implantation was measured and compared with the other rings. Patients with severe mitral regurgitation had significantly dilated annuli according to anterolateral-posteromedial diameter, anterior-posterior diameter and to annulus circumference. Anterior and posterior heights of the mitral annuli and non-planarity angle showed no significant differences among different patients with different degree of mitral regurgitation. The ratio of anterior-posterior to anterolateral-posteromedial diameter was almost identical in all groups with identical annular shapes. The implantation of the Carpentier-Edwards Classic Annuloplasty Ring™ led to maximal displacement of mitral annulus, followed by the IM-Ring™, without a statistical significance. In contrary, the implantation of a MyxoETlogix Ring™ was associated with minimal displacement of mitral annulus throughout the groups, but without statistical significance. The implantation of different ring types in patients with different annuli shapes and dimensions did not lead to any significant change in the configuration of mitral annuli after the virtual implantation of the tested annuloplasty rings.

Double-orifice mitral valve associated with bicuspid aortic valve.

PubMed

Khani, Mohammad; Rohani, Atoosheh

2017-06-01

Double-orifice mitral valve is a rare congenital anomaly that usually does not cause a significant hemodynamic effect. Double-orifice mitral valve and a bicuspid aortic valve were detected in a 54-year-old lady who presented with dyspnea on exertion for one year. This is a rare association. Three-dimensional echocardiography is helpful to determine the type of malformation. The patient had no significant mitral regurgitation or stenosis, but demonstrated moderate aortic stenosis. She is undergoing periodic monitoring.

[Experience of Mitral Valve Replacement Using a Pulmonary Autograft (Ross II Operation) in an Infant;Report of a Case].

PubMed

Kawahito, Tomohisa; Egawa, Yoshiyasu; Yoshida, Homare; Shimoe, Yasushi; Onishi, Tatsuya; Miyagi, Yuhichi; Terada, Kazuya; Ohta, Akira

2015-07-01

A 24-day-old boy suddenly developed progressive heart failure and was transported to our hospital. Echocardiography showed massive mitral regurgitation due to chordal rupture. Mitral valve repair was performed at 28 days of life, but postoperative valvular function was not satisfactory. A mechanical valve was implanted in the supra-annular position at 37 days of life. Two months after valve replacement, the mechanical valve was suddenly stuck. Emergent redo valve replacement was performed, but the prosthetic valve became stuck again 2 months after the 3rd operation, despite sufficient anti-coagulation therapy. At the 4th operation (6 months after birth), we implanted a pulmonary autograft in the mitral position instead of another mechanical valve in an emergent operation. The right ventricular outflow tract was reconstructed with a valved conduit. A postoperative catheter examination, which was performed 1 year after the Ross II operation, showed mild mitral stenosis with no regurgitation. Previous reports of Ross II operations in infants are rare and long-term results are unknown. However, we advocate that this procedure should be a rescue operation for mitral valve dysfunction in the early period of infants.

[Experimental mitral regurgitation in ischemia-induced papillary muscle dysfunction].

PubMed

Matsuzaki, M; Yonezawa, F; Toma, Y; Miura, T; Katayama, K; Fujii, T; Kohtoku, N; Otani, N; Ono, S; Tateno, S

1988-01-01

Mitral regurgitation (MR) reportedly develops by ischemia of the papillary muscles, which is called papillary muscle dysfunction. This report deals with the roles of papillary muscles and left ventricular walls on the pathogenesis of MR using graded injuries of these structures in 23 dogs. Implanted ultrasonic microcrystal and occluder with an electromagnetic flowmetry for the left circumflex coronary artery were the main experimental setting. Graded occlusion of the artery was done by the six-step approach regarding coronary blood flow (CBF) reduction (C1-C6). Left ventricular (LV) pressure, systolic thickening (%W: sonomicrometry) of the LV anterior (AW) and posterior walls (PW), and systolic longitudinal shortening (%S: sonomicrometry) of both the anterior and posterior papillary muscles (PPM) were measured. MR was assessed by left ventricular contrast two-dimensional echocardiography. In eight dogs, all the data were adequate for analysis. In category 3 (C3: 55-70% CBF of control), %S in PPM decreased, but %W did not change significantly, and only mild MR developed in three of the eight dogs. MR clearly developed in category 4 (C4: 40-54% CBF as compared with the control stage), where %S was replaced by holosystolic lengthening and %W reduced to 50% of the control state, and total occlusion (C6) accompanied by significant thinning of both the PW and AW. Thus, the asynergy of the LVPW was needed to induce the MR in seven of the eight dogs. It was concluded that the injury of the PPM alone is not sufficient to cause MR, and the associated ischemic changes of the LV free wall as well as LV dilatation are necessary to induce severe MR.

Echocardiographic predictors of survival in dogs with myxomatous mitral valve disease.

PubMed

Sargent, Julia; Muzzi, Ruthnea; Mukherjee, Rajat; Somarathne, Sharlene; Schranz, Katherine; Stephenson, Hannah; Connolly, David; Brodbelt, David; Fuentes, Virginia Luis

2015-03-01

To evaluate vena contracta and other echocardiographic measures of myxomatous mitral valve disease (MMVD) severity in a multivariable analysis of survival in dogs. 70 dogs diagnosed with MMVD from stored echocardiographic images that met study inclusion criteria. Left heart dimensions were measured as well as mitral regurgitant jet area/left atrial area (JAR), early mitral filling velocity (Evel), extent of mitral valve prolapse in right and left views (ProlR, ProlL), Prol indexed to aortic diameter (ProlR:Ao, ProlL:Ao), presence of a flail leaflet (FlailR, FlailL), and mitral regurgitation vena contracta diameter (VCR, VCL) indexed to aortic diameter (VCR:Ao, VCL:Ao). Follow-up from referring veterinarians was obtained by questionnaire or telephone to determine survival times. Inter- and intra-observer agreement was evaluated with Bland-Altman plots and weighted Kappa analysis. Survival was analyzed using Kaplan-Meier curves, logrank tests and Cox's proportional hazards. Logrank analysis showed VCL:Ao, VCR:Ao, FlailL, ProlR:Ao, ProlL:Ao, left ventricular internal dimension in diastole indexed to aortic diameter (LVIDD:Ao) >2.87, left atrium to aorta ratio (LA/Ao) >1.6, and Evel >1.4 m/s were predictors of cardiac mortality. In a multivariable analysis, the independent predictors of cardiac mortality were Evel >1.4 m/s [hazard ratio (HR) 5.0, 95% confidence interval (CI) 2.5-10.3], FlailL (HR 3.1, 95% CI 1.3-7.9), and ProlR:Ao (HR 2.8, 95% CI 1.3-6.3). Echocardiographic measures of mitral regurgitation severity and mitral valve pathology provide valuable prognostic information independent of chamber enlargement in dogs with MMVD. Copyright © 2014 Elsevier B.V. All rights reserved.

Subacute Staphylococcus epidermidis Bacterial Endocarditis Complicated by Mitral-Aortic Intervalvular Fibrosa Pseudoaneurysm

DTIC Science & Technology

2012-12-01

Staphylococcus epidermidis Bacterial Endocarditis Complicated byMitral-Aortic Intervalvular Fibrosa Pseudoaneurysm Diane Elegino-Steffens,1 Amy Stratton,1... endocarditis . 1. Introduction The mitral-aortic intervalvular fibrosa (MAIF), also known as the mitral-aortic membrane, is a fibrous region of the heart...of his aortic valve for severe aortic regurgitation that was subsequently found to have infective endocarditis prompting antibiotic treatment. His

Three-Dimensional Color Doppler Echocardiography for Direct Measurement of Vena Contracta Area in Mitral Regurgitation

PubMed Central

Little, Stephen H.; Pirat, Bahar; Kumar, Rahul; Igo, Stephen R.; McCulloch, Marti; Hartley, Craig J.; Xu, Jiaqiong; Zoghbi, William A.

2012-01-01

OBJECTIVES Our goal was to prospectively compare the accuracy of real-time three-dimensional (3D) color Doppler vena contracta (VC) area and two-dimensional (2D) VC diameter in an in vitro model and in the clinical assessment of mitral regurgitation (MR) severity. BACKGROUND Real-time 3D color Doppler allows direct measurement of VC area and may be more accurate for assessment of MR than the conventional VC diameter measurement by 2D color Doppler. METHODS Using a circulatory loop with an incorporated imaging chamber, various pulsatile flow rates of MR were driven through 4 differently sized orifices. In a clinical study of patients with at least mild MR, regurgitation severity was assessed quantitatively using Doppler-derived effective regurgitant orifice area (EROA), and semiquantitatively as recommended by the American Society of Echocardiography. We describe a step-by-step process to accurately identify the 3D-VC area and compare that measure against known orifice areas (in vitro study) and EROA (clinical study). RESULTS In vitro, 3D-VC area demonstrated the strongest correlation with known orifice area (r = 0.92, p < 0.001), whereas 2D-VC diameter had a weak correlation with orifice area (r = 0.56, p = 0.01). In a clinical study of 61 patients, 3D-VC area correlated with Doppler-derived EROA (r = 0.85, p < 0.001); the relation was stronger than for 2D-VC diameter (r = 0.67, p < 0.001). The advantage of 3D-VC area over 2D-VC diameter was more pronounced in eccentric jets (r = 0.87, p < 0.001 vs. r = 0.6, p < 0.001, respectively) and in moderate-to-severe or severe MR (r = 0.80, p < 0.001 vs. r = 0.18, p = 0.4, respectively). CONCLUSIONS Measurement of VC area is feasible with real-time 3D color Doppler and provides a simple parameter that accurately reflects MR severity, particularly in eccentric and clinically significant MR where geometric assumptions may be challenging. PMID:19356505

Surgical results of mitral valve repair for congenital mitral valve stenosis in paediatric patients.

PubMed

Cho, Sungkyu; Kim, Woong-Han; Kwak, Jae Gun; Lee, Jeong Ryul; Kim, Yong Jin

2017-12-01

Mitral valve (MV) repairs have been performed in paediatric patients with congenital MV stenosis. However, congenital MV stenosis lesions are a heterogeneous group of lesions, and their repair remains challenging. From March 1999 to September 2014, MV repair was performed in 22 patients with congenital MV stenosis. The median age was 10.3 months (ranging from 22 days to 9.1 years), and the mean body weight was 7.9 ± 4.0 kg at the time of the operation. Multiple-level left-side heart obstructions were present in 9 (45%) patients. The main aetiology of the mitral stenosis was a supravalvular mitral ring in 8 patients, valvular stenosis in 4 patients, a parachute deformity of the papillary muscles in 4 patients and other abnormal papillary muscles in 6 patients. The mean MV pressure gradient improved from 10.4 ± 3.9 mmHg to 3.4 ± 1.7 mmHg after MV repair (n = 18, P < 0.0001). The mean follow-up duration was 6.7 ± 5.4 years. One patient died postoperatively due to septic shock. Four patients required a second operation (2 patients for mitral stenosis, 1 patient for left ventricular outflow tract obstruction and mitral stenosis and 1 patient for mitral regurgitation). Among them, 2 patients died: 1 patient died due to cardiopulmonary bypass weaning failure and another patient died due to multiple cerebral infarcts. At the last follow-up, the mean MV pressure gradient was 4.5 ± 3.1 mmHg for all patients who did not have reoperation, and moderate or greater mitral insufficiency was detected in 3 patients. At 10 years, the survival rate was 85.9 ± 7.6%, and the freedom from reoperation rate was 77.5 ± 10.1%. In the log-rank test, MV repair in the neonate was associated with mortality (P = 0.010), and presentation of mitral insufficiency was associated with reoperation (P = 0.003). MV repair in paediatric patients with congenital mitral stenosis showed acceptable results. The follow-up echocardiogram also

Body size, but neither age nor asymptomatic mitral regurgitation, influences plasma concentrations of dimethylarginines in dogs.

PubMed

Pedersen, L G; Tarnow, I; Olsen, L H; Teerlink, T; Pedersen, H D

2006-06-01

Asymmetric dimethylarginine (ADMA) is a marker of various cardiovascular diseases in man. The aim of the present study was to test if Cavalier King Charles Spaniels (CKCS) with varying degrees of mitral regurgitation (MR) had increased plasma concentration of ADMA and furthermore, characterize the plasma level of ADMA and symmetric dimethylarginine (SDMA) in normal dogs. Seventy-six dogs were included (44 CKCS and 32 dogs of other breeds). The CKCS had various degrees of MR, whereas the remaining dogs had either no or minimal MR. Apart from cardiac murmurs, no dogs showed signs of cardiac or systematic disease. The degree of MR had no significant influence on ADMA (P = 0.33). Body weight was directly associated with ADMA (P = 0.0004) and creatinine was directly associated with SDMA (P<0.0001). Furthermore, the plasma concentration of ADMA was three to four times higher than found in healthy humans.

Improved mitral valve coaptation and reduced mitral valve annular size after percutaneous mitral valve repair (PMVR) using the MitraClip system.

PubMed

Patzelt, Johannes; Zhang, Yingying; Magunia, Harry; Ulrich, Miriam; Jorbenadze, Rezo; Droppa, Michal; Zhang, Wenzhong; Lausberg, Henning; Walker, Tobias; Rosenberger, Peter; Seizer, Peter; Gawaz, Meinrad; Langer, Harald F

2017-08-01

Improved mitral valve leaflet coaptation with consecutive reduction of mitral regurgitation (MR) is a central goal of percutaneous mitral valve repair (PMVR) with the MitraClip® system. As influences of PMVR on mitral valve geometry have been suggested before, we examined the effect of the procedure on mitral annular size in relation to procedural outcome. Geometry of the mitral valve annulus was evaluated in 183 patients undergoing PMVR using echocardiography before and after the procedure and at follow-up. Mitral valve annular anterior-posterior (ap) diameter decreased from 34.0 ± 4.3 to 31.3 ± 4.9 mm (P < 0.001), and medio-lateral (ml) diameter from 33.2 ± 4.8 to 32.4 ± 4.9 mm (P < 0.001). Accordingly, we observed an increase in MV leaflet coaptation after PMVR. The reduction of mitral valve ap diameter showed a significant inverse correlation with residual MR. Importantly, the reduction of mitral valve ap diameter persisted at follow-up (31.3 ± 4.9 mm post PMVR, 28.4 ± 5.3 mm at follow-up). This study demonstrates mechanical approximation of both mitral valve annulus edges with improved mitral valve annular coaptation by PMVR using the MitraClip® system, which correlates with residual MR in patients with MR. Published on behalf of the European Society of Cardiology. All rights reserved. © The Author 2017. For permissions, please email: journals.permissions@oup.com.

Impact of exercise pulmonary hypertension on postoperative outcome in primary mitral regurgitation.

PubMed

Magne, Julien; Donal, Erwan; Mahjoub, Haifa; Miltner, Beatrice; Dulgheru, Raluca; Thebault, Christophe; Pierard, Luc A; Pibarot, Philippe; Lancellotti, Patrizio

2015-03-01

The management of asymptomatic patients with mitral regurgitation (MR) remains controversial. Exercise-induced pulmonary hypertension (ExPHT) was recently reported as a strong predictor of rapid onset of symptoms. We hypothesised that ExPHT is a predictor of postoperative cardiovascular events in patients with primary MR. One hundred and two patients with primary MR, no or mild symptoms (New York heart association (NYHA) ≤2), and no LV dysfunction/dilatation, were prospectively recruited in 3 centres and underwent exercise-stress echocardiography. The presence of ExPHT was defined as an exercise systolic pulmonary arterial pressure >60 mm Hg. All patients were closely followed up and operated on when indication for surgery was reached. Postoperative events were defined as the occurrence of atrial fibrillation (AF), stroke, cardiac-related hospitalisation or death. Among the 102 patients included, 59 developed ExPHT (58%). These patients were significantly older than those without ExPHT (p=0.01). During a mean postoperative follow-up of 50±23 months, 28 patients (26%) experienced a predefined cardiovascular event. Patients with ExPHT had significantly higher rate of postoperative events (39% vs 12%, p=0.005); the rate of events was still higher in these patients (32% vs 9%, p=0.013), even when excluding early postoperative AF (ie, within 48 h). Event-free survival was significantly lower in the ExPHT group (all events: 5-year: 60±8% vs 88±5%, p=0.007, events without early AF: 5-year: 67±7% vs 90±4%, p=0.02). Using Cox multivariable analysis, ExPHT remained independently associated with higher risk of postoperative events in all models (all p≤0.04). ExPHT is associated with increased risk of adverse cardiac events following mitral valve surgery in patients with primary MR. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.

Three-dimensional echocardiographic assessment of the repaired mitral valve.

PubMed

Maslow, Andrew; Mahmood, Feroze; Poppas, Athena; Singh, Arun

2014-02-01

This study examined the geometric changes of the mitral valve (MV) after repair using conventional and three-dimensional echocardiography. Prospective evaluation of consecutive patients undergoing mitral valve repair. Tertiary care university hospital. Fifty consecutive patients scheduled for elective repair of the mitral valve for regurgitant disease. Intraoperative transesophageal echocardiography. Assessments of valve area (MVA) were performed using two-dimensional planimetry (2D-Plan), pressure half-time (PHT), and three-dimensional planimetry (3D-Plan). In addition, the direction of ventricular inflow was assessed from the three-dimensional imaging. Good correlations (r = 0.83) and agreement (-0.08 +/- 0.43 cm(2)) were seen between the MVA measured with 3D-Plan and PHT, and were better than either compared to 2D-Plan. MVAs were smaller after repair of functional disease repaired with an annuloplasty ring. After repair, ventricular inflow was directed toward the lateral ventricular wall. Subgroup analysis showed that the change in inflow angle was not different after repair of functional disease (168 to 171 degrees) as compared to those presenting with degenerative disease (168 to 148 degrees; p<0.0001). Three-dimensional imaging provides caregivers with a unique ability to assess changes in valve function after mitral valve repair. Copyright © 2014 Elsevier Inc. All rights reserved.

Chymase inhibition prevents fibronectin and myofibrillar loss and improves cardiomyocyte function and LV torsion angle in dogs with isolated mitral regurgitation.

PubMed

Pat, Betty; Chen, Yuanwen; Killingsworth, Cheryl; Gladden, James D; Shi, Ke; Zheng, Junying; Powell, Pamela C; Walcott, Greg; Ahmed, Mustafa I; Gupta, Himanshu; Desai, Ravi; Wei, Chih-Chang; Hase, Naoki; Kobayashi, Tsunefumi; Sabri, Abdelkarim; Granzier, Henk; Denney, Thomas; Tillson, Michael; Dillon, A Ray; Husain, Ahsan; Dell'italia, Louis J

2010-10-12

The left ventricular (LV) dilatation of isolated mitral regurgitation (MR) is associated with an increase in chymase and a decrease in interstitial collagen and extracellular matrix. In addition to profibrotic effects, chymase has significant antifibrotic actions because it activates matrix metalloproteinases and kallikrein and degrades fibronectin. Thus, we hypothesize that chymase inhibitor (CI) will attenuate extracellular matrix loss and LV remodeling in MR. We studied dogs with 4 months of untreated MR (MR; n=9) or MR treated with CI (MR+CI; n=8). Cine MRI demonstrated a >40% increase in LV end-diastolic volume in both groups, consistent with a failure of CI to improve a 25% decrease in interstitial collagen in MR. However, LV cardiomyocyte fractional shortening was decreased in MR versus normal dogs (3.71±0.24% versus 4.81±0.31%; P<0.05) and normalized in MR+CI dogs (4.85±0.44%). MRI with tissue tagging demonstrated an increase in LV torsion angle in MR+CI versus MR dogs. CI normalized the significant decrease in fibronectin and FAK phosphorylation and prevented cardiomyocyte myofibrillar degeneration in MR dogs. In addition, total titin and its stiffer isoform were increased in the LV epicardium and paralleled the changes in fibronectin and FAK phosphorylation in MR+CI dogs. These results suggest that chymase disrupts cell surface-fibronectin connections and FAK phosphorylation that can adversely affect cardiomyocyte myofibrillar structure and function. The greater effect of CI on epicardial versus endocardial titin and noncollagen cell surface proteins may be responsible for the increase in torsion angle in chronic MR.

Comparative effects of amlodipine and benazepril on left atrial pressure in dogs with experimentally-induced mitral valve regurgitation.

PubMed

Suzuki, Shuji; Fukushima, Ryuji; Ishikawa, Taisuke; Yamamoto, Yuta; Hamabe, Lina; Kim, Soomin; Yoshiyuki, Rieko; Machida, Noboru; Tanaka, Ryou

2012-09-18

One of the purposes of treatment for dogs with mitral regurgitation (MR) is lowering left atrial pressure (LAP). There has been few study of the amlodipine in dogs with MR and amlodipine's effect on LAP has not been fully evaluated in a quantitative manner because of difficulties in directly measuring LAP. The objective of our study was to compare the short-term effects of amlodipine (0.2 mg/kg PO q12h) vs benazepril (0.5 mg/kg PO q12h), on LAP and echocardiographic parameters in five beagle dogs with experimentally-induced MR. LAP of eight dogs that has own control were measured using radiotelemetry system at baseline and again on days 1, 2, 3, 4, 5, 6, 7 of the drug administration. Mean LAP decreased significantly after amlodipine (11.20 ± 4.19 mmHg vs 14.61 ± 3.81 mmHg at baseline, p < .01) but not after benazepril treatment (13.19 ± 3.47 mmHg, p > .05). LAP was lower after 7 days of amlodipine treatment than after 7 days of benazepril treatment. Significant reduction was seen for the first time 4 days after the administration amlodipine. The rate of the maximal area of the regurgitant jet signals to the left atrium area (ARJ/LAA) of the amlodipine treatment was significantly lower (p < .05) after 7 days compared to baseline. Other echocardiographic parameters did not change significantly. LAP was significantly decreased after amlodipine treatment in dogs with surgically-induced MR but not after benazepril treatment. Although this study did not focus on adverse effects, amlodipine may be an effective drug for helping the patients with acute onset of severe MR, such as rupture of chordae tendinae or end stage patients were the LAP is likely to be elevated. Additional studies in clinical patients with degenerative mitral valve disease and acute chordal rupture are warranted because the blood-pressure lowering effects of amlodipine can decrease renal perfusion and this can further activate the RAAS.

Intravalvular Implantation of Mitral Valve Prostheses

PubMed Central

Cooley, Denton A.; Ingram, Michael T.

1987-01-01

We describe a technique of intravalvular implantation of a low-profile prosthesis that has been used in nine patients with mitral valve lesions. This technique preserves the anterior and posterior chordae and papillary mechanisms, which may decrease the incidence of postoperative left ventricular dysfunction that has been noted following standard mitral valve replacement. The technique may also be useful in some patients with aortic and tricuspid regurgitation when the annulus and leaflets are relatively normal pathologically. (Texas Heart Institute Journal 1987;14:188-193) PMID:15229740

Mitral valve disease—morphology and mechanisms

PubMed Central

Levine, Robert A.; Hagége, Albert A.; Judge, Daniel P.; Padala, Muralidhar; Dal-Bianco, Jacob P.; Aikawa, Elena; Beaudoin, Jonathan; Bischoff, Joyce; Bouatia-Naji, Nabila; Bruneval, Patrick; Butcher, Jonathan T.; Carpentier, Alain; Chaput, Miguel; Chester, Adrian H.; Clusel, Catherine; Delling, Francesca N.; Dietz, Harry C.; Dina, Christian; Durst, Ronen; Fernandez-Friera, Leticia; Handschumacher, Mark D.; Jensen, Morten O.; Jeunemaitre, Xavier P.; Le Marec, Hervé; Le Tourneau, Thierry; Markwald, Roger R.; Mérot, Jean; Messas, Emmanuel; Milan, David P.; Neri, Tui; Norris, Russell A.; Peal, David; Perrocheau, Maelle; Probst, Vincent; Pucéat, Michael; Rosenthal, Nadia; Solis, Jorge; Schott, Jean-Jacques; Schwammenthal, Ehud; Slaugenhaupt, Susan A.; Song, Jae-Kwan; Yacoub, Magdi H.

2016-01-01

Mitral valve disease is a frequent cause of heart failure and death. Emerging evidence indicates that the mitral valve is not a passive structure, but—even in adult life—remains dynamic and accessible for treatment. This concept motivates efforts to reduce the clinical progression of mitral valve disease through early detection and modification of underlying mechanisms. Discoveries of genetic mutations causing mitral valve elongation and prolapse have revealed that growth factor signalling and cell migration pathways are regulated by structural molecules in ways that can be modified to limit progression from developmental defects to valve degeneration with clinical complications. Mitral valve enlargement can determine left ventricular outflow tract obstruction in hypertrophic cardiomyopathy, and might be stimulated by potentially modifiable biological valvular–ventricular interactions. Mitral valve plasticity also allows adaptive growth in response to ventricular remodelling. However, adverse cellular and mechanobiological processes create relative leaflet deficiency in the ischaemic setting, leading to mitral regurgitation with increased heart failure and mortality. Our approach, which bridges clinicians and basic scientists, enables the correlation of observed disease with cellular and molecular mechanisms, leading to the discovery of new opportunities for improving the natural history of mitral valve disease. PMID:26483167

Fluid-Structure Interactions of the Mitral Valve and Left Heart: Comprehensive Strategies, Past, Present and Future

PubMed Central

Einstein, Daniel R.; Del Pin, Facundo; Jiao, Xiangmin; Kuprat, Andrew P.; Carson, James P.; Kunzelman, Karyn S.; Cochran, Richard P.; Guccione, Julius M.; Ratcliffe, Mark B.

2009-01-01

SUMMARY The remodeling that occurs after a posterolateral myocardial infarction can alter mitral valve function by creating conformational abnormalities in the mitral annulus and in the posteromedial papillary muscle, leading to mitral regurgitation (MR). It is generally assumed that this remodeling is caused by a volume load and is mediated by an increase in diastolic wall stress. Thus, mitral regurgitation can be both the cause and effect of an abnormal cardiac stress environment. Computational modeling of ischemic MR and its surgical correction is attractive because it enables an examination of whether a given intervention addresses the correction of regurgitation (fluid-flow) at the cost of abnormal tissue stress. This is significant because the negative effects of an increased wall stress due to the intervention will only be evident over time. However, a meaningful fluid-structure interaction model of the left heart is not trivial; it requires a careful characterization of the in-vivo cardiac geometry, tissue parameterization though inverse analysis, a robust coupled solver that handles collapsing Lagrangian interfaces, automatic grid-generation algorithms that are capable of accurately discretizing the cardiac geometry, innovations in image analysis, competent and efficient constitutive models and an understanding of the spatial organization of tissue microstructure. In this manuscript, we profile our work toward a comprehensive fluid-structure interaction model of the left heart by reviewing our early work, presenting our current work and laying out our future work in four broad categories: data collection, geometry, fluid-structure interaction and validation. PMID:20454531

Diagnostic and therapeutic considerations in acute, severe mitral regurgitation: experience in 42 consecutive patients entering the intensive care unit with pulmonary edema.

PubMed

Horstkotte, D; Schulte, H D; Niehues, R; Klein, R M; Piper, C; Strauer, B E

1993-09-01

Forty-two consecutive patients received emergency treatment for acute mitral insufficiency causing pulmonary edema between 1984 and 1992. The underlying diagnoses were acute myocardial infarction (n = 21), acute bacterial endocarditis on the native mitral valve (n = 9), prosthetic endocarditis in the mitral position (n = 4), acute failure of a replacement valve (n = 5), blunt chest trauma (n = 1) and chordal rupture in Marfan's syndrome (n = 2). Dysfunction of the subvalvular apparatus was present in 24 patients, verified by transthoracic echocardiography in 18 (75%) and by transoesophageal echocardiography in all patients in whom this technique was used. There were four cases of outflow strut fracture of a Björk-Shiley mitral prosthesis; a reliable diagnosis was made by fluoroscopy in all patients. Bedside hemodynamic monitoring was found to be unreliable both for differential diagnosis and for the quantitative assessment of the degree of mitral insufficiency. The right ventricular filling pressure was normal in 32/39 patients (82%), and the pulmonary artery and pulmonary capillary pressures elevated in 37/39 (95%). Diagnostically important, high pulmonary capillary v-waves were documented in 13 patients (33%). The left ventricular impedance could be influenced with sodium nitroprussid combined in some cases with dobutamin, and the resultant decrease of the peripheral vascular resistance from 1480 +/- 222 to 702 +/- 86 dyn x sec x cm-5 was followed by a proportionate reduction in the transmitral regurgitant fraction. Three patients died prior to the intended emergency surgical intervention. Emergency surgery was completed in 21 patients with an early mortality of 23.8% (n = 5). Ten patients underwent elective surgery within, and another three later than one year from the onset of the acute symptoms with an early mortality of 7.7% (n = 1). Four patients are alive and clinically well with medical treatment alone.

Percutaneous direct mitral annuloplasty using the Mitralign Bident system: description of the method and a case report.

PubMed

Siminiak, Tomasz; Dankowski, Rafał; Baszko, Artur; Lee, Christopher; Firek, Ludwik; Kałmucki, Piotr; Szyszka, Andrzej; Groothuis, Adam

2013-01-01

Functional mitral regurgitation (FMR) is known to contribute to a poor prognosis in patients with heart failure (HF). Current guidelines do not recommend cardiac surgery in patients with FMR and impaired ejection fraction due to the high procedural risk. Percutaneous techniques aimed at mitral valve repair may constitute an alternative to currently used routine medical treatment. To provide a description of a novel percutaneous suture-based technique of direct mitral annuloplasty using the Mitralign Bident system, as well as report our first case successfully treated with this method. A deflectable guiding catheter is advanced via the femoral route across the aortic valve to the posterior wall of the ventricle. A nested deflectable catheter is advanced through the guide toward the mitral annulus that allows the advancement of an insulated radiofrequency wire to cross the annulus. The wire is directed across the annulus in a target area that is 2-5 mm from the base of the leaflet into the annulus, as assessed by real-time 3D transoesophageal echocardiography. After placement of the first wire, another wire is positioned using a duel lumen bident delivery catheter, which provides a predetermined separation between wires (i.e. 14, 17 or 21 mm). Each wire provides a guide rail for implantation of sutured pledget implants within the annulus. Two pairs of pledgets are implanted, one pair in each of the P1 and P3 scallop regions of the posterior mitral annulus. A dedicated plication lock device is used to provide a means for plication of the annulus within each pair of the pledgets, and to retain the plication by delivering a suture locking implant. The plications result in improved leaflet coaptation and a reduction of the regurgitant orifice area. A 60-year-old female with diagnosed dilated cardiomyopathy, concomitant FMR class III and congestive HF was successfully treated with the Mitralign Bident system. Two pairs of pledgets were implanted resulting in an

Mitral Valve Surgery in Patients with Systemic Lupus Erythematosus

PubMed Central

Hekmat, Manouchehr; Ghorbani, Mohsen; Ghaderi, Hamid; Majidi, Masoud; Beheshti, Mahmood

2014-01-01

Valvular heart disease is the common cardiac manifestation of systemic lupus erythematosus (SLE) with a tendency for mitral valve regurgitation. In this study we report a case of mitral valve replacement for mitral stenosis caused by Libman-Sacks endocarditis in the setting of SLE. In addition, we provide a systematic review of the literature on mitral valve surgery in the presence of Libman-Sacks endocarditis because its challenge on surgical options continues. Surgical decision depends on structural involvement of mitral valve and presence of active lupus nephritis and antiphospholipid antibody syndrome. Review of the literature has also shown that outcome is good in most SLE patients who have undergone valvular surgery, but association of antiphospholipid antibody syndrome with SLE has negative impact on the outcome. PMID:25401131

Flexible band versus rigid ring annuloplasty for functional tricuspid regurgitation

PubMed Central

Izutani, Hironori; Nakamura, Teruya; Kawachi, Kanji

2010-01-01

We review and compare our experience with tricuspid ring annuloplasty between usage of the Cosgrove-Edwards flexible band and the MC3 rigid ring for repair of functional tricuspid regurgitation to determine the efficacy and mid-term durability of tricuspid annuloplasty. 117 patients with functional tricuspid regurgitation undergoing open heart surgery and tricuspid valve repair from May 2005 to December 2007 were reviewed. The flexible bands were used in thirty five patients before October 2006. Since then, the rigid rings were used in the next consecutive eighty two cases. Echocardiographic evaluation of tricuspid regurgitation was performed preoperatively and postoperatively in follow-up schedule. The degree of tricuspid regurgitation was reduced from 2.80±0.67 to 0.71±1.0 (regurgitation severity grade: 0 to 4) in the patients with flexible bands at discharge. It was from 2.68±0.70 to 0.22±0.60 in the patients with rigid rings. At thirty six months postoperative period, tricuspid regurgitation grades in patients with flexible bands and rigid rings were 0.80±0.95 and 0.36±0.77, respectively. Freedom from recurrent tricuspid regurgitation (grade 2 or 3) in patients with flexible bands and rigid rings were 68.6% and 87.8%, respectively. Recurrent tricuspid regurgitation was significantly lower in the patients with rigid rings. Although both flexible band and rigid ring annuloplasty provide low rate of recurrent tricuspid regurgitation, rigid ring annuloplasty might be more effective than flexible band annuloplasty for decreasing functional tricuspid regurgitation in immediate and mid-term postoperative periods. PMID:21977298

Systolic arterial blood pressure estimated by mitral regurgitation velocity, high definition oscillometry, and Doppler ultrasonography in dogs with naturally occurring degenerative mitral valve disease.

PubMed

Hanzlicek, A S; Baumwart, R D; Payton, M E

2016-09-01

To determine if systolic blood pressure estimated by mitral regurgitation (MR) velocity can be used interchangeably with that estimated by high definition oscillometry (HDO) and Doppler ultrasonography (DU) in dogs with naturally occurring mitral valve disease (MVD). Forty-nine client-owned dogs with naturally occurring MVD. This is a retrospective study. Medical records were reviewed and dogs with MR caused by degenerative MVD were included if systolic blood pressure was estimated from MR velocity determined by continuous wave Doppler (CW), DU and HDO at the same visit. A Pearson product moment correlation coefficient was determined for each combination of measures and tested for significance with a paired t-test. Limits of agreement between 2 measures were determined by the 95% confidence interval of the average difference of the means and illustrated by Bland-Altman plots. Systolic pressure estimated from CW was significantly but only moderately correlated to DU (r = 0.42, p=0.0015) and HDO (r = 0.40, p=0.0021). Pressure estimated from DU was significantly but only moderately correlated to HDO (r = 0.57, p≤0.0001). Limits of agreement were wide for all measures including DU and CW (-61.9to 44.6 mmHg), HDO and CW (-65.2to 26.9 mmHg), and HDO and DU (-63.1 to 42.06 mmHg). Systolic blood pressure estimated by CW cannot be used interchangeably with HDO or DU in dogs with naturally occurring MVD. Copyright © 2016 Elsevier B.V. All rights reserved.

Posterior leaflet preservation during mitral valve replacement for rheumatic mitral stenosis.

PubMed

Djukić, P L; Obrenović-Kirćanski, B B; Vranes, M R; Kocica, M J; Mikić, A Dj; Velinović, M M; Kacar, S M; Kovacević, N S; Parapid, B J

2006-01-01

Mitral valve replacement with posterior leaflet preservation was shown beneficial for postoperative left vetricular (LV) performance in patients with mitral regurgitation. Some authors find it beneficial even for the long term LV function. We investigated a long term effect of this technique in patients with rheumatic mitral stenosis. We studied 20 patents with mitral valve replacement due to rheumatic mitral stenosis, in the period from January 1988 to December 1989. In group A (10 patients) both leaflets and coresponding chordal excision was performed, while in group B (10 patients) the posterior leaflet was preserved. In all patients a Carbomedics valve was inserted. We compared clinical pre and postoperative status, as well as hemodynamic characteristics of the valve and left ventricle in both groups. Control echocardiographyc analysis included: maximal (PG) and mean (MG) gradients; effective valve area (AREA); telediastolic (TDV) and telesystolic (TSV) LV volume; stroke volume (SV); ejection fraction (EF); fractional shortening (FS) and segmental LV motion. The mean size of inserted valve was 26.6 in group A and 27.2 in group B. Hemodynamic data: PG (10.12 vs 11.1); MG (3.57 vs 3.87); AREA (2.35 vs 2.30); TDV 126.0 vs 114.5); TSV (42.2 vs 36.62); SV (83.7 vs 77.75); EF (63.66 vs 67.12); FS (32.66 vs 38.25). Diaphragmal segmental hypokinesis was evident in one patient from group A and in two patients from group B. In patients with rheumatic stenosis, posterior leaflet preservation did not have increased beneficial effect on left ventricular performance during long-term follow-up. An adequate posterior leaflet preservation does not change hemodynamic valvular characteristics even after long-term follow-up.

Impact of a Geometric Correction for Proximal Flow Constraint on the Assessment of Mitral Regurgitation Severity Using the Proximal Flow Convergence Method.

PubMed

Jang, Jeong Yoon; Kang, Joon-Won; Yang, Dong Hyun; Lee, Sahmin; Sun, Byung Joo; Kim, Dae-Hee; Song, Jong-Min; Kang, Duk-Hyun; Song, Jae-Kwan

2018-03-01

Overestimation of the severity of mitral regurgitation (MR) by the proximal isovelocity surface area (PISA) method has been reported. We sought to test whether angle correction (AC) of the constrained flow field is helpful to eliminate overestimation in patients with eccentric MR. In a total of 33 patients with MR due to prolapse or flail mitral valve, both echocardiography and cardiac magnetic resonance image (CMR) were performed to calculate regurgitant volume (RV). In addition to RV by conventional PISA (RV PISA ), convergence angle (α) was measured from 2-dimensional Doppler color flow maps and RV was corrected by multiplying by α/180 (RV AC ). RV measured by CMR (RV CMR ) was used as a gold standard, which was calculated by the difference between total stroke volume measured by planimetry of the short axis slices and aortic stroke volume by phase-contrast image. The correlation between RV CMR and RV by echocardiography was modest [RV CMR vs. RV PISA (r = 0.712, p < 0.001) and RV CMR vs. RV AC (r = 0.766, p < 0.001)]. However, RV PISA showed significant overestimation (RV PISA - RV CMR = 50.6 ± 40.6 mL vs. RV AC - RV CMR = 7.7 ± 23.4 mL, p < 0.001). The overall accuracy of RV PISA for diagnosis of severe MR, defined as RV ≥ 60 mL, was 57.6% (19/33), whereas it increased to 84.8% (28/33) by using RV AC ( p = 0.028). Conventional PISA method tends to provide falsely large RV in patients with eccentric MR and a simple geometric AC of the proximal constraint flow largely eliminates overestimation.

Impact of preoperative atrial fibrillation on mortality and cardiovascular outcomes of mechanical mitral valve replacement for rheumatic mitral valve disease.

PubMed

Wang, Bin; Xu, Zhi-yun; Han, Lin; Zhang, Guan-xin; Lu, Fang-lin; Song, Zhi-gang

2013-03-01

The prognostic significance of preoperative atrial fibrillation on mitral valve replacement remains unclear. The aim of this study was to explore the effects of the presence of preoperative atrial fibrillation on mortality and cardiovascular outcomes of mitral valve replacement for rheumatic valve disease. A retrospective analysis was performed on a total of 793 patients who underwent mitral valve replacement with or without tricuspid valve repair in our hospital. The patients selected were divided into two groups according to preoperative rhythm status. Patients with preoperative atrial fibrillation were assigned to the AF group, while patients in preoperative sinus rhythm were assigned to the SR group. Postoperative follow-up was performed by outpatient visits, as well as by telephone and written correspondence. Data gathered included survivorship, postoperative complications, left ventricular function and tricuspid regurgitation. For patients with atrial fibrillation vs those in sinus rhythm, there was no difference in postoperative mortality and morbidity. Follow-up was a mean of 8.6 ± 2.4 years. For patients with preoperative atrial fibrillation, 10-year survival from a Kaplan-Meier curve was 88.7%, compared with 96.6% in patients with preoperative sinus rhythm (P = 0.002). Multivariate analysis identified low left ventricular ejection fraction, older age, large left atrium and preoperative atrial fibrillation as significant adverse predictors for overall survival. Freedom from thromboembolism complications at 13 years was lower for patients with preoperative atrial fibrillation without maze procedure and left atrial appendage ligation, compared with that for patients with preoperative sinus rhythm without maze procedure and left atrial appendage ligation, and patients with concomitant maze procedure and left atrial appendage ligation (76.3 vs 94.8 vs 94.0%, respectively; P = 0.001). On echocardiography, the proportion of patients with significant tricuspid

Rheumatic mitral valve stenosis mimicking advanced lung cancer.

PubMed

von Lueder, Thomas; Steine, Kjetil; Nerdrum, Tone; Steen, Torkel; Bay, Dag; Humerfelt, Sjur; Atar, Dan

2007-09-01

This report describes a patient with a perihilar mass and mediastinal lymphadenopathy mimicking advanced lung cancer. The patient, a 45-year old regular smoker, was admitted to hospital for dyspnea and tachyarrhythmia, and during hospitalization he was diagnosed with severe rheumatic mitral valve stenosis (MVS) and aortic regurgitation as well as pulmonary venous hypertension. Surgical valve replacement and removal of an atrial thrombus was delayed considerably by diagnostic work-up for suspected malignancy. After cardiac surgery had been performed, recovery was uneventful. On follow-up 1 year later, echocardiography showed well-functioning prosthetic mitral and aortic valves, and normal findings on chest X-ray. Perihilar masses and mediastinal lymphadenopathy presented in this case constitute infrequent yet established findings in MVS, resulting from pulmonary venous congestion and hypertension, and focal lymphedema.

Development of an off bypass mitral valve repair.

PubMed

Morales, D L; Madigan, J D; Choudhri, A F; Williams, M R; Helman, D N; Elder, J B; Naka, Y; Oz, M C

1999-01-01

The Bow Tie Repair (BTR), a single edge-to-edge suture opposing the anterior and posterior leaflets of the mitral valve (MV), has led to satisfactory reduction of mitral regurgitation (MR) with few re-operations and excellent hemodynamic results. The simplicity of the repair lends itself to minimally invasive approaches. A MV grasper has been developed that will coapt both leaflets and fasten the structures with a graduated spiral screw. Eleven explanted adult human MVs were mounted in a mock circulatory loop created for simulating a variety of hemodynamic conditions. The MV grasper was used to place a screw in each valve, which was then continuously run for 300,000 to 1,000,000 cycles with a fixed transvalvular pressure gradient. At the completion of these studies, the valves were stressed to a maximal transvalvular gradient for ten minutes. In seven cases, MR was induced and subsequently repaired using the MV screw. In vivo, the MV screw was tested in nine male canines. Through a subcostal incision, the MV grasper entered the left ventricle, approximated the mitral leaflets and deployed the MV screw under direct visualization via an atriotomy. Follow-up transthoracic echocardiograms were done at postoperative week 1, 6, and 12 to identify screw migration, MV regurgitation/stenosis or clot formation. Dogs were sacrificed up to postoperative week 12 to allow gross and histologic assessment. In vitro, no MV screw detached from the valve leaflets or migrated during the durability testing period of 6.8 million cycles, including periods of stress load testing up to 350 mm Hg. The percent regurgitant flow used to assess MR statistically decreased with the placement of the screw from 72 +/- 7% to 34 +/- 17%; p = 0.0025. In vivo, seven dogs whose valves were examined within the first 48 hours revealed leaflet coaptation with an intact MV screw and no evidence of MR. Two dogs, followed for a prolonged period, had serial postoperative echocardiograms demonstrating

Papillary Muscle Repositioning as a Subvalvular Apparatus Preservation Technique in Mitral Stenosis Patients with Normal Left Ventricular Systolic Function

PubMed Central

Lafci, Gokhan; Cagli, Kerim; Korkmaz, Kemal; Turak, Osman; Uzun, Alper; Yalcinkaya, Adnan; Diken, Adem; Gunertem, Eren; Cagli, Kumral

2014-01-01

Subvalvular apparatus preservation is an important concept in mitral valve replacement (MVR) surgery that is performed to remedy mitral regurgitation. In this study, we sought to determine the effects of papillary muscle repositioning (PMR) on clinical outcomes and echocardiographic left ventricular function in rheumatic mitral stenosis patients who had normal left ventricular systolic function. We prospectively assigned 115 patients who were scheduled for MVR surgery with mechanical prosthesis to either PMR or MVR-only groups. Functional class and echocardiographic variables were evaluated at baseline and at early and late postoperative follow-up examinations. All values were compared between the 2 groups. The PMR group consisted of 48 patients and the MVR-only group of 67 patients. The 2 groups’ baseline characteristics and surgery-related factors (including perioperative mortality) were similar. During the 18-month follow-up, all echocardiographic variables showed a consistent improvement in the PMR group; the mean left ventricular ejection fraction deteriorated significantly in the MVR-only group. Comparison during follow-up of the magnitude of longitudinal changes revealed that decreases in left ventricular end-diastolic and end-systolic diameters and in left ventricular sphericity indices, and increases in left ventricular ejection fractions, were significantly higher in the PMR group than in the MVR-only group. This study suggests that, in patients with rheumatic mitral stenosis and preserved left ventricular systolic function, the addition of papillary muscle repositioning to valve replacement with a mechanical prosthesis improves left ventricular dimensions, ejection fraction, and sphericity index at the 18-month follow-up with no substantial undesirable effect on the surgery-related factors. PMID:24512397

Conventional Surgery for Early and Late Symptomatic Mitral Valve Stenosis After MitraClip® Intervention: An Institutional Experience With Four Consecutive Patients.

PubMed

Alozie, Anthony; Paranskaya, Liliya; Westphal, Bernd; Kaminski, Alexander; Steinhoff, Gustav; Sherif, Mohammad; Ince, Hüseyin; Öner, Alper

2017-12-01

Surgical mitral valve repair is the gold standard for treatment of mitral regurgitation. Recently, the transcatheter treatment of mitral regurgitation with the MitraClip ® device (Abbot Vascular Structural Heart, Menlo Park, CA) has demonstrated promising results in treating patients not amenable for surgical correction of mitral valve regurgitation. Most patients reported in the literature requiring surgical bailout after MitraClip treatment presented with residual or recurrent mitral valve regurgitation. Mitral valve stenosis after MitraClip treatment has been rarely reported. From February 2010 to December 2014, four patients out of 165 patients who underwent MitraClip therapy developed symptomatic mitral valve stenosis (2.4%) and needed surgical correction. Data of the four patients were reviewed retrospectively. Follow-up data were obtained from each patient's general practitioner/cardiologist by phone calls and facsimile and were complete in all patients. All four patients were treated with ≥ 2 MitraClip (MC) devices during their initial presentation. All four patients underwent MV replacement with a tissue valve. The postoperative course was uneventful and there was no 30-day mortality. At 6-month follow-up, all patients were alive and in NYHA class I-III. Placement of multiple clip devices may lead to slightly elevated transmitral gradients. This may not necessarily interpret into symptomatic mitral stenosis. However, in some cases this is possible. Caution should be exercised at this phase of the learning curve of the percutaneous MC treatment, especially in use of multiple MC devices. Copyright © 2017 Australian and New Zealand Society of Cardiac and Thoracic Surgeons (ANZSCTS) and the Cardiac Society of Australia and New Zealand (CSANZ). Published by Elsevier B.V. All rights reserved.

Is minimally invasive mitral valve repair with artificial chords reproducible and applicable in routine surgery?

PubMed

Panos, Aristotelis; Vlad, Sylvio; Milas, Fotios; Myers, Patrick O

2015-06-01

Traditional resectional techniques and chordal transfer are difficult to apply in video-assisted mitral valve repair. Using artificial chords appears easier in this setting. The purpose of this study was to review the effectiveness and reproducibility of neochordal repair as a routine approach to minimally invasive mitral repair, and to assess the stability of neochord implantation using the figure-of-eight suture without pledgets in this setting. This is a retrospective review of all patients who underwent minimally invasive video-assisted mitral valve repair from 2008 to 2013. The primary endpoints were recurrent mitral regurgitation and reoperation. A total of 426 consecutive patients were included during the study period, with a mean age of 55 ± 18 years. Neochords were used in all patients, and in association with leaflet resection in 47 patients. One patient was not repairable and underwent valve replacement (repair rate, 99.8%). Fifteen patients had Grade I (3.5%) regurgitation, whereas the remainder had none. Patients were fast-tracked, with 25% extubated in the operation theatre and the remainder within 6 h. There were 5 deaths within 30 days (1.2%). Follow-up ranged 3-60 months, during which all of the patients remained with no or trace mitral regurgitation. No de-insertion or rupture of any neochords was found, and no patients required a reoperation. Minimally invasive mitral valve repair using neochords provided a high rate of repair, reproducible results in a routine cardiac surgery setting and stable repair during follow-up. This has become our preferred technique for mitral valve surgery. © The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Closed Mitral Commissurotomy in Istanbul, Turkey: Results in 4403 Cases

PubMed Central

Eren, Ergin; Samilgil, Atila; Özler, Azmi; Ulufer, Tanju; Tulpar, Semih

1986-01-01

During the 17 years from 1962 to 1979, 4403 closed mitral commissurotomies were performed at the Istanbul Thoracic Surgery Center in Istanbul, Turkey. There were 60 hospital deaths (1.36%), 30 cerebral emboli (0.68%), 14 peripheral emboli (0.31%), five instances of severe mitral regurgitation (0.11%) and improvement of at least one New York Heart Association Class level in 92.2% of the patients available for late follow-up 1 to 17 years later (mean 4.2 years). Closed mitral commissurotomy without cardiopulmonary bypass can be a safe and effective alternative to open mitral commissurotomy where circumstances dictate its use. PMID:15226845

Dynamic heart phantom with functional mitral and aortic valves

NASA Astrophysics Data System (ADS)

Vannelli, Claire; Moore, John; McLeod, Jonathan; Ceh, Dennis; Peters, Terry

2015-03-01

Cardiac valvular stenosis, prolapse and regurgitation are increasingly common conditions, particularly in an elderly population with limited potential for on-pump cardiac surgery. NeoChord©, MitraClipand numerous stent-based transcatheter aortic valve implantation (TAVI) devices provide an alternative to intrusive cardiac operations; performed while the heart is beating, these procedures require surgeons and cardiologists to learn new image-guidance based techniques. Developing these visual aids and protocols is a challenging task that benefits from sophisticated simulators. Existing models lack features needed to simulate off-pump valvular procedures: functional, dynamic valves, apical and vascular access, and user flexibility for different activation patterns such as variable heart rates and rapid pacing. We present a left ventricle phantom with these characteristics. The phantom can be used to simulate valvular repair and replacement procedures with magnetic tracking, augmented reality, fluoroscopy and ultrasound guidance. This tool serves as a platform to develop image-guidance and image processing techniques required for a range of minimally invasive cardiac interventions. The phantom mimics in vivo mitral and aortic valve motion, permitting realistic ultrasound images of these components to be acquired. It also has a physiological realistic left ventricular ejection fraction of 50%. Given its realistic imaging properties and non-biodegradable composition—silicone for tissue, water for blood—the system promises to reduce the number of animal trials required to develop image guidance applications for valvular repair and replacement. The phantom has been used in validation studies for both TAVI image-guidance techniques1, and image-based mitral valve tracking algorithms2.

Initial Experience and Early Results of Mitral Valve Repair with Cardiocel Pericardial Patch.

PubMed

Tomšič, Anton; Bissessar, Daniella D; van Brakel, Thomas J; Marsan, Nina Ajmone; Klautz, Robert J M; Palmen, Meindert

2018-06-07

To assess the performance of a tissue engineering process-treated bovine pericardium patch (CardioCel) in the setting of reconstructive mitral valve surgery. Between 3/2014 and 4/2016, 30 patients (57.2±14.3 years, 27% female) underwent mitral valve leaflet repair with a CardioCel patch. Perioperative mortality was 7% (2 patients, non-graft-related). In 28 remaining patients, pre-discharge echocardiography demonstrated good repaired valve function. At a mean follow-up of 1.7±0.9 years, 3 additional deaths occurred (2 due to infective endocarditis, 1 non-cardiac related). On follow-up echocardiography [follow-up time 1.7±0.8 years, available for 26/28 (93%) hospital survivors], recurrent regurgitation was seen in 2 patients (both infective endocarditis) and 1 underwent reoperation (no infection at the level of patch repair was observed). In the remaining patients, the most recent echocardiogram demonstrated ≤mild regurgitation and stable gradients. The thickness and echodensity of the implanted patch on follow-up echocardiograms were comparable with postoperative echocardiograms. Initial results of the CardioCel patch in mitral valve repair surgery are satisfactory. The resistance to infection and late degeneration will need to be assessed in the future. Copyright © 2018. Published by Elsevier Inc.

Hypoplasia or Absence of Posterior Leaflet: A Rare Congenital Anomaly of The Mitral Valve in Adulthood - Case Series.

PubMed

Parato, Vito Maurizio; Masia, Stefano Lucio

2018-01-01

We present a case series of two adult patients with almost complete absence of the posterior mitral valve leaflet and who are asymptomatic or mildly symptomatic, with two different degrees of mitral regurgitation.

Pulmonary hypertension in dogs with mitral regurgitation attributable to myxomatous valve disease.

PubMed

Chiavegato, David; Borgarelli, Michele; D'Agnolo, Gino; Santilli, Roberto A

2009-01-01

Pulmonary hypertension has been associated with mitral insufficiency caused by chronic degenerative valve disease in dogs. Our aim was to search for associations between left atrial to aortic root ratio, end-systolic and end-diastolic volume indices, and changes in the right ventricular to right atrial pressure gradient as estimated by the peak velocity of tricuspid regurgitation in dogs with chronic degenerative valve disease and different classes of heart failure. Dogs, for which follow-up was available were evaluated for changes in the right ventricular to right atrial systolic pressure gradient over time. Three hundred and forty-four dogs were studied; 51 in the International Small Animal Cardiac Health Council class la, 75 in class 1b, 113 in class 2, 97 in class 3a, and 8 in class 3b. The mean values for right ventricular to right atrial systolic pressure gradient, end-systolic volume index, end-diastolic volume index, and left atrial to aortic ratio were 49.2 +/- 17.1 mmHg, 149.12 +/- 60.8 and 37.7 +/- 21.6 ml/m2, and 1.9 +/- 0.5, respectively. A weak positive correlation was found between the right ventricular to right atrial systolic pressure gradient and the left atrial to aorta ratio (r = 0.242, P < 0.0001), end-diastolic volume index (r = 0.242, P < 0.0001), and end-systolic volume index (r = 0.129, P < 0.001). Follow up was available for 49 dogs. Of these, 18 had an increased, 12 a decreased, and 19 a stable right ventricular to right atrial systolic pressure gradient despite therapy. The equivalence point between the sensitivity and specificity curves of about 80% in the coincident point corresponded to a right ventricular to right atrial systolic pressure gradient of 48 mmHg. Our results suggest an association between the progressive nature of chronic degenerative mitral valve disease and pulmonary hypertension. It is of clinical interest that, with a right ventricular to right atrial systolic pressure gradient pressure gradient at or above 48 mm

Subvalvular apparatus and adverse outcome of balloon valvotomy in rheumatic mitral stenosis.

PubMed

Bhalgat, Parag; Karlekar, Shrivallabh; Modani, Santosh; Agrawal, Ashish; Lanjewar, Charan; Nabar, Ashish; Kerkar, Prafulla; Agrawal, Nandu; Vaideeswar, Pradeep

2015-01-01

Balloon mitral valvotomy (BMV) is a well-established therapeutic modality for rheumatic mitral stenosis (RMS). However, there are chances of procedural failure and the more ominous post-procedural severe mitral regurgitation. There are only a few prospective studies, which have evaluated the pathogenic mechanisms for these major complications of BMV, especially in relation to the subvalvular apparatus (SVA) pathology. All symptomatic patients of RMS suitable for BMV by echocardiographic criteria in a span of 1 year were selected. In addition to the standard echocardiographic assessment of RMS (Wilkins score and score by Padial et al.), a separate grading and scoring system was assigned to evaluate the severity of the SVA pathology. The SVA score was 'I', when none of the two SVAs had severe disease, 'II' when one of the two SVAs has severe disease, and 'III' when both SVAs had severe disease. With these scoring systems, the outcomes of BMV (successful procedure, failure, and post-procedural mitral regurgitation) were analyzed. Emergency valve replacement was performed depending on clinical situation, and in cases of replacement, the pathology of the excised mitral valves were compared with echocardiographic findings. Of the 356 BMVs performed in a year, 43 patients had adverse outcomes in the form of failed procedure (14 patients) and mitral regurgitation (29 patients). Forty-one among these had a SVA score of III. The sensitivity and specificity of the MR score was lesser than the SVA score (sensitivity 0.34 vs. 1.00, specificity 0.92 vs. 0.99, respectively). The mitral valvular morphology in 39 patients who underwent post-procedural valve replacements correlated well with echocardiography findings. It is important to assess the degree of SVA pathology in the conventional echocardiographic assessment for RMS, as BMV would have adverse events when both SVAs were severely diseased. Copyright © 2015 Cardiological Society of India. Published by Elsevier B.V. All

Role of vortices in growth of microbubbles at mitral mechanical heart valve closure.

PubMed

Rambod, Edmond; Beizai, Masoud; Sahn, David J; Gharib, Morteza

2007-07-01

This study is aimed at refining our understanding of the role of vortex formation at mitral mechanical heart valve (MHV) closure and its association with the high intensity transient signals (HITS) seen in echocardiographic studies with MHV recipients. Previously reported numerical results described a twofold process leading to formation of gas-filled microbubbles in-vitro: (1) nucleation and (2) growth of micron size bubbles. The growth itself consists of two processes: (a) diffusion and (b) sudden pressure drop due to valve closure. The role of diffusion has already been shown to govern the initial growth of nuclei. Pressure drop at mitral MHV closure may be attributed to other phenomena such as squeezed flow, water hammer and primarily, vortex cavitation. Mathematical analysis of vortex formation at mitral MHV closure revealed that a closing velocity of approximately 12 m/s can induce a strong regurgitant vortex which in return can instigate a local pressure drop of about 0.9 atm. A 2D experimental model of regurgitant flows was used to substantiate the impact of vortices. At simulated flow and pressure conditions, a regurgitant vortex was observed to drastically enlarge micron size hydrogen bubbles at its core.

Percutaneous Transcatheter Mitral Valve Replacement: Patient-specific Three-dimensional Computer-based Heart Model and Prototyping.

PubMed

Vaquerizo, Beatriz; Theriault-Lauzier, Pascal; Piazza, Nicolo

2015-12-01

Mitral regurgitation is the most prevalent valvular heart disease worldwide. Despite the widespread availability of curative surgical intervention, a considerable proportion of patients with severe mitral regurgitation are not referred for treatment, largely due to the presence of left ventricular dysfunction, advanced age, and comorbid illnesses. Transcatheter mitral valve replacement is a promising therapeutic alternative to traditional surgical valve replacement. The complex anatomical and pathophysiological nature of the mitral valvular complex, however, presents significant challenges to the successful design and implementation of novel transcatheter mitral replacement devices. Patient-specific 3-dimensional computer-based models enable accurate assessment of the mitral valve anatomy and preprocedural simulations for transcatheter therapies. Such information may help refine the design features of novel transcatheter mitral devices and enhance procedural planning. Herein, we describe a novel medical image-based processing tool that facilitates accurate, noninvasive assessment of the mitral valvular complex, by creating precise three-dimensional heart models. The 3-dimensional computer reconstructions are then converted to a physical model using 3-dimensional printing technology, thereby enabling patient-specific assessment of the interaction between device and patient. It may provide new opportunities for a better understanding of the mitral anatomy-pathophysiology-device interaction, which is of critical importance for the advancement of transcatheter mitral valve replacement. Copyright © 2015 Sociedad Española de Cardiología. Published by Elsevier España, S.L.U. All rights reserved.

Mitral valve repair with adjustable ring annuloplasty.

PubMed

Andreas, Martin; Haberl, Thomas; Paul Werner, Paul Werner; Guri, Jani; Kocher, Alfred; Hamza, Ouafa; Podesser, Bruno; Laufer, Guenther

2018-02-28

We demonstrate the technical aspects of a novel adjustable mitral ring. This new ring was implanted in a female landrace pig, for training and educational purposes. It can be adjusted independently in the P1, P2 and P3 segments, if required, to treat  recurrent mitral regurgitation, and this is a key difference to comparable devices. The first-in-man implantation is anticipated in the near future. © The Author 2016. Published by MMCTS on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.

Comparative effects of amlodipine and benazepril on Left Atrial Pressure in Dogs with experimentally-induced Mitral Valve Regurgitation

PubMed Central

2012-01-01

Background One of the purposes of treatment for dogs with mitral regurgitation (MR) is lowering left atrial pressure (LAP). There has been few study of the amlodipine in dogs with MR and amlodipine’s effect on LAP has not been fully evaluated in a quantitative manner because of difficulties in directly measuring LAP. The objective of our study was to compare the short-term effects of amlodipine (0.2 mg/kg PO q12h) vs benazepril (0.5 mg/kg PO q12h), on LAP and echocardiographic parameters in five beagle dogs with experimentally-induced MR. LAP of eight dogs that has own control were measured using radiotelemetry system at baseline and again on days 1, 2, 3, 4, 5, 6, 7 of the drug administration. Results Mean LAP decreased significantly after amlodipine (11.20 ± 4.19 mmHg vs 14.61 ± 3.81 mmHg at baseline, p < .01) but not after benazepril treatment (13.19 ± 3.47 mmHg, p > .05). LAP was lower after 7 days of amlodipine treatment than after 7 days of benazepril treatment. Significant reduction was seen for the first time 4 days after the administration amlodipine. The rate of the maximal area of the regurgitant jet signals to the left atrium area (ARJ/LAA) of the amlodipine treatment was significantly lower (p < .05) after 7 days compared to baseline. Other echocardiographic parameters did not change significantly. Conclusions LAP was significantly decreased after amlodipine treatment in dogs with surgically-induced MR but not after benazepril treatment. Although this study did not focus on adverse effects, amlodipine may be an effective drug for helping the patients with acute onset of severe MR, such as rupture of chordae tendinae or end stage patients were the LAP is likely to be elevated. Additional studies in clinical patients with degenerative mitral valve disease and acute chordal rupture are warranted because the blood-pressure lowering effects of amlodipine can decrease renal perfusion and this can further

Mitral stenosis in 15 dogs.

PubMed

Lehmkuhl, L B; Ware, W A; Bonagura, J D

1994-01-01

Mitral stenosis was diagnosed in 15 young to middle-aged dogs. There were 5 Newfoundlands and 4 bull terriers affected, suggesting a breed predisposition for this disorder. Clinical signs included cough, dyspnea, exercise intolerance, and syncope. Soft left apical diastolic murmurs were heard only in 4 dogs, whereas 8 dogs had systolic murmurs characteristic of mitral regurgitation. Left atrial enlargement was the most prominent radiographic feature. Left-sided congestive heart failure was detected by radiographs in 11 dogs within 1 year of diagnosis. Electrocardiographic abnormalities varied among dogs and included atrial and ventricular enlargement, as well as atrial and ventricular arrhythmias. Abnormalities on M-mode and two-dimensional echocardiograms included abnormal diastolic motion of the mitral valve characterized by decreased leaflet separation, valve doming, concordant motion of the parietal mitral valve leaflet, and a decreased E-to-F slope. Increased mitral valve inflow velocities and prolonged pressure half-times were detected by Doppler echocardiography. Cardiac catheterization, performed in 8 dogs, documented a diastolic pressure gradient between the left atrial, pulmonary capillary wedge, or pulmonary artery diastolic pressures and the left ventricular diastolic pressure. Necropsy showed mitral stenosis caused by thickened, fused mitral valve leaflets in 5 dogs and a supramitral ring in another dog. The outcome in affected dogs was poor; 9 of 15 dogs were euthanatized or died by 2 1/2 years of age.

Polymer injection therapy to reverse remodel the papillary muscles: efficacy in reducing mitral regurgitation in a chronic ischemic model.

PubMed

Solis, Jorge; Levine, Robert A; Johnson, Benjamin; Guerrero, J Luis; Handschumacher, Mark D; Sullivan, Suzanne; Lam, Kaitlyn; Berlin, Jason; Braithwaite, Gavin J C; Muratoglu, Orhun K; Vlahakes, Gus J; Hung, Judy

2010-10-01

Ischemic mitral regurgitation (MR) results from displacement of the papillary muscles caused by ischemic ventricular distortion. Progressive left ventricular (LV) remodeling has challenged therapy. Our hypothesis is that repositioning of the papillary muscles can be achieved by injection of polyvinyl-alcohol (PVA) hydrogel polymer into the myocardium in chronic MR despite advanced LV remodeling. Ten sheep underwent ligation of the circumflex branches to produce chronic ischemic MR over 8 weeks. PVA was injected into the myocardium underlying the infarcted papillary muscle. Two-dimensional and 3D echocardiograms and hemodynamic data were obtained before infarct (baseline), before PVA (chronic MR), and after PVA. PVA injection significantly decreased MR from moderate to severe to trace (MR vena contracta, 5.8±1.2 to1.8±1.3 mm; chronic MR to post-PVA stage; P=0.0003). This was associated with a decrease in infarcted papillary muscle-to-mitral annulus tethering distance (30.3±5.7 to 25.9±4.6 mm, P=0.02), tenting volume (1.8±0.7 to 1.4±0.5 mL, P=0.01), and leaflet closure area (8.8±1.3 cm(2)to 7.6±1.3 cm(2), P=0.004) from chronic MR to post-PVA stages. PVA was not associated with significant decreases in LV ejection fraction (41±3% versus 40±3%, P=NS), end-systolic elastance, τ (82±36 ms to 72±26, P=NS), or LV stiffness coefficient (0.05±0.04 to 0.03±0.01). PVA hydrogel injections improve coaptation and reduce remodeling in chronic MR without impairing LV systolic and diastolic function. This new approach offers a potential alternative for relieving tethering and ischemic MR by correcting papillary muscle position.

Mitral valve surgery in emergency for severe acute regurgitation: analysis of postoperative results from a multicentre study.

PubMed

Lorusso, Roberto; Gelsomino, Sandro; De Cicco, Giuseppe; Beghi, Cesare; Russo, Claudio; De Bonis, Michele; Colli, Andrea; Sala, Andrea

2008-04-01

To evaluate postoperative outcome of emergency surgery for acute severe mitral regurgitation (ASMR) from a multicentre experience. In six centres, 279 patients (mean age 62+/-14 years, 62% female) undergoing emergency surgery for ASMR from December 1986 to March 2007 were analysed and followed up. Aetiology included acute myocardial infarction (AMI) in 126 patients (group 1, 45%), degenerative mitral valve disease in 74 (group 2, 26%), and acute endocarditis (AE) in 79 (group 3, 28%). Preoperatively, all patients were in haemodynamic instability, with 185 patients in cardiogenic shock (66%), 184 (66%) intubated, and 61 (22%) on IABP, respectively. Valve repair was performed in 76 (27%), whereas 203 (73%) underwent valve replacement. Median follow-up (98% complete) was 70.8 months (inter-quartile range 59.8-86.66 months). Overall 30-day mortality was 22.5% (63/279). Early death was significantly lower in group 2 (p<0.001 and p=0.005 vs group 1 and 3, respectively) whereas no difference was detected between group 1 and 3. At logistic regression analysis AMI, AE, shock, left ventricular dysfunction, and coronary artery disease were predictors of early death. Overall 15-year survival was 67+/-10%. Survival was lower in group 1 (39+/-11%) than in group 2 (75+/-9%) and group 3 (77+/-10%). Cox regression found AMI, and associated coronary artery disease to be predictors of late death. Overall 15-year actuarial and actual freedom from cardiac-related events were 44+/-9% and 28+/-10%, respectively, with the worst outcome in the presence of AE. Associated coronary artery disease, AE, AMI, preoperative atrial fibrillation, and chronic renal failure were independent predictors of cardiac-related events. Emergency surgery for ASMR remains a surgical challenge for high incidence of early and late cardiac-related events, particularly in patients with associated coronary artery disease and acute endocarditis. Apparently, type of mitral valve surgical approaches (repair or

Clinical significance of exercise pulmonary hypertension in secondary mitral regurgitation.

PubMed

Lancellotti, Patrizio; Magne, Julien; Dulgheru, Raluca; Ancion, Arnaud; Martinez, Christophe; Piérard, Luc A

2015-05-15

In patients with heart failure, exercise echocardiography can help in risk stratification and decision making. The prognostic significance of exercise pulmonary hypertension (PH) in patients with secondary mitral regurgitation (MR) remains unknown. The aim of the present study was to assess the prognostic value of exercise PH in patients with secondary MR and narrow QRS intervals. From 2005 to 2012, 159 consecutive patients with secondary MR, narrow QRS intervals, left ventricular dysfunction (mean ejection fraction 36 ± 7%), and measurable systolic pulmonary arterial pressure (SPAP) during exercise echocardiography were included. Resting and exercise PH were defined as SPAP >50 and >60 mm Hg, respectively. Exercise PH was more frequent than resting PH (40% vs 13%, p <0.0001). On multivariate logistic regression, the independent determinants of exercise PH were resting SPAP (p <0.0001), exercise MR severity (p <0.0001), and e'-wave velocity (p = 0.004). The incidence of cardiac events during follow-up was significantly higher in patients with exercise PH compared with those without exercise PH (4 years: 40 ± 7% vs 20 ± 5%, p <0.0001). Patients with exercise PH exhibited higher rates of cardiac events and death than those with resting PH. In a multivariate Cox proportional hazards model, exercise PH was independently associated with the occurrence of cardiac events (p <0.0001). In conclusion, in patients with secondary MR, exercise PH is determined mainly by resting SPAP, left ventricular diastolic burden, and exercise MR severity. Exercise PH is a powerful predictor of poor outcomes, with a 5.3-fold increased risk for cardiac-related death during follow-up. These results highlight the added value of exercise echocardiography in secondary MR. Copyright © 2015 Elsevier Inc. All rights reserved.

Mitral valve reconstruction in Barlow disease: long-term echographic results and implications for surgical management.

PubMed

Jouan, Jérôme; Berrebi, Alain; Chauvaud, Sylvain; Menasché, Philippe; Carpentier, Alain; Fabiani, Jean-Noël

2012-04-01

Owing to the complexity of the underlying lesions, Barlow disease remains a challenge for surgeons performing mitral valve repair. We aimed to assess whether our most recent results involving several surgeons were comparable with those of a previous experience in which mitral valve repair was performed by a more limited group of surgeons. From September 2000 to January 2007, 200 patients with Barlow disease (135 men and 65 women; mean age, 56 ± 13 years) were referred to our institution for surgical treatment of their mitral regurgitation. We retrospectively analysed the mitral lesions characteristics, the surgical techniques used, and clinical outcomes. Follow-up echocardiograms were biannually reviewed. Lesions comprised annular dilatation, excess tissue, and leaflet prolapse in all cases. The most frequent prolapsed segments were P2 (88.5%; n = 177) and A2 (55.5%; n = 111). Annular calcifications and restrictive valvular motion were associated in 20% (n = 40). Repair was feasible in 94.7% (n = 179/189) of non-redo interventions. Immediate postoperative echocardiography showed residual mitral regurgitation greater than 1+ in 6 cases; these patients were all reoperated on within the next months. Operative mortality was 1.5% (n = 3). Mean follow-up was 77.5 ± 25.6 months. At 8 years postoperatively, overall survival was 88.6% ± 3.1%, freedom from reintervention was 95.3% ± 1.7%, and freedom from late recurrent moderate mitral regurgitation (>2+) was 90.2% ± 3.1% Provided that the fundamental principles of mitral valve reconstruction are respected, the surgical techniques are highly reproducible with good long-term results, similar to those published during the pioneering phase of this surgery. Copyright © 2012 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

Emergent presentation of decompensated mitral valve prolapse and atrial septal defect.

PubMed

Kang, Jessie; Das, Bijon

2015-05-01

Mitral valve prolapse is not commonly on the list of differential diagnosis when a patient presents in the emergency department (ED) in severe distress, presenting with non-specific features such as abdominal pain, tachycardia and dyspnea. A healthy 55-year-old man without significant past medical history arrived in the ED with a unique presentation of a primary mitral valve prolapse with an atrial septal defect uncommon in cardiology literature. Early recognition of mitral valve prolapse in high-risk patients for severe mitral regurgitation or patients with underlying cardiovascular abnormalities such as an atrial septal defect is crucial to prevent morbid outcomes such as sudden cardiac death.

Progression of Tricuspid Regurgitation after Mitral Valve Replacement for Rheumatic Heart Disease.

PubMed

Q Tri, Ho H; Vinh, Pham N

2017-05-01

Progression of tricuspid regurgitation (TR) may occur after mitral valve replacement (MVR). The study aim was to define the independent predictors for new severe TR after MVR to treat rheumatic heart disease. A total of 413 patients (177 men, 236 women; mean age 40.9 ± 9.2 years) with rheumatic heart disease undergoing MVR without concomitant tricuspid valve repair at the authors' institute between 1995 and 2005, who did not have preoperative severe TR, were followed for at least one year postoperatively. Survival without severe TR was estimated using the Kaplan-Meier method. Independent predictors for new severe TR were identified using multiple Cox regression analysis. During a median follow up of 13 years there were two late deaths, and 46 patients (11.1%) had new severe TR. Survival without severe TR was 88.0 ± 1.7% at 10 years. Independent predictors for new severe TR were preoperative moderate TR (HR 2.401; p = 0.008) and atrial fibrillation (AF) (HR 2.119; p = 0.018). At the most recent follow up, furosemide was used in 23.9% patients with and 7.3% patients without new severe TR (p = 0.001). Patients with new severe TR had larger right ventricles and higher pulmonary artery pressures on echocardiography. Among patients with rheumatic heart disease undergoing MVR without concomitant tricuspid valve repair, independent predictors for new severe TR were preoperative moderate TR and AF. New severe TR was associated with increased furosemide use.

Hypoplasia or Absence of Posterior Leaflet: A Rare Congenital Anomaly of The Mitral Valve in Adulthood – Case Series

PubMed Central

Parato, Vito Maurizio; Masia, Stefano Lucio

2018-01-01

We present a case series of two adult patients with almost complete absence of the posterior mitral valve leaflet and who are asymptomatic or mildly symptomatic, with two different degrees of mitral regurgitation. PMID:29629259

Daily rhythms of left atrial pressure in beagle dogs with mitral valve regurgitation.

PubMed

Ishikawa, T; Tanaka, R; Suzuki, S; Saida, Y; Soda, A; Fukushima, R; Yamane, Y

2009-01-01

Mitral valve regurgitation (MR) causes increased left atrial pressure (LAP) and is associated with occurrence of clinical signs. It will be useful to understand diurnal variations of LAP for the management of MR. Circulatory parameters and diurnal rhythm are linked to clinical signs in cardiac diseases. LAP also exhibits a diurnal rhythm in dogs with MR. Five healthy Beagle dogs weighing 9.8-12.8 kg (3 males and 2 females; aged 2 years) were used. A radiotelemetry system for continuous measurement of LAP was used in this study. Rupture of the chordae tendineae was experimentally induced via left atriotomy, and a transmitter catheter was inserted into the left atrium. The body of the transmitter was implanted SC. After clinical condition was stabilized, the severity of MR was evaluated by echocardiography, and LAP was recorded for 72 consecutive hours for the analysis of diurnal variation. Abrupt increases in LAP, which averaged 16.7 mmHg, were observed at feeding periods. In contrast, strong diurnal LAP variations were found, with a significant but slight increase in daytime LAP compared with nighttime LAP. Diurnal LAP is characterized by a slight but significant nocturnal decrease and abrupt increases in response to excitation. The latter seemed to be more important considering the relationship with clinical manifestations. The clinical relevance of exercise restriction in the management of MR was acknowledged.

Evaluation of left ventricular Tei index (index of myocardial performance) in healthy dogs and dogs with mitral regurgitation.

PubMed

Teshima, Kenji; Asano, Kazushi; Iwanaga, Koji; Koie, Hiroshi; Uechi, Masami; Kato, Yuka; Kutara, Kenji; Kanno, Nobuyuki; Seki, Mamiko; Edamura, Kazuya; Hasegawa, Atsuhiko; Tanaka, Shigeo

2007-02-01

The left ventricular (LV) Tei index (index of myocardial performance) has been demonstrated to be clinically useful in estimating comprehensive LV function, including the systolic and diastolic performances, in various human cardiac diseases. The purposes of this study were to validate the correlation between the LV Tei index and LV function obtained by cardiac catheterization in healthy dogs, and to evaluate the LV Tei index in dogs with naturally occurring mitral regurgitation (MR). In healthy dogs, the LV Tei index was significantly correlated with the LV peak +dP/dt (r = -0.89) and LV peak -dP/dt (r=0.87). The LV Tei index significantly increased in dogs with MR compared with normal dogs and significantly increased with progressively more severe clinical signs due to heart failure. The elevation of the LV Tei index in dogs with symptomatic MR appears to be associated with shortening of ejection time. The LV Tei index significantly increased with age and was not correlated with heart rate and body weight in normal dogs. In conclusion, our study demonstrated that the LV Tei index was measurable in dogs and not influenced by heart rate and body weight. The LV Tei index significantly increased with the progression of clinical signs in MR dogs. In particular, the elevation of the LV Tei index in dogs with symptomatic MR due to shortening of ejection time may suggest LV systolic dysfunction and the decrement of forward stroke volume.

Successful surgical treatment of mitral valve stenosis in a dog.

PubMed

Borenstein, N; Daniel, P; Behr, L; Pouchelon, J L; Carbognani, D; Pierrel, A; Macabet, V; Lacheze, A; Jamin, G; Carlos, C; Chetboul, V; Laborde, F

2004-01-01

To report the successful surgical management (open mitral commissurotomy, OMC) of mitral stenosis (MS), incorporating heart-beating cardiopulmonary bypass (CPB), in a 1-year-old dog. Clinical case. One-year-old Cairn Terrier with MS. Diagnosis of MS was confirmed by means of 2-dimensional, continuous-wave and color-flow Doppler echocardiography. Surgery was performed through a left intercostal thoracotomy. CPB was initiated and the heart was kept beating. The fused commissures of the mitral valve were incised to free the cusps of the valve. Left intercostal thoracotomy allowed easy observation of the mitral orifice during heart-beating OMC. Persistent bleeding from the atriotomy site required a second surgical procedure after which the dog had an uneventful recovery. Echocardiography at 2 weeks and 1 year postoperatively indicated substantial improvement in left ventricular filling (pressure half-time=187 ms before surgery, 105 ms [2 weeks] and 110 ms [1 year] after surgery). Enlargement of the left atrium resolved; however, moderate mitral valve regurgitation was still present. MS can be successfully treated by OMC, facilitated by use of CPB. Substantial improvement in cardiac function was evident by ultrasound and Doppler examination postoperatively. OMC under heart-beating CPB should be considered for the treatment of MS in the dog.

Edge-to-edge repair for prevention and treatment of mitral valve systolic anterior motion.

PubMed

Myers, Patrick O; Khalpey, Zain; Maloney, Ann M; Brinster, Derek R; D'Ambra, Michael N; Cohn, Lawrence H

2013-10-01

The edge-to-edge technique has been proposed to prevent systolic anterior motion (SAM) of the mitral valve. There is limited clinical data available on outcomes of this technique for this indication. We reviewed the midterm results of this technique for SAM prevention and treatment. A total of 2226 patients had mitral valve repair between 2000 and 2011, 1148 of which were for myxomatous mitral regurgitation. Beginning in 2000, predictability of postrepair SAM based on the prebypass, intraoperative transesophageal echocardiogram arose in our program. The edge-to-edge technique was used in 65 patients (5.7%) for SAM management, in 53 patients preemptively for transesophageal echocardiogram-based SAM prediction, and in 12 patients for postrepair SAM treatment. There was no operative mortality. Postoperative mitral regurgitation was significantly improved in all patients compared with the preoperative grade (P < .001). SAM was completely eliminated, the mean mitral regurgitation grade in the postoperative period was 0.7 ± 0.9, and the mean transmitral gradient was 1.3 ± 2.2 mm Hg. During a mean follow-up of 26 months, 1 patient in the SAM treatment group presented late recurrence of SAM and no patients developed mitral stenosis (mean transmitral gradient, 2.0 ± 2.6 mm Hg; P = .12). Without SAM prediction and preemptive edge-to-edge technique, the expected rate of SAM would have been 5.7%; however, the observed rate was 1% (12 of 1148 patients). Initiating an expectation for prebypass SAM prediction, combined with a surgical SAM prevention strategy, resulted in a reduced prevalence of SAM compared with our model of observed to-expected-ratios and to published norms. Copyright © 2013 The American Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.

Ultrasound based mitral valve annulus tracking for off-pump beating heart mitral valve repair

NASA Astrophysics Data System (ADS)

Li, Feng P.; Rajchl, Martin; Moore, John; Peters, Terry M.

2014-03-01

Mitral regurgitation (MR) occurs when the mitral valve cannot close properly during systole. The NeoChordtool aims to repair MR by implanting artificial chordae tendineae on flail leaflets inside the beating heart, without a cardiopulmonary bypass. Image guidance is crucial for such a procedure due to the lack of direct vision of the targets or instruments. While this procedure is currently guided solely by transesophageal echocardiography (TEE), our previous work has demonstrated that guidance safety and efficiency can be significantly improved by employing augmented virtuality to provide virtual presentation of mitral valve annulus (MVA) and tools integrated with real time ultrasound image data. However, real-time mitral annulus tracking remains a challenge. In this paper, we describe an image-based approach to rapidly track MVA points on 2D/biplane TEE images. This approach is composed of two components: an image-based phasing component identifying images at optimal cardiac phases for tracking, and a registration component updating the coordinates of MVA points. Preliminary validation has been performed on porcine data with an average difference between manually and automatically identified MVA points of 2.5mm. Using a parallelized implementation, this approach is able to track the mitral valve at up to 10 images per second.

Successful surgical treatment of intramural aortoatrial fistula, severe aortic regurgitation, mitral prolapse, and tricuspid insufficiency in a patient with Ehlers-Danlos syndrome type IV.

PubMed

Jiang, Shengli; Gao, Changqing; Ren, Chonglei; Zhang, Tao

2012-06-01

Patients with Ehlers-Danlos syndrome (EDS) type IV, an inherited connective tissue disorder, are predisposed to vascular and digestive ruptures, and arterial ruptures account for the majority of deaths. A 31-year-old man with EDS presented with an intramural aortoatrial fistula, severe aortic regurgitation, mitral valve prolapse, and severe tricuspid valve insufficiency combined with a severely dilated left ventricle. Determining the best surgical option for the patient was not easy, especially regarding the course of action for the aortic root with a tear in the sinus of Valsalva. The fistula tract was closed at the aorta with suture and with a patch in the right atrium, the mitral valve was repaired with edge-to-edge suture and then annuloplasty with a Cosgrove ring, the aortic valve was replaced with a mechanical prosthesis, and a modified De Vega technique was used for the tricuspid valvuloplasty. The postoperative course was uncomplicated, and the patient was discharged 2 weeks later. The considerations made to arrive at the chosen surgical course of action in this complex case are reviewed.

Different indicators for postprocedural mitral stenosis caused by single- or multiple-clip implantation after percutaneous mitral valve repair.

PubMed

Itabashi, Yuji; Utsunomiya, Hiroto; Kubo, Shunsuke; Mizutani, Yukiko; Mihara, Hirotsugu; Murata, Mitsushige; Siegel, Robert J; Kar, Saibal; Fukuda, Keiichi; Shiota, Takahiro

2018-04-01

Postprocedural mitral stenosis (MS) is a main limitation for MitraClip™ (Abbot Vascular, Inc., Santa Clara, CA, USA) procedure. The purpose of this study was to detect the preprocedural predictors of high transmitral pressure gradient (TMPG) after MitraClip™ implantation, which indicated postprocedural mitral stenosis (MS). We studied 79 patients who were implanted with MitraClip™ in our institute. Before the procedure, mitral valve orifice area (MVOA), and anterior-posterior (AP) and medial-lateral (ML) mitral annular diameters were measured at diastole using three-dimensional (3D) transesophageal echocardiography (TEE) data set. After the procedure, the mean TMPG was assessed using continuous-wave (CW) Doppler by periprocedural TEE. Preprocedural MVOA, and AP and ML diameter of left ventricular (LV) inflow orifices were larger in patients with mean TMPG ≤4mmHg than in patients with TMPG >4mmHg after 1-and 2-clip implantation. The large MVOA and ML diameter of LV inflow orifice strongly correlated with the low TMPG after 1- and 2-clip implantation. As a result of the receiver operating characteristic curve analysis, the preprocedural MVOA predicted the low postprocedural TMPG more accurately than the ML diameter of LV inflow orifice after 1-clip implantation either in the degenerative or functional mitral regurgitation (MR) patients. After 2-clip implantation, however, the preprocedural ML diameter of LV inflow orifice predicted it more accurately than the MVOA in the degenerative and functional MR patients. 3D TEE derived MVOA predicts the postprocedural MS after 1-clip implantation, however, preprocedural ML diameter of LV inflow orifice is more useful to predict after 2-clip implantation. Copyright © 2017 Japanese College of Cardiology. Published by Elsevier Ltd. All rights reserved.

Review of Congenital Mitral Valve Stenosis: Analysis, Repair Techniques and Outcomes.

PubMed

Baird, Christopher W; Marx, Gerald R; Borisuk, Michele; Emani, Sitram; del Nido, Pedro J

2015-06-01

The spectrum of congenital mitral valve stenosis (MS) consists of a complex of defects that result in obstruction to left ventricular inflow. This spectrum includes patients with underdeveloped left heart structures (Fig. 1) to those with isolated congenital MS. The specific mitral valve defects can further be divided into categories based on the relationship to the mitral valve annulus including valvar, supravalvar and subvalvar components. Clinically, these patients present based on the degree of obstruction, associated mitral regurgitation, secondary pulmonary hypertension, associated lung disease and/or associated cardiac lesions. There are a number of factors that contribute to the successful outcomes in these patients including pre-operative imaging, aggressive surgical techniques and peri-operative management.

Multiplanar visualization in 3D transthoracic echocardiography for precise delineation of mitral valve pathology.

PubMed

Kuppahally, Suman S; Paloma, Allan; Craig Miller, D; Schnittger, Ingela; Liang, David

2008-01-01

A novel multiplanar reformatting (MPR) technique in three-dimensional transthoracic echocardiography (3D TTE) was used to precisely localize the prolapsed lateral segment of posterior mitral valve leaflet in a patient symptomatic with mitral valve prolapse (MVP) and moderate mitral regurgitation (MR) before undergoing mitral valve repair surgery. Transesophageal echocardiography was avoided based on the findings of this new technique by 3D TTE. It was noninvasive, quick, reproducible and reliable. Also, it did not need the time-consuming reconstruction of multiple cardiac images. Mitral valve repair surgery was subsequently performed based on the MPR findings and corroborated the findings from the MPR examination.

Antiphospholipid antibody-associated non-infective mitral valve endocarditis successfully treated with medical therapy.

PubMed

Contractor, Tahmeed; Bell, Adrian; Khasnis, Atul; Silverberg, Bruce J; Martinez, Matthew W

2013-01-01

Non-bacterial endocarditis lesions associated with antiphospholipid antibodies (aPLs) in the absence of other criteria for antiphospholipid syndrome or systemic lupus erythematosus is termed an aPL-associated cardiac valve disease. Evidence regarding the management of this condition is sparse. A rare case is described of a 20-year-old female who presented with an incidental finding of 'vegetations on a heart valve'. Echocardiography revealed mitral valve leaflet thickening and echodensities with moderate mitral regurgitation. She had an elevated partial thromboplastin time that did not correct with a mixing study, and elevated levels of antiocardiolipin antibodies. Hence, a diagnosis of aPL-associated cardiac valve disease was made, and the patient commenced on warfarin, hydroxychloroquine, and a short course of oral prednisone. At one year after diagnosis the patient remained symptom-free, and follow up echocardiography revealed resolution of the vegetations with minimal mitral regurgitation. Further evidence is needed to guide the therapy of this rare condition.

Outcomes of De Vega versus biodegradable ring annuloplasty in the surgical treatment of tricuspid regurgitation (mid-term results).

PubMed

Basel, Halil; Aydin, Unal; Kutlu, Hakan; Dostbil, Aysenur; Karadag, Melike; Odabasi, Dolunay; Aydin, Cemalettin

2010-08-01

The aim of this study was to compare De Vega semicircular annuloplasty and a new biodegradable ring annuloplasty technique in patients requiring surgical intervention for tricuspid valve disease with concomitant disease of the mitral valve. Between January 2004 and May 2008, 129 consecutive patients underwent annuloplasty procedures to correct tricuspid valve regurgitation during a concomitant mitral valve operation requiring replacement. Additionally, 24 patients underwent aortic valve replacement (AVR), 11 underwent coronary artery bypass grafting (CABG), 5 underwent AVR plus CABG, 3 underwent mitral valve replacement plus atrial septal defect (ASD) closure, and 2 underwent ASD closure. The patients in this study were assigned to 2 groups: Kalangos ring annuloplasty was performed in 67 patients (group 1), and De Vega semicircular annuloplasty was performed in the remaining 62 patients (group 2). Both tricuspid valve repair techniques produced a low rate of complications; however, the number of patients who developed residual tricuspid regurgitation was significantly lower in group 1. The biodegradable ring annuloplasty technique may be used easily and safely in moderate and severe cases of tricuspid regurgitation; however, larger clinical series are necessary to confirm our promising results.

Worsening of left ventricular end-systolic volume and mitral regurgitation without increase in left ventricular dyssynchrony on acute interruption of cardiac resynchronization therapy.

PubMed

Kuppahally, Suman S; Fowler, Michael B; Vagelos, Randall; Wang, Paul; Al-Ahmad, Amin; Paloma, Allan; Liang, David

2009-08-01

Responders to cardiac resynchronization therapy (CRT) have greater left ventricular (LV) dyssynchrony than nonresponders prior to CRT. We conducted this study to see whether the long term responders have more worsening of LV dyssynchrony and LV function on acute interruption of CRT. We identified 22 responders and 13 nonresponders who received CRT as per standard criteria for 23.73 +/- 7.9 months (median 24.5 months). We assessed the acute change in LV function, mitral regurgitation (MR) and compared LV dyssynchrony in CRT on and off modes. On turning off CRT, there was no significant worsening of LV dyssynchrony in both responders and nonresponders. The dyssynchrony measurements by SPWMD, TDI and 3D echocardiography did not correlate significantly. LVESV increased (p = 0.02) and MR (p = 0.01) worsened in CRT-off mode in responders only without significant change in LVEF or LV dimensions. In long-term responders to CRT, there is alteration in the function of remodeled LV with acute interruption of CRT, without significant worsening of LV dyssynchrony. The role of different echocardiographic parameters in the assessment of LV dyssynchrony remains controversial. Even after long-term CRT reversely remodels the LV, the therapy needs to be continued uninterrupted for sustained benefits.

[Reconstructive surgery of the mitral and tricuspid valves with a Cosgrove-Edwards flexible ring].

PubMed

Pugliese, P; Pantani, P; Lusa, A M; Nuti, R; Bongiovanni, M; Conti, F; Biasi, C; Pigini, F; Palmisano, D

2000-04-01

Mitral and tricuspid valve asymmetric annular dilation represents the most important mechanism which produces insufficiency. Recent computerized in vitro and in vivo three-dimensional models have been developed in order to better understand the competing factors (annular dilation, displacement of papillary muscles, left and right ventricular geometry). The leading cause of mitral and tricuspid competence is a sphincteric action of both annuli, during systole and diastole, the loss of which produces asymmetric dilation and therefore the absence of cusp coaptation. The Cosgrove-Edwards dynamic ring corrects, alone or in combination with other procedures on the valves, this patho-anatomic feature in a physiological way by restoring the normal annular dimensions and the sphincteric movements during the cardiac cycle. Between June 1998 and May 1999, 30 adult patients underwent mitral (n = 20, Group I) or tricuspid valve repair (n = 10, Group II). Regurgitation was due to a degenerative disease in 13 Group I patients and to ischemic (n = 3), congenital (n = 2) or dilated cardiomyopathy (n = 2) in the others. In Group II the leading cause of insufficiency was functional regurgitation in 7 patients and organic in 3. Associated procedures were carried out in 4 Group I patients and in all Group II patients. Regurgitation was evaluated by transesophageal echocardiography before, during and 3 months after operation. The maximal regurgitant area (MRA) and the grade of insufficiency were evaluated using the equation: MRA < 2 cm2 = grade 0, MRA > 2 < 4 cm2 = 1+, MRA > 4 < 7 cm2 = grade 2+, MRA > 7 < 10 cm2 = 3+, MRA > 10 cm2 = 4+. The operative mortality was 0%. One Group I patient died 3 months after operation due to bronchopneumonia. No patient was reoperated on for plasty failure in both groups during the follow-up. Mitral insufficiency was absent (grade 0) in 17 Group I patients and mild (grade 1+) in 3 at the end of operation. At 3-month postoperative transesophageal

Quantitation of valve regurgitation severity by three-dimensional vena contracta area is superior to flow convergence method of quantitation on transesophageal echocardiography.

PubMed

Abudiab, Muaz M; Chao, Chieh-Ju; Liu, Shuang; Naqvi, Tasneem Z

2017-07-01

Quantitation of regurgitation severity using the proximal isovelocity acceleration (PISA) method to calculate effective regurgitant orifice (ERO) area has limitations. Measurement of three-dimensional (3D) vena contracta area (VCA) accurately grades mitral regurgitation (MR) severity on transthoracic echocardiography (TTE). We evaluated 3D VCA quantitation of regurgitant jet severity using 3D transesophageal echocardiography (TEE) in 110 native mitral, aortic, and tricuspid valves and six prosthetic valves in patients with at least mild valvular regurgitation. The ASE-recommended integrative method comprising semiquantitative and quantitative assessment of valvular regurgitation was used as a reference method, including ERO area by 2D PISA for assigning severity of regurgitation grade. Mean age was 62.2±14.4 years; 3D VCA quantitation was feasible in 91% regurgitant valves compared to 78% by the PISA method. When both methods were feasible and in the presence of a single regurgitant jet, 3D VCA and 2D PISA were similar in differentiating assigned severity (ANOVAP<.001). In valves with multiple jets, however, 3D VCA had a better correlation to assigned severity (ANOVAP<.0001). The agreement of 2D PISA and 3D VCA with the integrative method was 47% and 58% for moderate and 65% and 88% for severe regurgitation, respectively. Measurement of 3D VCA by TEE is superior to the 2D PISA method in determination of regurgitation severity in multiple native and prosthetic valves. © 2017, Wiley Periodicals, Inc.

True morphology of mitral regurgitant flow assessed by three-dimensional transesophageal echocardiography.

PubMed

Lombardero, Martin; Henquin, Ruth; Perea, Gabriel; Corneli, Mariana; Izurieta, Carlos

2017-01-01

Quantification of mitral regurgitation (MR) by two-dimensional (2D) transthoracic echocardiography (TTE) is based on the analysis of the proximal flow convergence (PFC) and the "vena contracta" (VC). This method assumes geometries and can be misleading. In contrast, three-dimensional (3D) echocardiography directly measures flow volumes and does not assume geometries, which allows for more accurate MR evaluation. To report the 3D transesophageal echocardiography (3DTEE) feasibility for MR quantification and evaluate its concordance with 2D echo. Twenty-seven consecutive patients undergoing 2D and 3DTEE for presurgical MR evaluation were studied prospectively. MR quantification was performed by classical 2D methods based on PFC. Diameters of the VC in orthogonal planes by 3DTEE were estimated, establishing the VC sphericity index as well as VC area (VCA) by direct planimetry. In case of multiple jets, we calculated the sum of the VCA. MR assessment by 3DTEE was feasible. An adequate concordance between VC measurements by 2D methods (TTE and TEE) was observed; however, there was a poor correlation when compared with 3DTEE. The sphericity index of the VC was: 2.08 (±0. 72), reflecting a noncircular VC. 3DTEE is a feasible method for the assessment of the MR true morphology, allowing a better quantification of MR without assuming any geometry. This method revealed the presence of multiple jets, potentially improving MR evaluation and leading to changes in medical decision when compared to 2D echo assessment. © 2016, Wiley Periodicals, Inc.

Late leaflet fracture and embolization of a Duromedics mitral prosthesis.

PubMed

Sudo, K; Sasagawa, N; Ide, H; Nunokawa, M; Fujiki, T; Tonari, K

2000-08-01

A case of leaflet fracture and embolization of a mitral prosthetic valve is described. A 54-year-old man had received mitral valve replacement with an Edwards-Duromedics 29M prosthetic valve, at 10 years ago. Emergency mitral valve replacement was performed because the patient had severe congestive left heart failure with severe acute mitral regurgitation caused by a fracture in one of the mitral valve leaflets. The leaflet, which was fractured into 2 pieces, was removed from the right common iliac artery at 3 months after valve replacement. Visual inspection revealed that the leaflet contained a midline fracture. The fracture originated within a cavitary erosion pit near the major radius of the leaflet. The patient recovered from acute renal failure, requiring hemodialysis for 80 days, and is currently without complaints. We have used a Duromedics mitral valve in 11 patients, from April 1987 to April 1988. No subsequent valve failure has occurred. The diagnosis, treatment and cause of a mechanical valve fracture are discussed.

Short communication: Distribution of Porphyromonas gulae fimA genotypes in oral specimens from dogs with mitral regurgitation.

PubMed

Shirai, Mitsuyuki; Nomura, Ryota; Kato, Yukio; Murakami, Masaru; Kondo, Chihiro; Takahashi, Soraaki; Yamasaki, Yoshie; Matsumoto-Nakano, Michiyo; Arai, Nobuaki; Yasuda, Hidemi; Nakano, Kazuhiko; Asai, Fumitoshi

2015-10-01

Porphyromonas gulae, a suspected pathogen for periodontal disease in dogs, possesses approximately 41-kDa fimbriae (FimA) that are encoded by the fimA gene. In the present study, the association of fimA genotypes with mitral regurgitation (MR) was investigated. Twenty-five dogs diagnosed with MR (age range 6-13 years old, average 10.8 years) and 32 healthy dogs (8-15 years old, average 10.8 years) were selected at the participating clinics in a consecutive manner during the same time period. Oral swab specimens were collected from the dogs and bacterial DNA was extracted, then polymerase chain reaction analysis was performed using primers specific for each fimA genotype, with the dominant genotype determined. The rate for genotype C dominant specimens was 48.0% in the MR group, which was significantly higher than that in the control group (18.8%) (P <0.05). These results suggest that P. gulae fimA genotype C is associated with MR. Copyright © 2015 Elsevier Ltd. All rights reserved.

Alterations in atrial electrophysiology and tissue structure in a canine model of chronic atrial dilatation due to mitral regurgitation.

PubMed

Verheule, Sander; Wilson, Emily; Everett, Thomas; Shanbhag, Sujata; Golden, Catherine; Olgin, Jeffrey

2003-05-27

Clinically, chronic atrial dilatation is associated with an increased incidence of atrial fibrillation (AF), but the underlying mechanism is not clear. We have investigated atrial electrophysiology and tissue structure in a canine model of chronic atrial dilatation due to mitral regurgitation (MR). Thirteen control and 19 MR dogs (1 month after partial mitral valve avulsion) were studied. Dogs in the MR group were monitored using echocardiography and Holter recording. In open-chest follow-up experiments, electrode arrays were placed on the atria to investigate conduction patterns, effective refractory periods, and inducibility of AF. Alterations in tissue structure and ultrastructure were assessed in atrial tissue samples. At follow-up, left atrial length in MR dogs was 4.09+/-0.45 cm, compared with 3.25+/-0.28 at baseline (P<0.01), corresponding to a volume of 205+/-61% of baseline. At follow-up, no differences in atrial conduction pattern and conduction velocities were noted between control and MR dogs. Effective refractory periods were increased homogeneously throughout the left and right atrium. Sustained AF (>1 hour) was inducible in 10 of 19 MR dogs and none of 13 control dogs (P<0.01). In the dilated MR left atrium, areas of increased interstitial fibrosis and chronic inflammation were accompanied by increased glycogen ultrastructurally. Chronic atrial dilatation in the absence of overt heart failure leads to an increased vulnerability to AF that is not based on a decrease in wavelength.

Percutaneous transvenous mitral commissurotomy in juvenile mitral stenosis.

PubMed

Adhikari, Chandra Mani; Malla, Rabi; Rajbhandari, Rajib; Shakya, Urmila; Sharma, Poonam; Shrestha, Nagma; Kc, Bishal; Limbu, Deepak; Kc, Man Bahadur

2016-02-01

Percutaneous transvenous mitral commissurotomy (PTMC) is a valid alternative to surgical therapy in selected patients with mitral stenosis. Juvenile mitral stenosis (JMS) varies uniquely from adult rheumatic heart disease (RHD). We aimed to evaluate the efficacy of PTMC in JMS patients. It was a single centre, retrospective study conducted between July 2013 to June 2015 in Shahid Gangalal National Heart Centre, Kathmandu, Nepal. Medical records of all consecutive patients aged less than 21 years who underwent PTMC were included. Mitral valve area (MVA), left atrial pressure and mitral regurgitation (MR) were compared pre and post procedure. During the study period 131 JMS patients underwent PTMC. Seventy (53.4%) were female and 61 (46.6%) were male. Among the 131 patients, 40 (30.5%) patients were below the age of 15 years. Patient age ranged between 9 to 20 years with the mean of 16.3±2.9 years. Electrocardiography (ECG) findings were normal sinus rhythm in 115 (87.7%) patients and atrial fibrillation in 16 (12.3%) patients. Left atrial size ranged from 2.9 to 6.1 cm with the mean of 4.5±0.6 cm. The mean MVA increased from 0.8±0.1 cm(2) to 1.6±0.2 following PTMC. Mean left atrial pressure decreased from their pre-PTMC state of 27.5±8.6 to 14.1±5.8 mmHg. Successful results were observed in 115 (87.7%) patients. Suboptimal MVA <1.5 cm(2) in 11 (8.4%) patients and post-procedure MR of more than moderate MR in 5 (3.8%) patients was the reason for unsuccessful PTMC. PTMC in JMS is safe and effective.

Mitral valve replacement for mitral stenosis: A 15-year single center experience.

PubMed

Al Mosa, Alqasem F; Omair, Aamir; Arifi, Ahmed A; Najm, Hani K

2016-10-01

Mitral valve replacement with either a bioprosthetic or a mechanical valve is the treatment of choice for severe mitral stenosis. However, choosing a valve implant type is still a subject of debate. This study aimed to evaluate and compare the early and late outcomes of mitral valve replacement [mechanical (MMV) vs. bioprosthetic (BMV)] for severe mitral stenosis. A retrospective cohort study was performed on data involving mitral stenosis patients who have undergone mitral valve replacement with either BMV (n = 50) or MMV (n = 145) valves from 1999 to 2012. Data were collected from the patients' records and follow-up through telephone calls. Data were analyzed for early and late mortality, New York Heart Association (NYHA) functional classes, stroke, pre- and postoperative echocardiographic findings, early and late valve-related complications, and survival. Chi-square test, logistic regression, Kaplan-Meier curve, and dependent proportions tests were some of the tests employed in the analysis. A total of 195 patients were included in the study with a 30-day follow-up echocardiogram available for 190 patients (97.5%), while 103 (53%) were available for follow-up over the telephone. One patient died early postoperatively; twelve patients died late in the postoperative period, six in the bioprosthesis group and six in the mechanical group. The late mortality had a significant association with postoperative stroke (p < 0.001) and postoperative NYHA Classes III and IV (p = 0.002). Postoperative NYHA class was significantly associated with age (p = 0.003), pulmonary disease (p = 0.02), mitral valve implant type (p = 0.01), and postoperative stroke (p = 0.02); 14 patients had strokes in the mechanical (9) and in the bioprosthetic (5) groups. NYHA classes were significantly better after the replacement surgeries (p < 0.001). BMV were significantly associated with worse survival (p = 0.03), worse NYHA postoperatively (p = 0.01), and more reoperations

[Atrio-ventricular pressure difference associated with mitral valve motion].

PubMed

Wang, L M; Mori, H; Minezaki, K; Shinozaki, Y; Okino, H

1990-05-01

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.

Survival in Patients with Degenerative Mitral Stenosis: Results from a Large Retrospective Cohort Study.

PubMed

Pasca, Ioana; Dang, Patricia; Tyagi, Gaurav; Pai, Ramdas G

2016-05-01

Severe mitral annular calcification causing degenerative mitral stenosis (DMS) is increasingly encountered in patients undergoing mitral and aortic valve interventions. However, its clinical profile and natural history and the factors affecting survival remain poorly characterized. The goal of this study was to characterize the factors affecting survival in patients with DMS. An institutional echocardiographic database was searched for patients with DMS, defined as severe mitral annular calcification without commissural fusion and a mean transmitral diastolic gradient of ≥2 mm Hg. This resulted in a cohort of 1,004 patients. Survival was analyzed as a function of clinical, pharmacologic, and echocardiographic variables. The patient characteristics were as follows: mean age, 73 ± 14 years; 73% women; coronary artery disease in 49%; and diabetes mellitus in 50%. The 1- and 5-year survival rates were 78% and 47%, respectively, and were slightly worse with higher DMS grades (P = .02). Risk factors for higher mortality included greater age (P < .0001), atrial fibrillation (P = .0009), renal insufficiency (P = .004), mitral regurgitation (P < .0001), tricuspid regurgitation (P < .0001), elevated right atrial pressure (P < .0001), concomitant aortic stenosis (P = .02), and low serum albumin level (P < .0001). Adjusted for propensity scores, use of renin-angiotensin system blockers (P = .02) or statins (P = .04) was associated with better survival, and use of digoxin was associated with higher mortality (P = .007). Prognosis in patients with DMS is poor, being worse in the aged and those with renal insufficiency, atrial fibrillation, and other concomitant valvular lesions. Renin-angiotensin system blockers and statins may confer a survival benefit, and digoxin use may be associated with higher mortality in these patients. Copyright © 2016 American Society of Echocardiography. Published by Elsevier Inc. All rights reserved.

First percutaneous Micra leadless pacemaker implantation and tricuspid valve repair with MitraClip NT for lead-associated severe tricuspid regurgitation.

PubMed

Tang, Gilbert H L; Kaple, Ryan; Cohen, Martin; Dutta, Tanya; Undemir, Cenap; Ahmad, Hasan; Poniros, Angelica; Bennett, Joanne; Feng, Cheng; Lansman, Steven

2017-02-03

Pacemaker lead-associated severe tricuspid regurgitation (TR) can lead to right heart failure and poor prognosis. Surgery in these patients carries significant morbidities. We describe a successful treatment of symptomatic severe TR by leadless pacemaker implantation followed by tricuspid valve (TV) repair with the MitraClip NT. A 71-year-old frail female with poor functional status, chronic atrial fibrillation and permanent pacemaker implantation in 2012 presented with symptomatic moderate-severe mitral regurgitation (MR) and severe TR with the pacemaker lead as the culprit. She was deemed extreme risk for double valve surgery and, because of her pacemaker dependency, the decision was to stage her interventions first with transcatheter mitral repair, then laser lead extraction and leadless pacemaker implantation to free the TV from tethering, then TV repair. An obstructive LAD lesion was identified and treated during mitral repair with the MitraClip NT. The Micra leadless pacemaker implantation and subsequent TV repair with the MitraClip NT were successful and the patient's MR improved to mild and TR to moderate, respectively. We report here a first successful transcatheter strategy to treat lead-associated severe TR by leadless pacemaker and MitraClip. Removing the pacemaker lead relieved leaflet tethering and improved the reparability of the TV.

Outcomes With Transcatheter Mitral Valve Repair in the United States: An STS/ACC TVT Registry Report.

PubMed

Sorajja, Paul; Vemulapalli, Sreekanth; Feldman, Ted; Mack, Michael; Holmes, David R; Stebbins, Amanda; Kar, Saibal; Thourani, Vinod; Ailawadi, Gorav

2017-11-07

Post-market surveillance is needed to evaluate the real-world clinical effectiveness and safety of U.S. Food and Drug Administration-approved devices. The authors examined the commercial experience with transcatheter mitral valve repair for the treatment of mitral regurgitation. Data from the Society of Thoracic Surgery/American College of Cardiology Transcatheter Valve Therapy Registry on patients commercially treated with transcatheter mitral valve repair were analyzed. The study population consisted of 2,952 patients treated at 145 hospitals between November 2013 and September 2015. In 1,867 patients, data were linked to patient-specific Centers for Medicare and Medicaid Services administrative claims for analyses. The median age was 82 years (55.8% men), with a median Society of Thoracic Surgery predicted risk of mortality of 6.1% (interquartile range: 3.7% to 9.9%) and 9.2% (interquartile range: 6.0% to 14.1%) for mitral repair and replacement, respectively. Overall, in-hospital mortality was 2.7%. Acute procedure success occurred in 91.8%. Among the patients with Centers for Medicare and Medicaid Services linkage data, the mortality at 30 days and at 1 year was 5.2% and 25.8%, respectively, and repeat hospitalization for heart failure at 1 year occurred in 20.2%. Variables associated with mortality or rehospitalization for heart failure after multivariate adjustment were increasing age, lower baseline left ventricular ejection fraction, worse post-procedural mitral regurgitation, moderate or severe lung disease, dialysis, and severe tricuspid regurgitation. Our findings demonstrate that commercial transcatheter mitral valve repair is being performed in the United States with acute effectiveness and safety. Our findings may help determine which patients have favorable long-term outcomes with this therapy. Copyright © 2017 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Malformation of the canine mitral valve complex.

PubMed

Litu, S K; Tilley, L P

1975-09-15

Twenty-nine dogs, including 13 Great Danes and 5 German Shepherd Dogs and averaging 7.3 months age, were diagnosed clinically and radiographically as having mitral regurgitation. Alterations of the mitral valve complex included enlarged anulus; short thick leaflets, with an occasional cleft; short and stout or long and thin chordae tendineae; upward malposition of atrophic or hypertrophic papillary muscles; insertion of one papillary muscle directly into one or both leaflets; and diffuse endocardial fibrosis, occasionally with jet lesions in te left atrium. Other cardiac anomalies included dysplasia of the tricuspid valve (5 dogs), patent ductus afteriosus (2 dogs), aortic stenosis (2 dogs), and ventricular septal defect (1 dog).

[Pannus Formation Six-years after Aortic and Mitral Valve Replacement with Tissue Valves;Report of a Case].

PubMed

Nakamura, Makoto; Muraoka, Arata; Aizawa, Kei; Akutsu, Hirohiko; Kurumisawa, Soki; Misawa, Yoshio

2015-07-01

A 77-year-old man presented with exertional dyspnea. He had undergone aortic and mitral valve replacement with tissue valves 6-years earlier. The patient's hemoglobin level was 9.8 g/dl and serum aspartate aminotransferase (70 mU/ml) and lactate dehydrogenase (1,112 mU/ml) were elevated. Echocardiography revealed stenosis of the prosthetic valve in the aortic position with peak flow velocity of 3.8 m/second and massive mitral regurgitation. The patient underwent repeat valve replacement. Pannus formation around both implanted valves was observed. The aortic valve orifice was narrowed by the pannus, and one cusp of the prosthesis in the mitral position was fixed and caused the regurgitation, but they were free from cusp laceration or calcification. The patient's postoperative course was uneventful, and he continues to do well 14 months after surgery.

From tricuspid to double orifice Morphology: Percutaneous tricuspid regurgitation repair with the MitraClip device in congenitally corrected-transposition of great arteries.

PubMed

Picard, Fabien; Tadros, Victor-Xavier; Asgar, Anita W

2017-09-01

Edge to edge transcatheter mitral valve repair with MitraClip (Abbott Vascular, Menlo Park, CA) is increasing for high-risk surgical patients with significant mitral regurgitation. Patients with congenitally corrected transposition of the great arteries (CCTGA) presenting with tricuspid valve regurgitation of a systemic right ventricle may represent particularly challenging candidates for MitraClip given their anatomy. We report the case of a 67-year-old gentleman with CCTGA and severe tricuspid regurgitation who was referred for MitraClip implantation after heart team consensus. Successful implantation of one clip was performed, achieving a significant reduction of the regurgitation. Similarly, favorable findings were confirmed at 6 months, 1 and 2 years follow-up and the patient had no recurrent heart failure admissions after 2-year follow-up. We describe the technical considerations and the importance of 3D-transoesophageal echocardiography for performing the MitraClip of a trileaflet systemic atrioventricular valve. © 2016 Wiley Periodicals, Inc. © 2016 Wiley Periodicals, Inc.

Impact of interventional edge-to-edge repair on mitral valve geometry.

PubMed

Schueler, Robert; Kaplan, Sarah; Melzer, Charlotte; Öztürk, Can; Weber, Marcel; Sinning, Jan-Malte; Welz, Armin; Werner, Nikos; Nickenig, Georg; Hammerstingl, Christoph

2017-03-01

The acute and long-term effects of interventional edge-to-edge repair on the mitral valve (MV) geometry are unclear. We sought to assess MV-annular geometry and the association of changes in MV-diameters with functional response one year after MitraClip implantation. Consecutive patients (n=84; age 81.2±8.3years, logistic EuroSCORE 21.7±17.9%) with symptomatic moderate-to-severe mitral regurgitation (MR) underwent MitraClip-procedure. MV-annular geometry was assessed with 3D TOE before, immediately and one year after clip implantation. 96.7% of secondary mitral regurgitation (SMR) patients presented with moderate-to-severe MR, 3.3% with severe SMR, respectively. 66.7% of primary MR (PMR) patients had moderate-to-severe MR, and 33.3% severe PMR respectively. When analyzing immediate effects of MitraClipC on mitral geometry, only patients with SMR (n=60, 71.4%) experienced significant reductions of the diastolic MV anterior-posterior diameters (AP: 3.9±0.5cm, 3.5±0.7cm; p<0.001), and annulus-areas (2D: 12.9±3.8cm2, 12.6±3.7cm2; p<0.001; 3D: 13.4±3.8, 13.1±3.2cm2; p<0.001). All measures on MV annular geometry were not significantly altered in patients with PMR (p>0.05). After one year of follow-up, MV annular parameters remained significantly reduced in SMR patients (p<0.05) and remained unchanged in subjects with PMR (p>0.05). Only SMR patients experienced significant increase in 6min walking distances (p=0.004), decrease in pulmonary pressures (p=0.007) and functional NYHA-class (p<0.001); in patients with PMR only NYHA class improved after one year (p<0.001). Edge-to-edge repair with the MitraClip-system impacts on MV-geometry in patients with SMR with stable results after 12months. Reduction of MV-annular dimensions was associated with higher rates of persisting MR reduction and better functional status in patients with SMR. Copyright © 2016 Elsevier Ireland Ltd. All rights reserved.

[Open mitral commissurotomy. Experience of the Ignacio Chávez National Institute of Cardiology].

PubMed

Rebollar y Pliego, L; Buzetta, I; Quijano Pitman, F

1982-01-01

From 1970 to 1979 open mitral commissurotomy (OMC) was indicated in 167 patients. In 22 cases a valvular prosthesis was inserted. In the 145 patients subjected to OMC there was one hospital and one late death. Four late systemic emboli (SE) in three patients. In 92% there was improvement in functional class. Poor post-op course in 8% due to mitral regurgitation (MR) added to mitral stenosis or iatrogenic MR subjected to annuloplasty with poor results and eventual mitral prosthetic implantation. Pre-op SE in 35%, intracavitary thrombosis (IT) in 23% and in 13% of cases without history of SE. IT found as often in atrium as in left auricular appendage. The vast majority of patients with IT were in atrial fibrillation (AF), this arrhythmia was present in 34% of the 145 cases. In hospitals where all cases of predominant mitral stenosis (MS) cannot be operated by OMC because of logistics, cases of MS with AF and surgical indication should be operated by OMC because of the correlations between AF and IT. Other indications for OMC are reviewed. The excellent post-op results with scarce late complications re-enforce the convenience of retaining the human mitral valve and avoiding valve replacement when repair is possible.

[Clinical evaluation of regurgitant blood flow by rapid cine magnetic resonance imaging in patients with valvular heart disease].

PubMed

Onishi, S; Fukui, S; Atsumi, C; Morita, R; Fujii, K; Kusuoka, H; Kitabatake, A; Kamada, T; Takizawa, O

1989-06-01

The clinical usefulness of magnetic resonance imaging (MRI) for evaluating regurgitant blood flow in patients with valvular heart disease was studied. The study subjects comprised three healthy volunteers and nine patients with valvular heart disease (aortic regurgitation 3, mitral regurgitation 2, tricuspid regurgitation 2, and pulmonary regurgitation 2). Five were men and seven were women, ranging in age from 31 to 85 years. Valvular heart disease was diagnosed by two-dimensional Doppler echocardiography. MRI was performed using a 1.5 tesla super-conductive magnet system (MAGNETOM, Siemens AG). A rapid MRI technique (fast low-angle shot [FLASH], flip angle = 30 degrees, TR = 65-90 msec, TE = 10-38 msec) was used to generate 11 frames throughout one cardiac cycle in the transaxial, coronal and oblique planes. These sequential frames were displayed in cine mode on a CRT. 1. Intracavitary blood was imaged as a high signal intensity on gradient echo images, while surrounding cardiac structures had somewhat lower signal intensities. 2. In healthy volunteers, systolic ejection blood flow from the left ventricle was observed on coronal images in the cine mode display. The influx of atrial blood into the left and right ventricles was also clearly observed on transaxial cine images. 3. Aortic regurgitant flow was observed as areas of no signal intensity within the left ventricular cavity during diastole on coronal images. 4. Mitral and tricuspid regurgitations were observed within the left and right atria, respectively, as areas of no signal intensity on transaxial images. The extent of regurgitant flow was determined in the vertical long-axis plane, equivalent to the right anterior oblique projection. 5. The vertical oblique scan was suitable for detecting pulmonary regurgitant flow. These results indicate that the rapid cine MRI technique is a useful tool for noninvasively determining regurgitant blood flow in patients with various valvular heart diseases.

The 'respect rather than resect' principle in mitral valve repair: the lateral dislocation of the P2 technique.

PubMed

Zanobini, Marco; Ricciardi, Gabriella; Mammana, Francesco Liborio; Kassem, Samer; Poggio, Paolo; Di Minno, Alessandro; Cavallotti, L; Saccocci, Matteo

2017-09-01

Leaflet resection represents the reference standard for surgical treatment of mitral valve (MV) regurgitation. New approaches recently proposed place emphasis on respecting, rather than resecting, the leaflet tissue to avoid the drawbacks of the 'resection' approach. The lateral dislocation of mid portion of mitral posterior leaflet (P2) technique for MV repair is a nonresectional technique in which the prolapsed P2 segment is sutured to normal P1 segment. Our study evaluates the effectiveness of this technique. We performed the procedure on seven patients. Once ring annular sutures were placed, the prolapsed P2 segment was dislocated toward the normal P1 segment with a rotation of 90° and without any resection. If present, residual clefts between P2 and P3 segments were closed. Once the absence of residual mitral regurgitation is confirmed by saline pressure test, ring annuloplasty was completed. The valve was evaluated using transesophageal echocardiography in the operating room and by transthoracic echocardiography before discharge. At the last follow-up visit, transthoracic echocardiography revealed no mitral regurgitation and normal TRANSVALVULAR gradients. The lateral dislocation of P2 is an easily fine-tuned technique for isolated P2 prolapse, with the advantage of short aortic cross-clamp and cardiopulmonary bypass times. We think it might be very favorable in older and frail patients. Long-term follow-up is necessary to assess the durability of this technique.

The Effects of Mitral Valve Repair on Memory Performance, Executive Function, and Psychological Measures in Patients With Heart Failure.

PubMed

Nikendei, Christoph; Schäfer, Hannah; Weisbrod, Matthias; Huber, Julia; Geis, Nicolas; Katus, Hugo A; Bekeredjian, Raffi; Herzog, Wolfgang; Pleger, Sven T; Schultz, Jobst-Hendrik

2016-05-01

Heart failure (HF) is a prevalent disease that remains costly and associated with a high mortality rate. HF is also associated with poor neurocognitive functioning. For the treatment for HF patients with severe mitral regurgitation, the MitraClip device has emerged as a promising interventional tool that reduces the mitral valve leakage and thus increases cardiac output. Currently, there is only limited knowledge on changes in cognitive and psychosocial functioning before and after the MitraClip intervention. Cognitive function (memory and executive function) and psychosocial measures (depression, anxiety, and quality of life) were assessed before and after the MitraClip intervention in 24 HF patients and 23 healthy participants (comparison group). MitraClip intervention in HF patients was followed by improvements in figural long-term memory (p = .003) and executive function (planning ability, p < .001) relative to the comparison group. In addition, the intervention resulted in a significant improvement in depression (p = .002), anxiety (p = .003) and quality of life scores (physical p = .017, mental p = .013) as well as improved 6-minute walk test results over time (p = .002). The presented data provide evidence of a significant improvement in memory and executive function as well as in depression, anxiety, and quality of life scores in patients with chronic HF after MitraClip intervention. Further research is needed to shed light on the long-term development of cognitive function, psychosocial well-being, and clinical parameters after MitraClip intervention and how these factors depend on one another.

Comparative effect of carperitide and furosemide on left atrial pressure in dogs with experimentally induced mitral valve regurgitation.

PubMed

Suzuki, S; Fukushima, R; Yamamoto, Y; Ishikawa, T; Hamabe, L; Kim, S; Yoshiyuki, R; Fukayama, T; Machida, N; Tanaka, R

2013-01-01

The effects of carperitide on left atrial pressure (LAP) in dogs with mitral valve disease (mitral regurgitation, MR) have not been documented. The objective was to compare the short-term effects of carperitide versus furosemide on LAP and neurohumoral factors in MR dogs. Six healthy Beagle dogs weighing 9.8-12.6 kg (2 males and 4 females; aged 3 years) were used. Experimental, randomized, cross-over, and interventional study. Carperitide 0.1 μg/kg/min or furosemide 0.17 mg/kg/h (1 mg/kg/6 h) was administered to dogs with surgically induced MR for 6 hours, and after a 14 day wash-out period, the other drug was administered. LAP, plasma renin activity, plasma aldosterone, and echocardiographic variables were measured. Left atrial pressure was decreased similarly after the administration of carperitide 0.1 μg/kg/min and furosemide 0.17 mg/kg/h (1 mg/kg/6 h) compared with baseline in dogs with MR (Baseline 14.75 ± 3.74 mmHg, carperitide 10.24 ± 4.97 mmHg, P < .01, furosemide 10.77 ± 5.06 mmHg, P < .05). Plasma renin activity and plasma aldosterone were significantly lower after the administration of carperitide than after the administration of furosemide (P < .05, respectively). Carperitide significantly decreased LAP in dogs with acute MR caused by experimental chordal rupture. Carperitide can have additional benefits from the viewpoint of minimal activation of neurohumoral factors in the treatment of dogs with MR. Additional studies in dogs with spontaneous disease are warranted. Copyright © 2013 by the American College of Veterinary Internal Medicine.

[Mitral valvuloplasty with double balloon catheter. Analysis of 200 cases].

PubMed

Gomes, N L; Esteves, C A; Braga, S L; Ramos, A I; Meneghelo, Z M; Mattos, L A; Pontes Júnior, S C; Arnoni, A S; Fontes, V F; Sousa, J E

1992-04-01

To study the immediate clinical, echocardiographic and hemodynamic results of 200 patients who underwent percutaneous mitral balloon valvotomy (PMV) with double balloon technique. Two hundred patients were submitted to PVM for treatment of congestive heart failure secondary to severe mitral stenosis, between August 1987 to July 1991. Their mean age was 35.2 years, and 86.5% were female patients: 81% of them was in functional class, New York Heart Association (NYHA) III or IV; 4% was in atrial fibrilation and 4% had previous surgical commissurotomy. PMV was successfully performed in 89% of the patients. The mitral valve area, by pressure half time method, increased from 0.91 +/- 0.27 to 2.10 +/- 0.47 cm2, p < 0.001; the mean mitral gradient decreased from 20.86 +/- 6.16 to 4.26 +/- 3.13 mmHg, p < 0.001; the left atrium and mean pulmonary artery pressure decreased from 22.3 +/- 7.1 to 11.9 +/- 8.3 and 36.47 +/- 12.93 to 24.56 +/- 9.98 mmHg, p < 0.001, respectively. Complications related to transeptal technique occurred in 12 patients, which resulted in cardiac tamponade in 5 and death in 1. In 19 patients the punction of the atrial septum could not be performed. Mitral regurgitation (MR) immediately after PMV appeared 1+ or more grade in 50 patients, increased in 8 patients and remained unchanged in 11 patients. Ten patients needed mitral valve replacement in the first 48h after PMV, for treatment of severe MR. PMV produces excellent immediate results and can be considered an alternative to surgery for the relief of mitral stenosis.

Catheter interventions for mitral stenosis in children: results and perspectives.

PubMed

Saxena, Anita

2015-04-01

Stenosis of the mitral valve most often occurs as a result of chronic rheumatic heart disease, causing thickening and fibrosis of the mitral valve apparatus. Rheumatic heart disease continues to be a major public health problem in several developing countries and mitral stenosis is also common in these regions. According to the reports from India and Africa, the disease tends to follow a rapidly progressive course in children. The treatment of choice is balloon dilatation of the mitral valve. Echocardiography is indispensable for this procedure. Before planning the procedure, it is essential to assess the suitability of balloon dilatation. Echocardiography performed during the procedure helps to decide whether the size of the balloon needs to be increased in case of inadequate relief of stenosis. Most published series have reported an immediate success rate of over 90% with balloon dilatation in children and young adults. With an increase in mitral valve area and improvement in functional class, the left atrial pressure and the transmitral gradients fall. These gratifying results are also reported from very young children of less than 12 years of age. It is recommended to start with a smaller balloon size and increase its size in a stepwise fashion to minimize complications. The complications, seen in about 1% to 2% of cases, include development of significant mitral regurgitation and hemopericardium, secondary to cardiac chamber perforation. The long-term results indicate slightly higher restenosis rates in children than in adults. Most children with restenosis can undergo successful repeat dilatation. © The Author(s) 2015.